Fine needle aspiration biopsy indications for thyroid nodules: compare a point-based risk stratification system with a pattern-based risk stratification system.

OBJECTIVES: We aim to compare the diagnostic performance to assess thyroid nodules and reliability for recommending fine needle aspiration biopsy (FNAB) between American College of Radiology thyroid image reporting and data system (ACR TI-RADS) and American Thyroid Association (ATA) guidelines. METHODS: In total, this retrospective study included 1001 consecutive thyroid nodules in 918 patients from May 2016 to December 2017. US features of the thyroid nodules, including composition, echogenicity, shape, margins, echogenic foci, and size, were reviewed and were classified according to ACR TI-RADS and ATA guidelines, respectively. The diagnostic performance to assess thyroid nodules and reliability for recommending fine needle aspiration biopsy were compared between ACR TI-RADS and ATA guidelines. RESULTS: Of the 1001 thyroid nodules, 609 (60.8%) were benign and 392 (39.2%) were malignant. The sensitivity, specificity, PPV, NPV, and accuracy were 96.7%, 77.3%, 73.3%, 97.3%, and 84.9%, respectively, for ACR TI-RADS and 99.2%, 16.1%, 43.2%, 97.0%, and 48.7%, respectively, for ATA guidelines. AUC of ACR TI-RADS was significantly greater than ATA guidelines (0.935 (0.918, 0.949) vs 0.884 (0.862, 0.903), p < 0.001). Biopsy yield of malignancy, biopsy rate of malignancy, and unnecessary FNAB rate were 59.5%, 91.3%, and 40.5%, respectively, for ACR TI-RDS and 38.5%, 97.4%, and 61.5%, respectively, for ATA guidelines. CONCLUSIONS: ACR TI-RADS was more accurate than ATA guidelines for differentiating malignant thyroid nodules from benign nodules and more reliable than ATA guidelines for recommending thyroid nodules for FNAB. KEY POINTS: • Malignant risk of thyroid nodules can be stratified by ultrasound. • American College of Radiology guidelines were more accurate for differentiating malignant thyroid nodules from benign nodules. • American College of Radiology guidelines were more reliable for recommending thyroid nodules for biopsy.

Computer-Aided Diagnosis of Solid Breast Lesions With Ultrasound: Factors Associated With False-negative and False-positive Results.

OBJECTIVES: To investigate factors that may lead to false-positive or false-negative results in a computer-aided diagnostic system (S-Detect; Samsung Medison Co, Ltd, Seoul, Korea) for ultrasound (US) examinations of solid breast lesions. METHODS: This prospective study was approved by the Institutional Review Board of Sun Yat-sen Memorial Hospital. All patients signed and provided written informed consent before biopsy or surgery. From September 2017 to May 2018, 269 consecutive women with 338 solid breast lesions were included. All lesions were examined with US and S-Detect before biopsy or surgical excision. The final US assessments made by radiologists and S-Detect were matched to the pathologic results. Patient and lesion factors in the "true" and "false" S-Detect groups were compared, and multivariate logistic regression analyses were used to identify the factors associated with false S-Detect results. RESULTS: The mean age of the patients ± SD was 42.6 ± 12.9 years (range, 18-77 years). Of the 338 lesions, 209 (61.8%) were benign, and 129 (38.2%) were malignant. Larger lesions, the presence of lesion calcifications detected by B-mode US, and grades of 2 and 3 according to Adler et al (Ultrasound Med Biol 1990; 16:553-559) were significantly associated with false-positive S-Detect results (odds ratio [OR], 1.071; P = .006; OR, 5.851; P = .001; OR, 1.726; P = .009, respectively). Smaller lesions and the absence of calcifications detected by B-mode US in malignant solid breast lesions were significantly associated with false-negative S-Detect results (OR, 1.141; P = .015; OR, 7.434; P = .016). CONCLUSIONS: Larger benign lesions, the presence of lesion calcifications, and high degrees of vascularity are likely to show false-positive S-Detect results. Smaller malignant lesions and the absence of calcifications are likely to show false-negative S-Detect results.

Radiofrequency Ablation versus Hepatic Resection for Small Hepatocellular Carcinoma: Systematic Review of Randomized Controlled Trials with Meta-Analysis and Trial Sequential Analysis.

