Longitudinal ultrasound-based AI model predicts axillary lymph node response to neoadjuvant chemotherapy in breast cancer: a multicenter study.

OBJECTIVES: Developing a deep learning radiomics model from longitudinal breast ultrasound and sonographer's axillary ultrasound diagnosis for predicting axillary lymph node (ALN) response to neoadjuvant chemotherapy (NAC) in breast cancer. METHODS: Breast cancer patients undergoing NAC followed by surgery were recruited from three centers between November 2016 and December 2022. We collected ultrasound images for extracting tumor-derived radiomics and deep learning features, selecting quantitative features through various methods. Two machine learning models based on random forest were developed using pre-NAC and post-NAC features. A support vector machine integrated these data into a fusion model, evaluated via the area under the curve (AUC), decision curve analysis, and calibration curves. We compared the fusion model's performance against sonographer's diagnosis from pre-NAC and post-NAC axillary ultrasonography, referencing histological outcomes from sentinel lymph node biopsy or axillary lymph node dissection. RESULTS: In the validation cohort, the fusion model outperformed both pre-NAC (AUC: 0.899 vs. 0.786, p < 0.001) and post-NAC models (AUC: 0.899 vs. 0.853, p = 0.014), as well as the sonographer's diagnosis of ALN status on pre-NAC and post-NAC axillary ultrasonography (AUC: 0.899 vs. 0.719, p < 0.001). Decision curve analysis revealed patient benefits from the fusion model across threshold probabilities from 0.02 to 0.98. The model also enhanced sonographer's diagnostic ability, increasing accuracy from 71.9% to 79.2%. CONCLUSION: The deep learning radiomics model accurately predicted the ALN response to NAC in breast cancer. Furthermore, the model will assist sonographers to improve their diagnostic ability on ALN status before surgery. CLINICAL RELEVANCE STATEMENT: Our AI model based on pre- and post-neoadjuvant chemotherapy ultrasound can accurately predict axillary lymph node metastasis and assist sonographer's axillary diagnosis. KEY POINTS: Axillary lymph node metastasis status affects the choice of surgical treatment, and currently relies on subjective ultrasound. Our AI model outperformed sonographer's visual diagnosis on axillary ultrasound. Our deep learning radiomics model can improve sonographers' diagnosis and might assist in surgical decision-making.

Head-to-head comparison of perfluorobutane contrast-enhanced US and multiparametric MRI for breast cancer: a prospective, multicenter study.

BACKGROUND: Multiparametric magnetic resonance imaging (MP-MRI) has high sensitivity for diagnosing breast cancers but cannot always be used as a routine diagnostic tool. The present study aimed to evaluate whether the diagnostic performance of perfluorobutane (PFB) contrast-enhanced ultrasound (CEUS) is similar to that of MP-MRI in breast cancer and whether combining the two methods would enhance diagnostic efficiency. PATIENTS AND METHODS: This was a head-to-head, prospective, multicenter study. Patients with breast lesions diagnosed by US as Breast Imaging Reporting and Data System (BI-RADS) categories 3, 4, and 5 underwent both PFB-CEUS and MP-MRI scans. On-site operators and three reviewers categorized the BI-RADS of all lesions on two images. Logistic-bootstrap 1000-sample analysis and cross-validation were used to construct PFB-CEUS, MP-MRI, and hybrid (PFB-CEUS + MP-MRI) models to distinguish breast lesions. RESULTS: In total, 179 women with 186 breast lesions were evaluated from 17 centers in China. The area under the receiver operating characteristic curve (AUC) for the PFB-CEUS model to diagnose breast cancer (0.89; 95% confidence interval [CI] 0.74, 0.97) was similar to that of the MP-MRI model (0.89; 95% CI 0.73, 0.97) (P = 0.85). The AUC of the hybrid model (0.92, 95% CI 0.77, 0.98) did not show a statistical advantage over the PFB-CEUS and MP-MRI models (P = 0.29 and 0.40, respectively). However, 90.3% false-positive and 66.7% false-negative results of PFB-CEUS radiologists and 90.5% false-positive and 42.8% false-negative results of MP-MRI radiologists could be corrected by the hybrid model. Three dynamic nomograms of PFB-CEUS, MP-MRI and hybrid models to diagnose breast cancer are freely available online. CONCLUSIONS: PFB-CEUS can be used in the differential diagnosis of breast cancer with comparable performance to MP-MRI and with less time consumption. Using PFB-CEUS and MP-MRI as joint diagnostics could further strengthen the diagnostic ability. Trial registration Clinicaltrials.gov; NCT04657328. Registered 26 September 2020. IRB number 2020-300 was approved in Chinese PLA General Hospital. Every patient signed a written informed consent form in each center.

