PURPOSE:To develop and temporally validate a predictive framework for molecular adequacy in computed tomography (CT)-guided transthoracic needle biopsy (TTNB) of lung lesions, integrating procedural variables with radiomic features derived from pre-procedural CT imaging. MATERIALS AND METHODS:This observational derivation-validation study included 670 CT-guided TTNB procedures performed in 633 patients. A retrospective twin-center cohort (522 procedures) was used for model development and internal validation, while a prospective single-center cohort (148 procedures) served as an independent temporal validation set. Molecular adequacy for next-generation sequencing and PD-L1 testing was the primary endpoint. A multivariable model based on procedural predictors was developed and evaluated, followed by an exploratory radiomics sub-study integrating quantitative imaging features. Model performance was assessed using area under the curve (AUC), calibration metrics, and transportability analyses. Procedural complications were classified according to the modified CIRSE classification system. RESULTS:Overall molecular adequacy for next-generation sequencing was 83.9%. The prospective validation cohort, managed under a standardized procedural framework, demonstrated a significantly higher adequacy rate compared with the retrospective cohort (91.2% vs. 82.6%). The procedural model achieved an AUC of 0.86 in the derivation cohort and 0.84 in the validation cohort. Integration of radiomics further improved discrimination (AUC 0.88), particularly in subsolid lesions. Complication rates were comparable between cohorts, with no increase in major complications. CONCLUSION:Molecular adequacy in CT-guided lung biopsy can be meaningfully improved through procedural standardization and further enhanced by integrating radiomics. The proposed framework provides a foundation for future prospective evaluation of decision-support strategies in interventional radiology.

BACKGROUND:Conjunctival melanoma is rare and prone to local recurrence, and optimal surveillance imaging of the ocular surface and periocular skin is not standardized. We report the use of ultra-high-frequency ultrasound (UHFUS) to map multiple clinically subtle recurrent nodules in a previously treated conjunctival melanoma (Co-M) patient undergoing immunotherapy. This case supports incorporating UHFUS into multidisciplinary follow-up, showing how it can non-invasively detect occult recurrence and guide staging and treatment planning. CASE SUMMARY:A middle-aged patient with a history of conservatively treated left Co-M was referred for suspected local recurrence, reporting a new palpable subcutaneous lump near the lateral orbital rim and a pigmented lesion at the medial canthus of the same eye. Clinical examination confirmed a periocular nodule suggestive of relapse. Cervical lymph node ultrasound showed no suspicious lymphadenopathy. UHFUS (48 MHz) with Doppler of the periocular region revealed epidermal thickening at the medial canthus and three subepidermal nodules in the lower eyelid and lateral canthus, with irregular morphology and increased vascularity, highly suggestive of recurrent melanoma and satellite lesions. The patient was already receiving first-line anti-programmed cell death 1 immunotherapy; high-frequency ultrasound findings refined local staging, confirmed absence of nodal involvement, and supported multidisciplinary planning and imaging-based follow-up. CONCLUSION:UHFUS can non-invasively detect and map recurrent Co-M, improving local staging and guiding multidisciplinary follow-up.

Small cell lung cancer (SCLC) is an aggressive neuroendocrine tumor with poor prognosis and limited benefit from immune checkpoint inhibitors (ICIs). Biomarker-driven patient stratification has been hindered by small biopsy samples, high tumor heterogeneity, and the limited predictive value of PD-L1 and tumor mutation burden. Mitochondrial antiviral-signaling protein (MAVS) has emerged as a potential immune activation marker, particularly in patients receiving DNA-damaging therapies. We report a proof-of-concept clinical study evaluating a surface plasmon resonance–plastic optical fiber (SPR‑POF) biosensor functionalized with anti-MAVS antibodies to detect the protein in serum from SCLC patients undergoing chemo-immunotherapy, with or without radiotherapy. The biosensor achieved a limit of detection of 0.13 nM in human diluted serum and demonstrated high selectivity against common serum proteins. In a cohort stratified as best responders (disease control >6 months) and non-responders (progressive disease as best response), MAVS levels measured in responders were on average tenfold higher than in non-responders, consistent with previous preclinical PBMC and western blot data. The SPR‑POF platform demonstrated portability, cost-effectiveness (estimated 5 USD/unit), and operational simplicity, highlighting its potential for point-of-care testing (POCT) applications. Although limited by small patient numbers, these findings support MAVS as a promising predictive biomarker in SCLC, warranting validation in larger prospective studies.