Purpose To compare the benefits and harms of radiofrequency ablation (RFA) and hepatic resection (HR) and to test the consistency of currently available evidence. Materials and Methods PubMed, Embase, and the Cochrane Library were systematically searched for randomized controlled trials (RCTs) that compared the effects of HR and RFA for Barcelona Clinic Liver Cancer very early or early stage hepatocellular carcinoma (HCC). The primary outcome was overall survival, and secondary outcomes were recurrence rate, complication rate, and hospitalization duration. A random- or fixed-effects model according to the level of heterogeneity was applied. The meta-analysis was performed by using software, and trial sequential analysis (TSA) was performed. Results Five trials examining 742 patients were included in this study (sizes of trials: 161, 230, 168, 120, and 63 patients). The meta-analysis showed that RFA and HR had similar overall survival at 1 year (relative risk [RR], 1.39; 95% confidence interval [CI]: 0.36, 5.33; P = .63) and 3 years (RR, 1.40; 95% CI: 0.75, 2.62; P = .29), whereas RFA resulted in decreased overall survival compared with HR at 5 years (RR: 1.91; 95% CI: 1.32, 2.79; P = .001). The TSA showed that more trials were needed to control random errors. The incidence of overall recurrence was markedly higher and the hospitalization duration was significantly shorter in the RFA group than in the HR group, which was confirmed by TSA. Complications may have been less frequent in the RFA group, but TSA showed that additional trials were necessary to confirm this conclusion. Conclusion The indication for RFA as a primary treatment for patients who are eligible for HR with early stage HCC is unclear, and additional well-designed RCTs are needed. © RSNA, 2017 Online supplemental material is available for this article.

Gail model and fifth edition of ultrasound BI-RADS help predict axillary lymph node metastasis in breast cancer-A multicenter prospective study.

RATIONALE AND OBJECTIVES: We aim to assess the performance of the Gail model and the fifth edition of ultrasound BI-RADS (Breast Imaging Reporting and Data System) in breast cancer for predicting axillary lymph node metastasis (ALNM). MATERIALS AND METHODS: We prospectively studied 958 female patients with breast cancer between 2018 and 2019 from 35 hospitals in China. Based on B-mode, color Doppler, and elastography, radiologists classified the degree of suspicion based on the fifth edition of BI-RADS. Individual breast cancer risk was assessed with the Gail model. The association between the US BI-RADS category and the Gail model in terms of ALNM was analyzed. RESULTS: We found that US BI-RADS category was significantly and independently associated with ALNM (P < 0.001). The sensitivity, specificity, and accuracy of BI-RADS category 5 for predicting ALNM were 63.6%, 71.6%, and 68.6%, respectively. Combining the Gail model with the BI-RADS category showed a significantly higher sensitivity than using the BI-RADS category alone (67.8% vs. 63.6%, P < 0.001). The diagnostic accuracy of the BI-RADS category combined with the Gail model was better than that of the Gail model alone (area under the curve: 0.71 vs. 0.50, P < 0.001). CONCLUSION: Based on the conventional ultrasound and elastography, the fifth edition of ultrasound BI-RADS category could be used to predict the ALNM of breast cancer. ALNM was likely to occur in patients with BI-RADS category 5. The Gail model could improve the diagnostic sensitivity of the US BI-RADS category for predicting ALNM in breast cancer.

ACR TI-RADS classification combined with number of nodules, halo features optimizes diagnosis and prediction of follicular thyroid cancer.

OBJECTIVES: To investigate the application value of The American College of Radiology (ACR) Thyroid Imaging Reporting and Data System (TI-RADS) category combined with other ultrasound features of nodules in distinguishing follicular thyroid carcinoma (FTC) from thyroid follicular adenoma (FTA). METHODS: We collected and retrospectively analyzed clinical and ultrasound data for 118 and 459 patients with FTCs and FTAs, respectively, at our hospital. Next, we used ACR TI-RADS classification combined with other ultrasound features of nodules to distinguish FTC from FTA. Multivariate Logistic regression was used to screen independent risk factors for FTC, which were subsequently used to construct a nomogram for predicting FTC. RESULTS: ACR TI-RADS categories 4 and 5, unilateral multiple nodules, and halo thickness≥2 mm were independent risk factors for FTC. ACR TI-RADS category combined with number of nodules, halo features of the nodule was a significantly better prediction model for FTC diagnosis (AUC = 0.869) than that of ACR TI-RADS classification alone (AUC = 0.756). CONCLUTIONS: Clinicians need to pay attention to the halo of nodules when distinguishing FTA from FTC. Notably, ACR TI-RADS combined with other nodule ultrasound features has superior predictive performance in diagnosis of FTC compared to ACR TI-RADS classification alone, thus can provide an important reference value for preoperative diagnosis of FTC.

