Prospective Evaluation of Semiquantitative Strain Ratio and Quantitative 2D Ultrasound Shear Wave Elastography (SWE) in Association with TIRADS Classification for Thyroid Nodule Characterization.

PURPOSE: To evaluate the diagnostic performance of strain ratio elastography (SRE) and shear wave elastography (SWE) alone and in combination with Thyroid Imaging Reporting and Data System (TIRADS) classification parameters to improve differentiation between benign and malignant thyroid nodules. MATERIALS AND METHODS: In this prospective study benign (n = 191) and malignant (n = 52) thyroid nodules were examined with high-resolution ultrasound (US) features using the TIRADS lexicon and SRE semiquantitative and SWE quantitative findings using histology or cytology as the gold standard with a 12-month follow-up. Sensitivity (Se), specificity (Sp) and the area under the ROC curve (AUROC) were used to evaluate the diagnostic performance of each feature and combinations of the methods. RESULTS: TIRADS score showed a sensitivity of 59.6 %, a specificity of 83.8 % with an AUROC of 0.717, a PPV of 50.0 % and an NPV of 88.4 %. SRE yielded the highest performance with a sensitivity of 82.7 %, a specificity of 92.7 % with AUROC of 0.877, a PPV 75.4 % and an NPV of 95.2 %. SWE (kPa) had a sensitivity and specificity of 67.3 % and 82.7 %, respectively, with an AUROC of 0.750, a PPV of 51.5 % and an NPV of 90.3 %. Differences were significant for SRE only but not for SWE. CONCLUSION: Ultrasound elastography may improve thyroid nodule discrimination. In particular, SRE has a better performance than TIRADS classification, while their combination improves sensitivity.

Value of MRI of the hand and the wrist in evaluation of bone age: preliminary results.

PURPOSE: To evaluate bone age determination using MRI of the hand and wrist. MATERIALS AND METHODS: A total of 179 (78 female and 101 males, 11 to 16 years old) subjects of 252 normal volunteers met entrance criteria. A low field open magnet (0.2 Tesla) was used for this study; coronal T1-weighted images with a slice thickness of 1.3mm were acquired. Two blinded radiologists evaluated the studies and the following elements were considered: the appearance of cartilage, vacuolization of cartilage, provisional calcification, progression of ossification, and complete ossification. Correlation between chronologic age and MR bone age was determined by means of simple linear regression analysis. RESULTS: Strong correlation between MR skeletal age and chronological age was observed for both investigators, Pearson correlation R2 = 0.9 for each. CONCLUSION: Determination of bone age with MRI is feasible and shows good interobserver reproducibility. Data from this study may be useful to develop an atlas of skeletal development and bone age.

Multiparametric ultrasound evaluation of parotid gland tumors: B-mode and color Doppler in comparison and in combination with contrast-enhanced ultrasound and elastography. A case report of a misleading diagnosis.

Preoperative characterization of parotid gland tumors using imaging or cytological examination (fine-needle aspiration cytology) has a strong clinical and therapeutic impact, but it is often difficult due to the tumors' histological heterogeneity. The recent introduction of contrast-enhanced ultrasound (CEUS) and elastography, in the context of multiparametric ultrasound evaluation, contributed to improving the preoperative diagnosis of many diseases affecting the liver, breast, and thyroid, as well as other organs. However, limited evidence is available on the use and the diagnostic power of these techniques in parotid gland neoplasms. In this paper, we present a case of a parotid lesion that highlights the importance of a complete workup using multiparametric ultrasound evaluation, including CEUS and elastography, to identify malignant tumors of the parotid gland.

Preoperative Multiparametric Ultrasound and Fine Needle Aspiration Cytology evaluation of parotid gland tumors: which is the best technique?