Background: We tested whether a contrast-free protocol can reproduce contrast-enhanced VI-RADS scoring and whether reader expertise influences results. Methods: In this retrospective single-center study (January-December 2024), 65 patients (69 lesions) underwent bladder multiparametric MRI. Two blinded radiologists assigned VI-RADS scores using only T2-weighted and diffusion-weighted imaging (biparametric, non-contrast MRI): an expert (>15 years in urogenital radiology) in genitourinary MRI and a non-expert (5 years of experience in genitorurinary radiology). Two complementary reference standards were used. For reproducibility analysis, the reference standard was the VI-RADS score from the original clinical report based on the full multiparametric examination including contrast-enhanced imaging. For diagnostic accuracy analysis, histopathology was used as the reference standard for muscle-invasive versus non-muscle-invasive disease. Agreement was evaluated with confusion matrices, overall agreement, and weighted Cohen's kappa. Discrimination for high likelihood of muscle invasion (VI-RADS ≥ 4) was assessed with receiver operating characteristic analysis. Results: Reference scores were VI-RADS 2 (34.8%), 3 (14.5%), 4 (20.3%), and 5 (30.4%). Agreement was higher for the expert than the non-expert (73.9% vs. 56.5%; weighted kappa 0.74 [95% confidence interval 0.56-0.89] vs. 0.58 [0.37-0.75]). The area under the curve for VI-RADS ≥ 4 was 0.87 (0.78-0.95) for the expert and 0.81 (0.69-0.91) for the non-expert. Sensitivity at a biparametric threshold of VI-RADS ≥ 4 was 88.6% for both readers; specificity was 85.3% vs. 73.5%. Post-resection cases showed more discrepancies, mainly overstaging. Conclusions: Contrast-free biparametric MRI may approximate multiparametric VI-RADS scoring only in treatment-naïve pre-TURBT cases with clearly low-risk, non-equivocal imaging features, but performance is reader-dependent and less reliable in equivocal, higher-risk, and post-resection examinations. Contrast-enhanced multiparametric MRI remains preferred for staging.

Background: Treatment monitoring in pulmonary tuberculosis increasingly requires assessment of residual inflammatory burden and structural lung damage beyond microbiologic response alone. High-resolution computed tomography (HRCT) can provide this information, but interpretation of serial examinations is time-consuming and partly subjective. This study did not aim to evaluate AI for the diagnosis of pulmonary tuberculosis. Instead, it explored whether artificial intelligence (AI)-assisted quantitative HRCT analysis could support longitudinal assessment of treatment-related imaging changes in patients with microbiologically confirmed pulmonary tuberculosis. Methods: We conducted a retrospective, single-center, exploratory longitudinal study of patients receiving treatment for pulmonary tuberculosis. HRCT examinations acquired at diagnosis and during follow-up were anonymized, reviewed by an expert thoracic radiologist, and processed using AVIEW Lung Texture (Coreline Soft v2.0). The software quantified total lung volume and six predefined parenchymal categories: normal lung, ground-glass opacity, consolidation, reticulation, honeycombing, and emphysema. Results: Ninety-six patients contributed 256 HRCT examinations. The most frequent software-detected abnormalities were ground-glass opacity, consolidation, and emphysema-labeled low-attenuation areas. Ground-glass opacity and consolidation showed the clearest decline across serial examinations, consistent with regression of active inflammatory disease during treatment. Reticulation showed a heterogeneous course, likely reflecting both inflammatory resolution and residual structural remodeling. Honeycombing was infrequent and quantitatively limited. Lung volume changed variably and did not consistently parallel visual improvement. A key methodological limitation was the absence of a dedicated cavity class. As a result, emphysema-labeled low-attenuation areas should not be interpreted as conventional emphysema alone, because tuberculous cavities and post-destructive abnormalities were frequently included in this category. Conclusions: AI-assisted HRCT quantification may support longitudinal assessment of pulmonary tuberculosis by providing structured and reproducible measures of interval change. However, tuberculosis-specific interpretation remains dependent on expert radiologic oversight, particularly in cavitary disease.