Gail Model Improves the Diagnostic Performance of the Fifth Edition of Ultrasound BI-RADS for Predicting Breast Cancer: A Multicenter Prospective Study.

RATIONALE AND OBJECTIVES: The sonographic appearance of benign and malignant breast nodules overlaps to some extent, and we aimed to assess the performance of the Gail model as an adjunctive tool to ultrasound (US) Breast Imaging Reporting and Data System (BI-RADS) for predicting the malignancy of nodules. MATERIALS AND METHODS: From 2018 to 2019, 2607 patients were prospectively enrolled by 35 health care facilities. An individual breast cancer risk was assessed by the Gail model. Based on B-mode US, color Doppler, and elastography, all nodules were evaluated according to the fifth edition of BI-RADS, and these nodules were all confirmed later by pathology. RESULTS: We demonstrated that the Gail model, age, tumor size, tumor shape, growth orientation, margin, contour, acoustic shadowing, microcalcification, presence of duct ectasia, presence of architectural distortion, color Doppler flow, BI-RADS, and elastography score were significantly related to breast cancer (all p < 0.001). The sensitivity, specificity, positive predictive value, negative predictive value, accuracy, and area under the curve (AUC) for combining the Gail model with the BI-RADS category were 95.6%, 91.3%, 85.0%, 97.6%, 92.8%, and 0.98, respectively. Combining the Gail model with the BI-RADS showed better diagnostic efficiency than the BI-RADS and Gail model alone (AUC 0.98 vs 0.80, p < 0.001; AUC 0.98 vs 0.55, p < 0.001) and demonstrated a higher specificity than the BI-RADS (91.3% vs 59.4%, p < 0.001). CONCLUSION: The Gail model could be used to differentiate malignant and benign breast lesions. Combined with the BI-RADS category, the Gail model was adjunctive to US for predicting breast lesions for malignancy. For the diagnosis of malignancy, more attention should be paid to high-risk patients with breast lesions.

The Utility of the Fifth Edition of the BI-RADS Ultrasound Lexicon in Category 4 Breast Lesions: A Prospective Multicenter Study in China.

RATIONALE AND OBJECTIVES: The objective of this study was to evaluate the utility of the fifth edition of the Breast Imaging-Reporting and Data System (BI-RADS) in clinical breast radiology by using prospective multicenter real-time analyses of ultrasound (US) images. MATERIALS AND METHODS: We prospectively studied 2049 female patients (age range, 19-86 years; mean age 46.88 years) with BI-RADS category 4 breast masses in 32 tertiary hospitals. All the patients underwent B-mode, color Doppler US, and US elastography examination. US features of the mass and associated features were described and categorized according to the fifth edition of the BI-RADS US lexicon. The pathological results were used as the reference standard. The positive predictive values (PPVs) of subcategories 4a-4c were calculated. RESULTS: A total of 2094 masses were obtained, including 1124 benign masses (54.9%) and 925 malignant masses (45.1%). For BI-RADS US features of mass shape, orientation, margin, posterior features, calcifications, architectural distortion, edema, skin changes, vascularity, and elasticity assessment were significantly different for benign and malignant masses (p< 0.05). Typical signs of malignancy were irregular shape (PPV, 57.2%), spiculated margin (PPV, 83.7%), nonparallel orientation (PPV, 63.9%), and combined pattern of posterior features (PPV, 60.6%). For the changed or newly added US features, the PPVs for intraductal calcifications were 80%, 56.4% for internal vascularity, and 80% for a hard pattern on elastography. The associated features such as architectural distortion (PPV, 89.3%), edema (PPV, 69.2%), and skin changes (PPV, 76.2%) displayed high predictive value for malignancy. The rate of malignant was 7.4% (72/975) in category 4a, 61.4% (283/461) in category 4b, and 93.0% (570/613) in category 4c. The PPV for category 4b was higher than the likelihood ranges specified in BI-RADS and the PPVs for categories 4a and 4c were within the acceptable performance ranges specified in the fifth edition of BI-RADS in our study. CONCLUSION: Not only the US features of the breast mass, but also associated features, including vascularity and elasticity assessment, have become an indispensable part of the fifth edition of BI-RADS US lexicon to distinguish benign and malignant breast lesions. The subdivision of category 4 lesions into categories 4a, 4b, and 4c for US findings is helpful for further assessment of the likelihood of malignancy of breast lesions.