AIMS: To evaluate the pre-surgical diagnostic value of Multiparametric Ultrasound (MPUS) and Fine Needle Aspiration Cytology (FNAC) in differentiating parotid gland tumors, comparing the results with histology. MATERIALS AND METHODS: The study enrolled 84 patients with parotid gland lesions surgically treated in a single tertiary center and evaluated by MPUS. Each patient underwent FNAC. Histological examination was considered the gold standard. RESULTS: Histology identified 62 benign tumors and 22 malignancies. In the differential diagnosis between malignant and benign lesions, B-mode Ultrasound (US), Color-Doppler US, Contrast-Enhanced US (CEUS), Elastography (USE) and FNAC showed the following values of sensitivity: 82%, 81%, 86%, 77%, 73% respectively; specificity: 97%, 61%, 95%, 71%, 97% respectively; PPV: 90%, 43%, 86%, 50%, 89% respectively; NPV: 93%, 90%, 95%, 88%, 91% respectively; and accuracy: 89%, 71%, 90%, 78%, 84% re-spectively. CONCLUSIONS: CEUS proved to be a valid and accurate method for identifying malignant tumors of parotid gland; the combination of B-mode US with CEUS showed similar diagnostic accuracy, but better sensitivity than CEUS taken alone. USE did not improve the diagnostic performance of the B-mode US, alone or in association with CEUS; however, it revealed the highest diagnostic accuracy in the differentiation between benign lesions. FNAC demonstrated lower values in comparison with CEUS and with USE. Therefore, according to our study, MPUS could be proposed as a valid alternative to FNAC.

Narrative review of multiparametric ultrasound in parotid gland evaluation.

Disorders affecting parotid gland represent a heterogeneous group comprising congenital, inflammatory and neoplastic diseases which show a focal or diffuse pattern of appearance. The differentiation of neoplastic from non-neoplastic conditions of parotid glands is pivotal for the diagnostic imaging. Frequently there is evidence of overlapping between the clinical and the imaging appearance of the various pathologies. The parotid gland is also often object of study with the combination of different techniques [ultrasound-computed tomography-magnetic resonance imaging (US-CT-MRI), ex.]. Compared to other dominant methods of medical imaging, US has several advantages providing images in real-time at lower cost, and without harmful use of ionizing radiation and of contrast enhancement. B-mode US, and the microvascular pattern color Doppler are usually used as first step evaluation of parotid lesions. Elastography and contrast-enhanced US (CEUS) has opened further possible perspectives to improve the differentiation between benign and malignant parotid lesions. The characterization of the parotid tumors plays a crucial role for their treatment planning and for the prediction of possible surgical complications. We present, here an updated review of the most recurrent pathologies of parotid gland focusing on the diagnostic power of multiparametric US including CEUS and ultrasound elastography (USE); limitations, advantages and the main key-points will be presented.

Automated classification of focal breast lesions according to S-detect: validation and role as a clinical and teaching tool.

PURPOSE: To assess the diagnostic performance and the potential as a teaching tool of S-detect in the assessment of focal breast lesions. METHODS: 61 patients (age 21-84 years) with benign breast lesions in follow-up or candidate to pathological sampling or with suspicious lesions candidate to biopsy were enrolled. The study was based on a prospective and on a retrospective phase. In the prospective phase, after completion of baseline US by an experienced breast radiologist and S-detect assessment, 5 operators with different experience and dedication to breast radiology performed elastographic exams. In the retrospective phase, the 5 operators performed a retrospective assessment and categorized lesions with BI-RADS 2013 lexicon. Integration of S-detect to in-training operators evaluations was performed by giving priority to S-detect analysis in case of disagreement. 2 × 2 contingency tables and ROC analysis were used to assess the diagnostic performances; inter-rater agreement was measured with Cohen's k; Bonferroni's test was used to compare performances. A significance threshold of p = 0.05 was adopted. RESULTS: All operators showed sensitivity > 90% and varying specificity (50-75%); S-detect showed sensitivity > 90 and 70.8% specificity, with inter-rater agreement ranging from moderate to good. Lower specificities were improved by the addition of S-detect. The addition of elastography did not lead to any improvement of the diagnostic performance. CONCLUSIONS: S-detect is a feasible tool for the characterization of breast lesions; it has a potential as a teaching tool for the less experienced operators.

Ultrasonography scoring systems can rule out malignancy in cytologically indeterminate thyroid nodules.