Background: High-and ultra-high-frequency ultrasound (HFUS/UHFUS) may enhance early detection of clinically occult local recurrence at melanoma excision scars, where postoperative fibrotic or inflammatory changes can obscure subtle dermal-subcutaneous foci. Methods: This single-center retrospective observational study included all consecutive patients with histologically confirmed cutaneous melanoma who underwent HFUS/UHFUS assessment of the excision scar between November 2024 and October 2025 at a tertiary referral center. Examinations were performed with a Vevo 3100 system using a 48-70 MHz linear transducer by an experienced radiologist (>10 years), following a standardized institutional protocol. Scars were classified as benign remodeling, indeterminate, or suspicious/highly suspicious according to predefined morphologic and vascular features. Suspicious/highly suspicious findings were referred for biopsy/excision; indeterminate findings underwent short-interval follow-up; benign-appearing scars were monitored per protocol. Histopathology and/or longitudinal follow-up served as reference standards. Results: Among 320 patients (730 examinations), 53 scars were categorized as suspicious/highly suspicious; recurrence was histologically confirmed in 50 cases, while 3 represented fibroblast-rich extracellular matrix remodeling. All recurrences were clinically occult at imaging. No false negatives were observed within the available follow-up of ultrasound-negative scars (median 12 months; range 3-12). Sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy were 100%, 98.9%, 94.3%, 100%, and 99.1%, respectively. Conclusion: In an expert setting, HFUS/UHFUS provides highly reliable detection of subclinical local recurrence at melanoma excision sites and robust discrimination from benign postoperative changes, supporting its integration as an adjunct tool in specialized follow-up pathways.

Background: Accurate preoperative staging is the cornerstone of therapeutic decision-making in gastric cancer (GC), yet standard modalities often fail to capture the full extent of disease, particularly in diffuse and poorly cohesive histotypes. This review aims to provide a comprehensive update on diagnostic imaging for GC, evaluating the established roles of CT, EUS, and PET/CT alongside the emerging capabilities of Magnetic Resonance Imaging (MRI) and Artificial Intelligence (AI). Methods: A structured narrative review was conducted by searching indexed biomedical databases for studies published between 2015 and 2024. A structured literature search screening process identified 410 relevant studies focusing on T, N, and M staging accuracy, quantitative imaging biomarkers, and radiomics. Results: While Multidetector CT remains the universal first-line modality, its sensitivity declines in infiltrative tumors and low-volume peritoneal carcinomatosis. EUS retains superiority for early (T1-T2) lesions but may offer limited value in advanced stages. Conversely, MRI (leveraging diffusion-weighted imaging (DWI) and multiparametric protocols) indicates superior soft-tissue contrast, potentially outperforming CT in the assessment of serosal invasion, nodal involvement, and occult peritoneal metastases. Furthermore, emerging fibroblast activation protein inhibitor (FAPI) PET tracers show promise in overcoming the limitations of FDG in mucinous and diffuse GC. Finally, radiomics and deep learning models are providing novel quantitative biomarkers for non-invasive risk stratification. Conclusions: Contemporary GC staging requires a tailored, multimodality approach. Evidence supports the increasing integration of MRI and quantitative imaging into clinical workflows to overcome the limitations of conventional techniques and support precision oncology.

Background: Accurate characterization of complex renal cystic lesions is essential for individualized patient management, as enhancement patterns of septa and walls determine Bosniak classification, malignancy risk, and tailored follow-up strategies. While contrast-enhanced ultrasound (CEUS) is widely used to assess enhancement, Superb Microvascular Imaging (SMI) offers a non-contrast alternative that is capable of detecting slow-flow microvascular signals. This study aimed to evaluate the diagnostic concordance, accuracy, and reproducibility of SMI compared with CEUS in the Bosniak 2019 classification, and to explore its role in personalized imaging pathways for patients with contraindications to contrast media. Methods: Eighty patients (92 cystic renal lesions) who underwent both SMI and CEUS between January 2024 and July 2025 were retrospectively analyzed. Lesions were categorized using the Bosniak 2019 criteria. CEUS served as the reference standard. Concordance between modalities was evaluated using Cohen's κ, and diagnostic accuracy was determined by ROC analysis. Inter- and intra-reader agreement were assessed with κ and intraclass correlation coefficients (ICC), respectively. Histopathologic confirmation was available for resected Bosniak III-IV lesions. Results: SMI showed excellent concordance with CEUS (κ = 0.84, 95% CI 0.76-0.91; overall agreement 83.7%). Concordance was perfect for Bosniak I-II, good for IIF (85%), and moderate for III (68%) and IV (64%) categories. Using CEUS as the reference, SMI achieved a sensitivity of 88.5%, specificity of 90.0%, and AUC of 0.94 for distinguishing low- from high-risk lesions. Inter-reader (κ = 0.83) and intra-reader (ICC = 0.91) agreements were excellent. Among 18 surgically resected Bosniak III-IV lesions, 14 (77.8%) were malignant; SMI correctly identified 12/14 malignant and 3/4 benign cases. Conclusions: SMI shows high diagnostic accuracy and reproducibility in the assessment of complex renal cystic lesions, with strong concordance to CEUS within the Bosniak 2019 system. By providing vascular characterization without contrast administration, SMI supports more personalized renal cyst management, enabling safer imaging for patients at risk from contrast agents and potentially reducing unnecessary interventions. Further multicenter validation is warranted to define its integration into precision-oriented multiparametric renal ultrasound protocols.