Risk-predicted dual nomograms consisting of clinical and ultrasound factors for downgrading BI-RADS category 4a breast lesions - A multiple centre study.

Purpose: To develop and to validate a risk-predicted nomogram for downgrading Breast Imaging Reporting and Data System (BI-RADS) category 4a breast lesions. Patients and Methods: We enrolled 680 patients with breast lesions that were diagnosed as BI-RADS category 4a by conventional ultrasound from December 2018 to June 2019. All 4a lesions were randomly divided into development and validation groups at the ratio of 3:1. In the development group consisting of 499 cases, the multiple clinical and ultrasound predicted factors were extracted, and dual-predicted nomograms were constructed by multivariable logistic regression analysis, named clinical nomogram and ultrasound nomogram, respectively. Patients were twice classified as either "high risk" or "low risk" in the two nomograms. The performance of these dual nomograms was assessed by an independent validation group of 181 cases. Receiver Operating Characteristic (ROC) curve and diagnostic value were calculated to evaluate the applicability of the new model. Results: After multiple logistic regression analysis, the clinical nomogram included 2 predictors: age and the first-degree family members with breast cancer. The area under the curve (AUC) value for the clinical nomogram was 0.661 and 0.712 for the development and validation groups, respectively. The ultrasound nomogram included 3 independent predictors (margins, calcification and strain ratio), and the AUC value in this nomogram was 0.782 and 0.747 in the development and validation groups, respectively. In the development group of 499 patients, approximately 50.90% (254/499) of patients were twice classified "low risk", with a malignancy rate of 1.18%. In the validation group of 181 patients, approximately 47.51% (86/181) of patients had been twice classified as "low risk", with a malignancy rate of 1.16%. Conclusions: A dual-predicted nomogram incorporating clinical factors and imaging characteristics is an applicable model for downgrading the low-risk lesions in BI-RADS category 4a and shows good stability and accuracy, which is useful for decreasing the rate of invasive examinations and surgery.

Variability in the interpretation of grey-scale ultrasound features in assessing thyroid nodules: A systematic review and meta-analysis.

PURPOSE: To investigate the interobserver agreement of different thyroid imaging report and data system (TI-RADS) and ultrasound (US) features. METHODS: Two researchers independently searched PubMed, Embase and the Web of Science for relevant studies published between October 1972 and December 2018. Studies investigating interobserver agreement between different radiologists were included. The Guidelines for Reporting Reliability and Agreement Studies (GRRAS) and the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) score tools were applied to assess the quality of the studies. The data for the inter-agreements of TI-RADS categories and ultrasound features were extracted, and combined with STATA 12.0 (StataCorp, College Station, TX) was used. RESULTS: Seven studies including 927 patients were eligible for this meta-analysis. There was a moderate variability in the TI-RADS categories among radiologists (0.54; 95% CI: 0.49-0.58). Regarding the US features, the reliability of composition (0.61; 95% CI: 0.55-0.66) and calcification (0.71; 95% CI: 0.65-0.77) was good, the reliability of echogenicity (0.58; 95% CI: 0.51-0.64), shape (0.53; 95% CI: 0.45-0.62), margin (0.40; 95% CI: 0.32-0.48) and echogenic foci (0.43; 95% CI: 0.32-0.54) was moderate. Subgroup analyses showed that experience/training, the number of observers and the number of patients were the main factors influencing the variability. CONCLUSIONS: The interobserver agreement for the TI-RADS categories was moderate. There remains potential for improvement, especially in terms of the echogenicity, shape, margin and echogenic foci, the precision of the description and the targeted training needed.

Can Combined Screening of Ultrasound and Elastography Improve Breast Cancer Identification Compared with MRI in Women with Dense Breasts-a Multicenter Prospective Study.