PURPOSE: To assess the accuracy and reproducibility of ultrasonography classification systems in characterizing cytologically indeterminate thyroid nodules. METHODS: We retrospectively identified 49 nodules that had been surgically resected owing to features classified as indeterminate according to 2010 Italian Consensus on Thyroid Cytology criteria. Three experienced sonographers independently reviewed original sonographic images of each nodule and classified it using the 2015 American Thyroid Association (ATA) guidelines and the Thyroid Imaging Reporting and Data System (TI-RADS) classification proposed by Korean radiologists; later, images were reviewed jointly to obtain consensus classifications of each nodule. Original cytology slides were similarly reviewed by three experienced cytopathologists, who reclassified the nodule (independently, then jointly) according to revised Italian Consensus on Thyroid Cytology (ICTC-2014) criteria. Consensus ICTC-2014, ATA, and TI-RADS classifications were analyzed against surgical histology reports to estimate each system's sensitivity, specificity, positive and negative predictive values. RESULTS: Of the 49 indeterminate nodules examined, 30 (61.2 %) were histologically benign. Consensus ICTC-2014 classification correctly classified malignant nodules with positive predictive value of 50 % and negative predictive value of 90 %. Sonographic classification of nodules as intermediate to high suspicion by ATA or TI-RADS category 4c displayed positive predictive value of 63 and 71 %, respectively; positive predictive values dropped to 44 and 42 % when lower positivity thresholds were used (ATA low suspicion, TI-RADS category 4a). Negative predictive values for ATA and TI-RADS were 91 and 74 %, respectively, with higher positivity thresholds and 100 % for both with lower thresholds. All systems displayed appreciable inter-observer variability (Krippendorff alphas: ATA 0.36, TIRADS 0.42, ICTC-2014 0.74). CONCLUSIONS: With stringent negativity cut-offs, American Thyroid Association and Thyroid Imaging Reporting and Data System assessment of cytologically indeterminate thyroid nodules allows high-confidence exclusion of malignancy.

Prospective evaluation of acoustic radiation force impulse technology in the differentiation of thyroid nodules: accuracy and interobserver variability assessment.

PURPOSE: The aim of this study is to assess the diagnostic efficacy and interobserver agreement of acoustic radiation force impulse (ARFI) elasticity imaging in differentiating thyroid nodules. METHODS: In our study, 74 consecutive patients (52 females, 22 males; age range 27-77 years, mean: 41 years) with 82 thyroid nodules (60 benign nodules, and 22 malignant) were examined by two radiologists with different experience. Patients underwent either cytology using fine needle aspiration cytology or thyroid surgery. The diagnostic performance of the two operators at ARFI with sensitivity, specificity, positive predictive and negative predictive value, and ROC curves was estimated. Inter-reader variability between the two operators was defined using Cohen's k. RESULTS: According to receiver operating characteristics ROC curves (AUROC = 0.86 for observer 1; 0.81 for observer 2) sensitivity, specificity, PPV and NPV of reader 1 and 2 were respectively: 90, 75, 90.91 and 96.55 %; (cut-off value of shear wave: 2.455 m/s); 90, 72, 90 and 96.90 % (cut-off value shear wave: 2.365 m/s). Concordance between the two operators was good (k = 0.755). CONCLUSIONS: This work is a feasibility study evaluating ARFI imaging. Its results suggest that ARFI imaging is a reproducible method which can be utilized with good diagnostic performance in the thyroid for discriminating benign and malignant nodules using the cut-off value of 2.455 m/s. However, larger studies are needed to validate this method.

CEUS and strain elastography in gastric carcinoma.

Gastric cancer is the fourth most common type of cancer, but diagnosis is often delayed. Esophagogastroduodenoscopy is currently the gold standard for evaluating gastric cancer. Also other imaging modalities, such as computed tomography and magnetic resonance imaging are employed for identifying gastric cancer, but particularly for cancer staging. Ultrasound (US) is a first-line imaging modality used to examine organs in the abdomen, and during these examinations gastric cancer may be incidentally detected. Very few studies in the literature have investigated the role of US in gastric disease. However, more recently, some authors have reported on the use of contrast-enhanced US (CEUS) and US-elastography in gastric disease using both endoscopic and transabdominal approach. In this paper, we present a case of gastric cancer studied by CEUS and transabdominal US-elastography.

Association between Pituitary Langerhans Cell Histiocytosis and Papillary Thyroid Carcinoma.

Here we report a case of panhypopituitarism caused by pituitary Langerhans cell hystocitosis (LCH) in a 22-year-old woman affected by papillary thyroid carcinoma (PTC). Although several cases of the coexistence of PTC and LCH within thyroid tissue have been described in relative literature, in this case, the patient presented a unique suprasellar retrochiasmatic histocytosis localization which, to the best of our knowledge, had never been described before in association with PTC. Even if this aspect is not addressed in the present case report, it is worth noting that about 50% of the patients affected either by LCH or PTC are characterized by activating mutations of the proto-oncogene BRAF. This, along with other clinical studies, may warrant further biomolecular large-scale case study investigations in order to evaluate a possible connection between the 2 conditions and shed light on the etiology of these diseases, which are still largely unknown.