Objectives:Treatment of idiopathic pulmonary fibrosis (IPF) and progressive fibrosing interstitial lung disease (PF-ILD) remain challenging in elderly patients with frailty, which negatively impact outcomes. This study aims at describing the prevalence of frailty in a cohort of patients with PF-ILD on antifibrotic therapy and to investigate its potential impact on treatment effectiveness and tolerability. Methods:This monocentric, retrospective study enrolled a total of 64 patients with either IPF or other progressive pulmonary fibrosis (PPF) treated with antifibrotic treatment at our center between June 2022 and November 2023. The frailty status of patients with ILD was measured using the Clinical Frailty Scale (CFS). Baseline data were used to classify patients into two groups according to CFS: (1) non-frail patients with CFS < 5 or (2) frail patients with CFS ≥ 5. Results:The mean CFS score in the overall population was 5.02 ± 1.62. Thirty-seven (58%) were frail while 27 (42%) met criteria for no-frailty. Frail patients, compared to non-frail, were older (74.4 ± 4.66 vs. 70.6 ± 4.78, p = 0.004), and had significantly lower FVC (L) (2.31 ± 0.75 L vs. 2.78 ± 0.75 L, p = 0.03), percent predicted DLco (%DLco) (43.47 ± 13.52 vs. 54.6 ± 11.48, p = 0.003) and lower 6-min walk distance (6MWD) (305 ± 159 vs. 410 ± 94, p = 0.006) compared to no-frail patients at baseline. Frail patients had higher ILD-GAP index (4.62 ± 1.41 vs. 3.88 ± 1.18, p = 0.037) compared to non-frail patients. Interestingly, functional trajectories decline was not significantly different between frail and no-frail patients. Regarding safety profile, medication dose reduction due to adverse events was greater in frail patients (51.3% vs. 26%, p = 0.04) while not significant differences emerged in side effects. Conclusion:Frailty has been associated with poorer lung function and greater physical impairment in patients with fibrotic ILDs under antifibrotic treatment. Frail patients also more frequently require medication dose reduction due to adverse effects.

Introduction: Esophagogastric junction outflow obstruction (EGJOO) is a heterogeneous manometric pattern requiring symptoms and supportive evidence to establish clinical relevance. Timed barium esophagography (TBE) provides functional radiologic assessment of esophageal emptying through timed imaging, quantitative barium column measurements, and morphologic evaluation. Methods: This single-center retrospective study included 42 patients referred for TBE for suspected EGJOO between June 2024 and December 2025. TBE was performed upright after ingestion of low-density barium suspension. Positivity required a continuous residual esophageal barium column with craniocaudal height ≥ 2 mm at 1′ after bolus ingestion. Minimal mucosal coating, non-columnar traces, and contrast confined to a hiatal hernia were recorded qualitatively but not considered positive. Quantitative measurements, clearance patterns, morphology, interobserver reliability, and exploratory concordance with Chicago Classification v4.0-adjudicated categories were assessed. Results: TBE was positive in 12/42 patients (28.6%). Mean age was 58.0 ± 13.9 years; 26/42 patients were female. In positive studies, mean column height and width were 122.9 ± 65.4 mm and 31.1 ± 17.8 mm at 1 min, and 89.0 ± 54.6 mm and 28.2 ± 18.2 mm at 2 min. Persistent 5 min retention occurred in two patients. Interobserver reliability was excellent (ICC 0.90). Morphologic abnormalities were frequent in positive examinations, supporting overall radiologic phenotype-based interpretation. In the EGJOO-focused subset, exploratory concordance metrics were 41.7%, 100%, 100%, and 46.2% for sensitivity-like, specificity-like, positive predictive, and negative predictive concordance, respectively. Conclusions: In this small exploratory cohort, standardized TBE provided functional and morphologic information on esophageal bolus transit. Positive TBE findings showed exploratory concordance with clinically relevant EGJOO, whereas a negative study did not exclude it. These findings require validation in larger prospective cohorts.