Objectives: To assess the performance of elastography (ES) and ultrasound (US) in predicting the malignancy of breast lesions and to compare their combined diagnostic value with that of magnetic resonance imaging (MRI). Materials and Methods: The study prospectively enrolled 242 female patients with dense breasts treated in 35 heath care facilities in China between November 2018 and October 2019. Based on conventional US and elastography, radiologists classified the degree of suspicion of breast lesions according to the US Breast Imaging Reporting and Data System (BI-RADS) criteria. The diagnostic value was compared between US BI-RADS and MRI BI-RADS, with pathological results used as the reference standard. Results: The results demonstrated that irregular tumor shape, a nonparallel growth orientation, indistinct margins, angular contours, microcalcifications, color Doppler flow and ES score on US imaging were significantly related to breast cancer in dense breasts (P=0.001; P=0.001; P=0.008; P<0.001; P=0.019; P=0.008; P=0.002, respectively). The sensitivity, specificity, PPV, NPV, accuracy and AUC of US BI-RADS category were 94.7%, 90.7%, 95.8%, 88.0%, 93.4% and 0.93 (95%CI, 0.88-0.97), respectively, while those of MRI BI-RADS category were 98.2%, 57.5%, 84.3%, 83.3%, 86.0% and 0.78 (95%CI, 0.71-0.85), respectively. MRI BI-RADS showed a significantly higher sensitivity than US BI-RADS (98.2% vs 94.7%, P=0.043), whereas US BI-RADS showed significantly higher specificity (90.7% vs 57.5%, P<0.001). US BI-RADS showed better diagnostic efficiency in differentiating nodules in dense breasts than MRI BI-RADS (AUC 0.93 vs 0.78, P<0.001). Conclusion: By combining the use of ES and conventional US, US BI-RADS had better diagnostic efficiency in differentiating nodules in dense breasts than MRI. For the diagnosis of malignant tumors in patients with dense breasts, MRI and US BI-RADS can be used as supplemental diagnostic tools to detect lesions, with US BI-RADS considered the preferred adjunctive resource.

Acidic pH-Activated Gas-Generating Nanoparticles with Pullulan Decorating for Hepatoma-Targeted Ultrasound Imaging.

Contrast-enhanced ultrasound (US) is a widely used imaging modality for hepatocellular carcinoma diagnosis. Mostly, US imaging is confined to the intravascular process because of the limitation of the microbubble contrast agent currently utilized. Targeted contrast agents that incline to accumulate in tumor tissue or tumor cells and enhance the US signal may advance the sensitivity of ultrasonography and exploit the dimension of US imaging of tumor at the molecular level. In this study, we developed CaCO3/pul-PCB (CPP) hybrid nanoparticles with hepatoma-targeting pullulan decorating on the surface through a mineralization route using the pullulan- graft-poly(carboxybetaine methacrylate) (pul-PCB) copolymer as a modifier. This particle was stable in blood physiological pH and generated echogenic CO2 bubbles under tumoral acidic conditions, which enabled the US signal enhancement. Upon intravenous injection, CPP hybrid nanoparticles accumulated efficiently in tumor tissue and exhibited sixfold contrast enhancement in 35 min at the tumor site in the hepatoma-bearing mice model. By contrast, there was barely any signal change in normal liver tissue. Therefore, the presented CPP hybrid nanoparticle is a promising contrast agent for effective US imaging of hepatoma.

[Factors affecting the performance of ultrasonic elastography in breast tumors and its solutions].

Ultrasonic elastography (UE) is a new technique used in diagnosis of breast tumors. Approaches to determine the potential influential factors and to increase the diagnostic accuracy of UE include: understanding the principles of UE and mastering the correct examination methods; further research on the relevant pathologic changes of breast tumors under UE; establishment of the Logistic model of malignant breast tumors based on the ultrasound characteristics. Biopsy remains an option for the atypical lesions.

What Help Could Ultrasound Elastography Give to the Diagnosis of Breast Papillary Lesions?

On the basis of results of our previous studies and the findings of other scholars, the most common histologic type of false-positive diagnosis with strain elastography (SE) was papilloma. The objectives of our study were to evaluate whether SE could contribute to conventional ultrasound differentiation between benign and malignant papillary lesions and between papillary lesions and other common benign breast lesions. Data on 89 papillary lesions at our hospital, including 74 benign and 15 malignant papillary lesions, were included in our study. In addition, 198 non-papillary benign tumors were selected as the control group, including 126 fibroadenomas and 72 cases of fibrocystic mastopathy. All patients gave written informed consent. All patients with breast lesions underwent conventional ultrasound and SE examination. Breast Imaging Recording and Data System (BI-RADS) category and SE score were compared with respect to sensitivity, specificity and accuracy in differentiating between benign and malignant papillary lesions. We then explored the possibility of using BI-RADS combined with SE to differentiate papillary lesions from non-papillary benign tumors. For differentiating between benign and malignant papillary lesions, the area under the receiver operating characteristic curve (AUC) of BI-RADS was 0.568, whereas the AUC values of SE score, strain ratio and BI-RADS combined with SE were 0.517, 0.584 and 0.509, respectively (p > 0.05). For differentiating between papillary lesions and non-papillary benign lesions, the AUC of BI-RADS combined with SE was 0.835, which was higher than the values for BI-RADS (0.775) and SE (SE score: 0.648, strain ratio: 0.661) (p < 0.001). The specificity and accuracy of BI-RADS combined with SE were significantly higher than those for BI-RADS alone without a decrease in sensitivity (p < 0.05). SE could not improve the diagnostic efficiency of BI-RADS in differentiating between benign and malignant papillary lesions. However, BI-RADS combined with SE could improve the specificity of BI-RADS without decrease in sensitivity for differentiating breast papillary lesions from non-papillary benign lesions.

