Lixiu Cao ^1* Haoxuan Yang ^2* Huijing Wu ^1,3* Hongbo Zhong ^1,3* Haifeng Cai ^1,3* Yixing Yu ^4* Lei Zhu ^5* Yongliang Liu ^6* Jingwu Li ^1,3*

• ¹ Tangshan People's Hospital, Tangshan, Hebei Province, China
• ² Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
• ³ Other, Tangshan, China
• ⁴ Department of Radiology, First Affiliated Hospital, Soochow University Medical College, Suzhou, Jiangsu Province, China
• ⁵ National Clinical Research Center for Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, Tianjin Municipality, China
• ⁶ Department of Neurosurgery, Tangshan People’s Hospital, Tangshan, China

1 Objective There is a paucity of research using different machine learning algorithms for distinguishing between adrenal metastases and benign tumors in lung cancer patients with adrenal indeterminate nodules based on plain and biphasic-enhanced CT radiomics. 2 Materials and Methods This study retrospectively enrolled 292 lung cancer patients with adrenal indeterminate nodules (training dataset, 205 (benign, 96; metastases, 109); testing dataset, 87(benign, 42; metastases, 45)). Radiomics features were extracted from the plain, arterial, and portal CT images, respectively. The independent risk radiomics features selected by least absolute shrinkage and selection operator (LASSO) and multivariate logistic regression (LR) were used to construct the single-phase and combined-phase radiomics models, respectively, by support vector machine (SVM), decision tree (DT), random forest (RF), and LR. The independent clinical-pathological and radiological risk factors for predicting adrenal metastases selected by using univariate and multivariate LR were used to develop the traditional model. The optimal model was selected by ROC curve, and the models’ clinical values were estimated by decision curve analysis (DCA). 3 Results In the testing dataset, all SVM radiomics models showed the best robustness and efficiency, and then RF, LR, and DT models. The combined radiomics model had the best ability in predicting adrenal metastases (AUC=0.938), and then the plain (AUC=0.935), arterial (AUC=0.870), and portal radiomics model (AUC=0.851). Besides, compared to clinical-pathological-radiological model(AUC=0.870), the discriminatory capability of the plain and combined radiomics model were further improved. All radiomics models had good calibration curves and DCA showed the plain and combined radiomics models had more optimal clinical efficacy compared to other models, with the combined radiomics model having the largest net benefit. 4 Conclusions The combined SVM radiomics model can non-invasively and efficiently predict adrenal metastatic nodules in lung cancer patients. In addition, the plain radiomics model with high predictive performance provides a convenient and accurate new method for patients with contraindications in enhanced CT.