To evaluate the diagnostic reliability and time efficiency of an abbreviated non-contrast magnetic resonance enterography (MRE) protocol for assessing Crohn’s disease activity. This retrospective study included 312 patients who underwent MRE between March 2024 and November 2025. An abbreviated dataset was derived from each full examination by masking sequences not included in the abbreviated protocol, such as all contrast-enhanced acquisitions. Two radiologists independently reviewed the abbreviated and full datasets in separate sessions, fully blinded to clinical information and the alternative dataset. The interpretation of the full MRE dataset served as the reference standard. Outcomes included agreement (Cohen’s kappa), sensitivity and specificity for active disease, image quality ratings (4-point scale), and estimated acquisition time. Agreement for overall disease activity was substantial (κ = 0.83), with sensitivity of 92.3

The liver is the most common site of metastases from colorectal cancer (CRC), affecting up to half of patients throughout their disease course. Although contrast-enhanced computed tomography (CECT) is routinely used for staging and treatment monitoring, RECIST criteria poorly reflect biological heterogeneity and antiangiogenic therapy effects. Integrating radiological and radiomic biomarkers may enhance response evaluation and personalized treatment. This study aimed to evaluate portal-phase ring enhancement as a potential imaging biomarker of disease progression and prognosis in patients with colorectal liver metastases (CRLM) treated with bevacizumab-based chemotherapy and to explore its correlation with CT-derived radiomic features. Eighty consecutive patients with histologically confirmed CRLM treated with standard chemotherapy plus bevacizumab were retrospectively analyzed. Baseline and 3-month CECT scans were evaluated for the presence and evolution of portal-phase ring enhancement. Radiomic features were extracted and correlated with morphologic patterns, while survival outcomes were assessed using Kaplan-Meier and logistic regression analyses. Baseline portal-phase ring enhancement was observed in 32.5% of patients and was significantly associated with inferior overall survival (p = 0.001), a finding confirmed on follow-up imaging (p = 0.016). Among radiomic features, sphericity showed the strongest correlation with ring enhancement (p = 0.003), yielding a modestly discriminative model. Portal-phase ring enhancement represents a reproducible imaging biomarker of poor prognosis in bevacizumab-treated CRLM. Its correlation with distinct radiomic signatures reinforces its biological plausibility as a marker of tumor aggressiveness. Integrating this feature with shape-based metrics into early imaging evaluation may refine risk stratification and personalized management.

High-frequency ultrasound (HFUS) allows non-invasive visualization of skin microarchitecture, offering quantitative assessment of dermal composition and vascularity, but its systematic use to track temporal changes in postoperative wound healing is still limited. This study aimed to describe and validate HFUS morphologic and vascular features corresponding to the biological phases of cutaneous surgical wound healing. A total of 730 patients who underwent surgical excision of skin lesions were evaluated at different postoperative intervals using high- and ultra-high-frequency ultrasound (48-70 MHz). Dermal thickness, echogenicity and vascularity were analysed with B-mode and colour Doppler imaging through quantitative and semi-quantitative methods and reproducibility was assessed using intraclass correlation coefficients (ICC) and Cohen's κ statistics. Cross-sectional analysis demonstrated a progressive structural and vascular evolution consistent with canonical healing phases: dermal thickness decreased from 2.45 ± 0.38 mm at T0 to 1.58 ± 0.21 mm at T4, while echogenicity increased from 0.5 [0-1] to 2.5 [2, 3], reflecting collagen compaction and maturation. Vascularity peaked at T2 (2.2 ± 0.5) and declined to 0.8 ± 0.3 by T4, paralleling the regression of angiogenesis. Measurement reproducibility was excellent (ICC = 0.91; κ = 0.82). HFUS morphologic patterns closely mirrored the biological sequence from inflammatory oedema through granulation and fibroplasia to collagen remodelling, providing real-time in vivo correlates of tissue repair. These findings support HFUS as a reliable, quantitative and reproducible tool for monitoring postoperative wound healing and as a potential imaging biomarker framework for early detection of abnormal scar evolution.