Superb microvascular imaging in diagnosis of breast lesions: a comparative study with contrast-enhanced ultrasonographic microvascular imaging.

OBJECTIVE: To evaluate the diagnostic performance of superb microvascular imaging (SMI) in breast lesions, comparing with contrast-enhanced ultrasonographic microvascular imaging (MVI). METHODS: From April to November 2015, 132 patients (with 132 breast lesions) were enrolled in the retrospective study. All lesions were evaluated with colour Doppler flow imaging (CDFI), colour SMI (cSMI), monochrome SMI (mSMI) and contrast-enhanced ultrasonographic MVI. Receiver-operating characteristic curve analysis was performed to compare the diagnostic performance of SMI and MVI for discrimination between benign and malignant breast lesions. RESULTS: Histological analysis showed 58 malignant and 74 benign lesions. mSMI was more sensitive in detecting blood flow signals in breast lesions than CDFI (p < 0.001) and cSMI (p < 0.001). Differences of vessels inside breast lesions and morphologic features of vessels between benign and malignant lesions were statistically significant on mSMI (p < 0.001). Using root hair-like and crab claw-like patterns as the criteria for malignant lesions, the sensitivity, specificity and accuracy for differentiation based on the microvascular architecture patterns were 77.6, 90.5 and 84.8% for mSMI and 89.6, 87.8 and 88.6% for MVI. Areas under curve of mSMI and MVI were not significantly different (p = 0.129). CONCLUSION: mSMI can increase blood flow detection and depict the microvascular architecture of breast lesions. The diagnostic performance of mSMI was not significantly different from MVI. SMI has potential in the differential diagnosis of breast lesions. ADVANCES IN KNOWLEDGE: mSMI is a non-invasive technique for vascularity evaluation of breast tumours and it is beneficial for breast tumour differentiation.

Ultrasound Elastography Combined With BI-RADS-US Classification System: Is It Helpful for the Diagnostic Performance of Conventional Ultrasonography?

PURPOSE: To evaluate the additive diagnostic performance of ultrasound elastography (UE) to ultrasound (US) with the 2003 or 2013 Breast Imaging Reporting and Data System (BI-RADS)-US classification systems for the differentiation of benign and malignant breast lesions. METHODS: From June 2010 to December 2012, 738 women with 770 breast lesions were recruited into this retrospective study. Breast lesions were evaluated separately by US, UE, and both. US assessment was based on the 2003 or 2013 BI-RADS-US, and UE assessment was based on a previously reported 5-point scale. Diagnostic performance of US, UE, and both was compared. RESULTS: Before category 4 lesions were subdivided, the area under the receiver operating characteristic curve (AUC) for US, UE, and both were, respectively, 0.735, 0.877, 0.878 (P < .01). When subcategories of 4 lesions were considered, the AUC for US, UE, and both were, respectively, 0.865, 0.877, and 0.883 (P > .05). Adding UE to analysis of 4A lesions can decrease the percentages of malignancy to 2.56%. CONCLUSION: When the 2003 BI-RADS was considered, UE could give US some help in differentiating breast lesions. However, when the 2013 BI-RADS was considered, UE gave little help to US, although it reduced unnecessary biopsies of benign category 4A lesions.

Ultrasonic Elastography Research Based on a Multicenter Study: Adding Strain Ratio after 5-Point Scoring Evaluation or Not.