Deep learning models of ultrasonography significantly improved the differential diagnosis performance for superficial soft-tissue masses: a retrospective multicenter study.

BACKGROUND: Most of superficial soft-tissue masses are benign tumors, and very few are malignant tumors. However, persistent growth, of both benign and malignant tumors, can be painful and even life-threatening. It is necessary to improve the differential diagnosis performance for superficial soft-tissue masses by using deep learning models. This study aimed to propose a new ultrasonic deep learning model (DLM) system for the differential diagnosis of superficial soft-tissue masses. METHODS: Between January 2015 and December 2022, data for 1615 patients with superficial soft-tissue masses were retrospectively collected. Two experienced radiologists (radiologists 1 and 2 with 8 and 30 years' experience, respectively) analyzed the ultrasound images of each superficial soft-tissue mass and made a diagnosis of malignant mass or one of the five most common benign masses. After referring to the DLM results, they re-evaluated the diagnoses. The diagnostic performance and concerns of the radiologists were analyzed before and after referring to the results of the DLM results. RESULTS: In the validation cohort, DLM-1 was trained to distinguish between benign and malignant masses, with an AUC of 0.992 (95% CI: 0.980, 1.0) and an ACC of 0.987 (95% CI: 0.968, 1.0). DLM-2 was trained to classify the five most common benign masses (lipomyoma, hemangioma, neurinoma, epidermal cyst, and calcifying epithelioma) with AUCs of 0.986, 0.993, 0.944, 0.973, and 0.903, respectively. In addition, under the condition of the DLM-assisted diagnosis, the radiologists greatly improved their accuracy of differential diagnosis between benign and malignant tumors. CONCLUSIONS: The proposed DLM system has high clinical application value in the differential diagnosis of superficial soft-tissue masses.

Deep Learning-Based Computer-Aided Diagnosis for Breast Lesion Classification on Ultrasound: A Prospective Multicenter Study of Radiologists Without Breast Ultrasound Expertise.

BACKGROUND. Computer-aided diagnosis (CAD) systems for breast ultrasound interpretation have been primarily evaluated at tertiary and/or urban medical centers by radiologists with breast ultrasound expertise. OBJECTIVE. The purpose of this study was to evaluate the usefulness of deep learning-based CAD software on the diagnostic performance of radiologists without breast ultrasound expertise at secondary or rural hospitals in the differentiation of benign and malignant breast lesions measuring up to 2.0 cm on ultrasound. METHODS. This prospective study included patients scheduled to undergo biopsy or surgical resection at any of eight participating secondary or rural hospitals in China of a breast lesion classified as BI-RADS category 3-5 on prior breast ultrasound from November 2021 to September 2022. Patients underwent an additional investigational breast ultrasound, performed and interpreted by a radiologist without breast ultrasound expertise (hybrid body/breast radiologists, either who lacked breast imaging subspecialty training or for whom the number of breast ultrasounds performed annually accounted for less than 10% of all ultrasounds performed annually by the radiologist), who assigned a BI-RADS category. CAD results were used to upgrade reader-assigned BI-RADS category 3 lesions to category 4A and to downgrade reader-assigned BI-RADS category 4A lesions to category 3. Histologic results of biopsy or resection served as the reference standard. RESULTS. The study included 313 patients (mean age, 47.0 ± 14.0 years) with 313 breast lesions (102 malignant, 211 benign). Of BI-RADS category 3 lesions, 6.0% (6/100) were upgraded by CAD to category 4A, of which 16.7% (1/6) were malignant. Of category 4A lesions, 79.1% (87/110) were downgraded by CAD to category 3, of which 4.6% (4/87) were malignant. Diagnostic performance was significantly better after application of CAD, in comparison with before application of CAD, in terms of accuracy (86.6% vs 62.6%, p < .001), specificity (82.9% vs 46.0%, p < .001), and PPV (72.7% vs 46.5%, p < .001) but not significantly different in terms of sensitivity (94.1% vs 97.1%, p = .38) or NPV (96.7% vs 97.0%, p > .99). CONCLUSION. CAD significantly improved radiologists' diagnostic performance, showing particular potential to reduce the frequency of benign breast biopsies. CLINICAL IMPACT. The findings indicate the ability of CAD to improve patient care in settings with incomplete access to breast imaging expertise.