e15553 Background: Antiangiogenic agents are widely used in mCRC. The ABACO trial recently showed that high angiogenesis genes expression in tumor samples, correlates with response to Cabozantinib. However, genomic predictors are poorly reproducible in clinical practice. The RADIANCE trial evaluates whether radiological biomarkers could predict antiangiogenics efficacy. Methods: We conducted a retrospective, observational study of mCRC patients (pts), progressed after ≥2 systemic regimens, treated with Cabozantinib (Cabo), Trifluridine–Tipiracil plus Bevacizumab (TT+B), Regorafenib (Rego), or Trifluridine–Tipiracil (TT) alone. Pts required ≥ 1 measurable lesion per RECIST 1.1 on baseline CT-scan. Radiological features assessed included intratumoral vascularization (ITV) (ΔHU portal–unenhanced > or ≤ 20), calcification (Calc) (Humax > or ≤ 150), and density (Dens) (HUbasal > or ≤ 50). Results: 63 pts with heavily pretreated mCRC were included. 19 pts received respectively Cabo and TT+B, 15 TT and 10 Rego. Liver and peritoneal metastases were the main target lesions studied across cohorts. ITV was significantly associated with improved outcomes in pts treated with antiangiogenics. In the Cabo cohort, pts with metastases showing higher ITV experienced a significantly longer median PFS (4.14 vs 2.03 months (mo); HR 0.30, p = 0.037) and a higher DCR (77.8% vs 25%). In the TT+B and Rego cohorts, a favorable trend in PFS (8.05 vs 3.63 mo and 5.11 vs ~1 mo respectively) was observed in the same subgroups. In TT+B treated pts, greater ITV was also associated with a significantly higher DCR (90.9% vs 25%, p = 0.006). Among all pts treated with antiangiogenics (n = 45), higher ITV correlated with statistically significant longer PFS (5.22 vs 2.33 mo; HR 0.45, p = 0.012) and higher DCR (75% vs 19%, p = 0.00028). No association was observed in pts treated with chemotherapy (Cht) alone. Absence of baseline Calc (HUmax ≤150) showed a consistent, though non-significant, trend toward improved PFS and DCR in antiangiogenic-treated pts, in particular in TT+B and Cabo cohorts, while no benefit was observed with Cht alone. No association, instead, between baseline metastases Dens and clinical outcomes was observed. An integrated model combining ITV and Calc stratified pts into 4 prognostic groups, with progressively decreasing PFS and DCR. Pts with high ITV and non-calcified metastases achieved the best outcomes (mPFS 7.52 mo; DCR 80%). A radiological predictive score based on ITV and Calc was, therefore, developed (high/low ITV: 2/0, Calc yes/no: 0/1). A composite score ≥2 identified patients with a higher likelihood of benefit from antiangiogenics. Conclusions: Our work points out that ITV and absence of Calc, at baseline CT-scan, may be associated with benefit from antiangiogenics. Findings are preliminary and need validation in larger prospective cohorts.

Pancreatic cystic lesions represent an increasingly common clinical finding due to the widespread use of cross sectional imaging, encompassing a heterogeneous spectrum ranging from benign entities to premalignant and malignant neoplasms. Their rising incidence poses significant challenges in diagnosis, risk stratification, and management, requiring a careful balance between avoiding unnecessary interventions and preventing malignant progression. This position paper, developed by an intersocietal multidisciplinary panel of experts in pancreatic disease, aims to provide a comprehensive and evidence-based overview of these lesions. Current classifications, imaging features, and differential diagnosis are discussed, with particular emphasis on the role of magnetic resonance imaging. Key entities including serous cystic neoplasms, mucinous cystic neoplasms, intraductal papillary mucinous neoplasms, and rarer cystic tumors are analyzed in terms of biological behavior and radiological characteristics. Furthermore, the document reviews available international guidelines and proposes a pragmatic approach to clinical management, including indications for surveillance, endoscopic evaluation, and surgical treatment. Special attention is given to risk stratification based on high-risk stigmata and worrisome features, as well as to individualized patient management. In conclusion, this paper provides a shared expert perspective to support standardized and personalized management of pancreatic cystic lesions in clinical practice.