BACKGROUND: This study aimed to confirm whether strain ratio should be added after evaluation of lesions with 5-point elasticity scoring for differentiating benign and malignant breast lesions on ultrasonographic elastography(UE). MATERIALS AND METHODS: From June 2010 to March 2012, 1080 consecutive female patients with breast lesions were recruited into a multicenter retrospective study, which involved 8 centers across China. Each institutional ethic review board approved the study, and all the patients gave written informed consent. All the patients underwent the UE procedure and the strain ratios were calculated and the final diagnosis was made by histological findings. The sensitivity, specificity, accuracy, PPV and NPV were calculated for each of the two evaluation systems and the areas under the ROC curve were compared. RESULTS: The strain ratios of benign lesions (mean, 2.6±2.0) and malignant lesions (mean,7.9±5.8) were significantly different (p <0.01). When the cutoff point was 3.01, strain ratio method had 79.8% sensitivity, 82.8% specificity, and 81.3% accuracy, while the 5-point scoring method had 93.1% sensitivity, 73.0% specificity, and 76.8% accuracy. The areas under the ROC curve with the strain ratio method and 5-point scoring method were 0.863 and 0.865, respectively(p>0.05). The strain ratio method shows better a diagnosis performance of the lesions with elasticity score 3 and 4. CONCLUSIONS: Although the two UE methods have similar diagnostic performance, separate calculation of the strain ratios seems compulsory, especially for the large solid breast lesions and the lesions with elasticity score 3 and 4.

Percutaneous ethanol injection, radiofrequency and their combination in treatment of hepatocellular carcinoma.

AIM: To evaluate the therapeutic effect and the indication of percutaneous ethanol injection (PEI), radiofrequency ablation (RFA) and their combination in treatment of hepatocellular carcinoma (HCC). METHODS: Two hundred and fifty-five patients with HCC received treatment of PEI, RFA or their combination. Group 1 (< 3 cm in diameter, n=85) was treated with PEI, group 2 (< 3 cm in diameter, n=153) with RFA. Group 3 (> 3 cm in diameter, n=86) was divided into two groups. Group 3a (n=34) was treated with RFA, while group 3b (n=52) was treated with RFA for 2 wk after transcatheter arterial chemoembolization or PEI. Contrast-enhanced sonography was performed for 61 patients before and after RFA. Liver function and serum alpha-fetoprotein (AFP) were measured for all patients. Changes of the lesions on ultrasound and contrast-enhanced CT/MRI were evaluated for assessing the therapeutic responses. The 1-, 2-, 3- and 5-year survival rates were recorded after treatment. RESULTS: In group 1, the complete necrosis rate of lesions after 1 mo was 77.6% (66/85). The level of AFP declined conspicuously after 1 mo. The 1-, 2-, 3- and 5-year survival rate after treatment was 80.0% (52/65), 60.4% (32/53), 52.5% (21/40) and 33.3% (7/21), respectively. In group 2, the complete necrosis rate of lesions after 1 moh was 92.2% (141/153). The level of AFP decreased conspicuously after 1 mo. The 1-, 2-, 3- and 5-year survival rate after treatment was 94.6% (88/93), 73.2% (52/71), 63.5% (33/52) and 46.4% (13/28), respectively. In group 3a, the complete necrosis rate of lesions after 1 mo was 23.5% (8/34). AFP dropped down to the normal level in only one patient after 1 mo. The 1-, 2- and 3-year survival rate after treatment was 47.6% (10/21), 42.9% (6/14) and 27.3% (3/11), respectively. Only one patient was still alive after 5 years. In group 3b, the complete necrosis rate of lesions after 1 mo was 57.7% (30/52). The level of AFP decreased after 1 mo. The 1-, 2-, 3- and 5-year survival rate after treatment was 68.6% (24/35), 46.2% (12/26), 36.8% (7/19) and 27.3% (3/11), respectively. CONCLUSION: The therapeutic effect of RFA on small HCC is better than that of PEI. Small HCC is the optimal indication of RFA. For recurrent HCC (diameter > 3 cm), the combined treatment of RFA and PEI/ACE should be used.

Differentiation between malignant and benign nodules in the liver: use of contrast C3-MODE technology.