Can Short-term Follow-up with Ultrasound be Offered as an Acceptable Alternative to Immediate Biopsy or Surgery for Patients with First Ultrasound Diagnosis of BI-RADS 4A Lesions?

OBJECTIVES: To evaluate the relevant factors associated with malignancy in Breast Imaging Reporting and Data System (BI-RADS) 4A and to determine whether it was possible to establish a safe follow-up guideline for lower-risk 4A lesions. METHODS: In this retrospective study, patients categorized as BI-RADS 4A on ultrasound who underwent ultrasound-guided biopsy or/and surgery between June 2014 and April 2020 was analyzed. Classification-tree method and cox regression analysis were used to explore the possible correlation factors of malignancy. RESULTS: Among 9965 patients enrolled, 1211 (mean age, 44.3 ± 13.5 years; range, 18-91 years) patients categorized as BI-RADS 4A were eligible. The result of cox regression analysis revealed the malignant rate was only associated with patient age (hazard ratio (HR) = 1.038, p < 0.001, 95% confidence interval (CI): 1.029-1.048) and the mediolateral diameter of the lesion (HR = 1.261, p < 0.001, 95% CI: 1.159-1.372). The malignant rate for patients (≤ 36 y) with BI-RADS 4A lesions (the mediolateral diameter ≤ 0.9 cm) was 0.0% (0/72). This subgroup included fibrocystic disease and adenosis in 39 patients (54.2%), fibroadenoma in 16 (22.2%), intraductal papilloma in 8 (11.1%), inflammatory lesions in 6 (8.3%), cyst in 2 (2.8%), and hamartoma in 1 (1.4%). CONCLUSIONS: Patient age and lesion size are associated with the rate of malignancy in BI-RADS 4A. For patients with lower-risk BI-RADS 4A lesions (≤ 2% likelihood of malignancy), short-term follow-up with ultrasound may be offered as an acceptable alternative to immediate biopsy or surgery.

Ultrasound-Guided Vacuum-Assisted Excision to Treat Intraductal Papilloma.

BACKGROUND: To evaluate the value of ultrasound-guided vacuum-assisted excision (US-guided VAE) in the treatment of intraductal papillomas, including intraductal papillomas with atypical ductal hyperplasia (ADH), and to evaluate the lesion characteristic features affecting the local recurrence rate. MATERIALS AND METHODS: Between August 2011 and December 2020, 91 lesions of 91 patients underwent US-guided VAE and were diagnosed with intraductal papilloma with or without ADH. The recurrence rate of intraductal papilloma was evaluated on follow-up US. The lesion characteristic features were analyzed to identify the factors affecting the local recurrence rate. RESULTS: The local recurrence rate of intraductal papillomas removed by US-guided VAE was 7.7% (7/91), with the follow-up duration 12-92 months (37.4 ± 23.9 months). Of the 91 patients, five cases diagnosed as intraductal papilloma with ADH did not recur, with the follow-up time 12-47 months (26.4 ± 14.4 months). There were no malignant transformation in all 91 cases during the follow-up period. All 7 patients recurred 7-58 months (22.8 ± 19.2 months) after US-guided VAE. There were no significant differences between the non-recurrence and recurrence groups in terms of age, side, distance from nipple, lesion size, BI-RADS category, with ADH, or history of excision (p > 0.05). CONCLUSIONS: US-guided VAE is an effective method for the treatment of intraductal papilloma, including intraductal papilloma with ADH. It avoids invasive surgical excision, but regular follow-up is recommended to prevent recurrence or new onset due to multifocality. Any suspicious lesions during the follow-up should be actively treated.