Background: The fibrovascular stalk is characteristic of papillary bladder tumors and may be visualized on MRI as the inchworm sign. Contrast-enhanced ultrasound (CEUS) may depict the same structure dynamically by demonstrating pedicle perfusion before tumor enhancement. We hypothesized that CEUS would be more sensitive than the MRI inchworm sign for detecting a histologically confirmed fibrovascular stalk and that stalk presence would be associated with non-muscle-invasive bladder cancer without completely excluding detrusor muscle invasion. Methods: This retrospective study assessed 80 consecutive patients with one focal bladder lesion; 69 patients with technically adequate imaging and an adequate TURBT reference standard were included in the final paired analysis. Dedicated retrospective rereads of anonymized stored CEUS cine loops and complete mpMRI datasets were independently performed by two experienced readers per modality, who were blinded to the other imaging modality, histopathology, and each other’s assessments. A blinded pathologist assessed fibrovascular stalk presence and detrusor muscle invasion. Paired performance was evaluated using exact McNemar testing. Results: Histopathology identified a stalk in 48 lesions. CEUS detected 46 of 48 stalks, and MRI detected 36, corresponding to sensitivities of 95.8% and 75.0%, specificities of 90.5% and 81.0%, and accuracies of 94.2% and 76.8%, respectively. Interobserver agreement was 94.2% for both signs, with almost-perfect agreement for the CEUS vascular stalk sign (κ = 0.86) and the MRI inchworm sign (κ = 0.88). For MIBC detection, overall CEUS impression and VI-RADS 4–5 showed sensitivities of 66.7% and 87.5% (paired p = 0.063), specificities of 88.9% and 68.9% (paired p = 0.004), and accuracies of 81.2% and 75.4% (paired p = 0.424), respectively. Conclusions: However, the two signs are not operationally equivalent because the MRI inchworm sign additionally requires preservation of the underlying muscular layer, a criterion that may have contributed to its lower observed sensitivity. The stalk strongly favored non-muscle-invasive disease but did not exclude detrusor invasion. CEUS provides complementary perfusion information, whereas MRI-based VI-RADS remains central to local staging.

Introduction: Small hyperechoic renal masses are frequently detected incidentally on conventional ultrasound and are often presumed to represent benign lesions, particularly angiomyolipomas. However, malignant renal tumors, including renal cell carcinoma, may also appear hyperechoic when small, creating a diagnostic challenge at first-line imaging. This study aimed to evaluate the feasibility and exploratory diagnostic performance of B-mode ultrasound radiomics for differentiating benign and malignant small hyperechoic renal masses. Methods: This retrospective single-center study included adult patients with incidentally detected small hyperechoic renal masses measuring ≤3 cm and examined between July 2022 and April 2025. All lesions underwent standardized B-mode ultrasound assessment and multidisciplinary review. Final diagnosis was established by histopathology when available or by longitudinal ultrasound follow-up stability for lesions considered benign. Lesions were manually segmented on representative B-mode DICOM images, and original radiomic features were extracted using PyRadiomics version 3.0 according to standardized definitions compatible with the Image Biomarker Standardisation Initiative framework. A total of 114 original radiomic features were extracted from each lesion. The primary comparison was benign versus malignant lesions. Diagnostic performance was assessed using feature-level receiver operating characteristic analysis. Results: Forty-two lesions were included in the final radiomic cohort, including 26 malignant renal cell carcinomas and 16 benign angiomyolipomas. Malignant lesions included papillary renal cell carcinoma, chromophobe renal cell carcinoma, and clear-cell renal cell carcinoma. All malignant lesions were histologically confirmed. Among benign lesions, 14 angiomyolipomas were classified based on longitudinal ultrasound stability, whereas 2 were confirmed by ultrasound-guided percutaneous biopsy after mild dimensional increase during imaging surveillance. Among the extracted radiomic features, firstorder_Variance and firstorder_MeanAbsoluteDeviation showed the highest exploratory discriminatory performance, each achieving an area under the receiver operating characteristic curve of 0.837. Both features are first-order measures of gray-level dispersion within the segmented lesion. Higher values were observed in malignant lesions, suggesting greater intralesional grayscale heterogeneity compared with benign angiomyolipomas. Conclusions: B-mode ultrasound radiomics is feasible for the quantitative assessment of small hyperechoic renal masses and may provide complementary information for differentiating benign angiomyolipomas from malignant renal cell carcinomas. firstorder_Variance emerged as a representative candidate imaging biomarker of grayscale dispersion, with firstorder_MeanAbsoluteDeviation showing concordant performance as a related dispersion measure. These findings should be considered preliminary and hypothesis-generating and require validation in larger multicenter cohorts before clinical implementation.