AIM: To investigate the value of contrast-enhanced C3-MODE technology in differentiating malignant nodules of liver from the benign ones. METHODS: Forty-six nodules in 36 patients (29 men and 7 women) were studied by contrast-enhanced C3-MODE technology and contrast-enhanced CT in 1 wk before the biopsy or operation. A low MI monitor and a high MI flash imaging were intermittently performed. After the injection of contrast agent, the period from 10 to 30 s and the time later than 100 s were respectively defined as early arterial phase and the late phase. The vascularities of the liver nodules in the two phases were combined for differential diagnosis. Corresponding to the pathological diagnosis, the accuracy, sensitivity and specificity of contrast-enhanced C3-MODE technology were compared to those of contrast-enhanced CT. RESULTS: By C3-MODE technology, 33 of the 46 liver nodules were demonstrated as defected area in the late phase and were diagnosed as malignant tumors. Of them, 28 with hypervascularity in the early arterial phase were assessed as hepatocellular carcinoma, the other five nodules with rim-like enhancement in the early arterial phase were diagnosed as metastatic tumors. Thirteen nodules were shown as iso or hypervascularity in the late phase as well as centripetal filling in the early arterial phase and we made a diagnosis of hemangioma. Corresponding to the pathological results, the sensitivity, specificity and accuracy of contrast-enhanced C3-MODE technology in differentiating malignant and benign nodules in the liver were 97.0%, 92.3% and 95.7%, respectively. With comparison to those of contrast CT (sensitivity, 94.1%; specificity, 91.7%; accuracy, 93.5%), the difference was not significant. CONCLUSION: Contrast-enhanced C3-MODE technology can effectively differentiate malignant liver tumors from the benign nodules. It highly agrees diagnostically with the pathology. We suggest that it provides a new approach for differential diagnosis of liver nodules in addition to contrast-enhanced CT.

Hydroxyapatite nanoparticles modified by branched polyethylenimine are effective non-viral vectors for siRNA transfection of hepatoma cells in vitro.

Small interfering RNA (siRNA) technology is a powerful tool in biomedical research and holds great potential for RNA interference-based therapies for HIV, hepatitis and cancer. However, the absence of a safe and efficient method for the delivery of siRNA has become a bottleneck for their development. Nanocrystallized hydroxyapatite (nHAP) appears to be an optimal candidate non-viral gene vector for several reasons, including its good biocompatibility and ease of production, however, nHAP microemulsions cannot remain monodispersed for long periods of time. Due to their high surface energy, nHAP particles gradually aggregate into large ones that are difficult for the cell to take up. To overcome this we modified nHAP with polyethylenimine (PEI) to generate a compound (MnHAP) with a tight size-distribution of <200 nm. The positive surface potential of MnHAP inhibited particle aggregation and thus made it easier to conjugate more siRNA. The transfection efficiency of MnHAP/fluorescent FAM-labeled siRNA complex was tested using flow cytometry, and the transfected cells were observed using fluorescence microscopy. The cytotoxicity of MnHAP/siRNA complexes to the human liver cancer cell line BEL-7402 was assessed in vitro by a formazan dye assay. Our results show that the in vitro transfection efficiency of MnHAP/siRNA was equivalent to that of the commercially available transfection agent Lipofectamine® 2000, but with decreased cytotoxicity. The MnHAP nanoparticles were also able to deliver siRNA for silencing of glyceraldehyde-3-phosphate dehydrogenase (GAPDH) in BEL-7402 cells, which supports that MnHAP might be a promising non-viral vector for biomedical research and gene delivery.

Could ultrasonic elastography help the diagnosis of breast cancer with the usage of sonographic BI-RADS classification?

OBJECTIVES: The purpose was to evaluate whether BI-RADS (the Breast Imaging Recording and Data System) combined with UE (ultrasound elastography) could improve the differentiation and characterization of benign and malignant breast lesions by comparing with BI-RADS. METHODS: A total of 1080 patients with 1194 breast lesions were studied retrospectively at 8 different institutions from 3 geographic areas across China (North, South, and West) from June 2010 to March 2012. Each institutional ethic review board approved the study and all patients gave written informed consent. All the cases were examined by conventional US (ultrasonography) and UE prior to ultrasound-guided core biopsy. Performance of BI-RADS and BI-RADS combined with UE were compared in different size groups, age groups and area groups. RESULTS: BI-RADS combined with UE cloud improve the accuracy by 13.2% compared to BI-RADS alone for all lesions, 23.2% for <10 mm lesions, 13.3% for ≥10-20 mm lesions, 6.3% for ≥20 mm lesions, 18.4% for <50 years group, 1.7% for ≥50 years group, 13.7% for northern area group, 17.7% for southern area group and 4.4% for western area group. CONCLUSIONS: The help which UE contributed to BI-RADS was greater for breast lesions <10mm and <50 years group.