High-Risk Breast Lesions Diagnosed by Ultrasound-Guided Vacuum-Assisted Excision.

PURPOSE: The aim of this study was to analyze the role of ultrasound-guided vacuum-assisted excision (US-guided VAE) in the treatment of high-risk breast lesions and to evaluate the clinical and US features of the patients associated with recurrence or development of malignancy. MATERIALS AND METHODS: Between April 2010 and September 2021, 73 lesions of 73 patients underwent US-guided VAE and were diagnosed with high-risk breast lesions. The incidence of recurrence or development of malignancy for high-risk breast lesions was evaluated at follow-up period. The clinical and US features of the patients were analyzed to identify the factors affecting the recurrence or development of malignancy rate. RESULTS: Only benign phyllodes tumors on US-guided VAE showed recurrences, while other high-risk breast lesions that were atypical ductal hyperplasia (ADH), lobular neoplasia (atypical lobular hyperplasia/lobular carcinoma in situ), radial scar, and flat epithelial atypia did not show recurrences or malignant transformation. The recurrence rate of the benign phyllodes tumor was 20.8% (5/24) in a mean follow-up period of 34.3 months. The recurrence rate of benign phyllodes tumor with distance from nipple of less than 1 cm was significantly higher than that of lesions with distance from nipple of more than 1 cm (75% vs. 10%, p < 0.05). CONCLUSIONS: Benign phyllodes tumors without concurrent breast cancer could be safely followed up instead of surgical excision after US-guided VAE when the lesions were classified as BI-RADS 3 or 4A by US.

Clinical Application of Computer-Aided Diagnosis System in Breast Ultrasound: A Prospective Multicenter Study.

OBJECTIVES: Ultrasound tends to present very high sensitivity but relatively low specificity and positive predictive value (PPV), which would result in unnecessary breast biopsies. The purpose of this study is to analyze the diagnostic performance of computer-aided diagnosis (CAD) (S-Detect) system in differentiating breast lesions and reducing unnecessary biopsies in non-university hospitals in less-developed regions of China. METHODS: The study was a prospective multicenter study from 8 hospitals. The ultrasound images, and cine, CAD analysis, and BI-RADS were recorded. The accuracy, sensitivity, specificity, PPV, negative predictive value (NPV), and area under the curve (AUC) were analyzed and compared between CAD and radiologists. The Youden Index (YI) was used to determine optimal cut-off for the number of planes to downgrade. RESULTS: A total of 491 breast lesions were included in the study. Less-experienced radiologists combined CAD was superior to less-experienced radiologists alone in AUC (0.878 vs 0.712, p < 0.001), and specificity (81.3% vs 44.6%, p < 0.001). There was no statistical difference in AUC (0.891 vs 0.878, p = 0.346), and specificity (82.3% vs 81.3%, p = 0.791) between experienced radiologists and less-experienced radiologists combined CAD. With CAD assistance, the biopsy rate of less-experienced radiologists was significantly decreased (100.0% vs 25.6%, p < 0.001), and malignant rate of biopsy was significantly increased (15.0% vs 43.9%, p < 0.001). CONCLUSIONS: CAD system can be an effective auxiliary tool in differentiating breast lesions and reducing unnecessary biopsies for radiologists from non-university hospitals in less-developed regions of China.

High-Resolution Ultrasound Imaging of Axillary Nerve and Relevant Injury.

OBJECTIVE: To evaluate the feasibility of axillary nerve (AN) visualization in healthy volunteers and the diagnostic value of AN injury via high-resolution ultrasonography (HRUS). METHODS: AN was examined by HRUS on both sides of 48 healthy volunteers and oriented the transducer according to three anatomical landmarks: quadrilateral space, anterior to subscapular muscle, and posterior to axillary artery. The maximum short-axis diameter (SD) and cross-sectional area (CSA) of AN were measured at different levels, and AN visibility was graded by using a five-point scale. The patients suspected of having AN injury were assessed by HRUS, and the HRUS features of AN injury were observed. RESULTS: AN can be visualized on both sides in all volunteers. There was no significant difference in SD and CSA of AN at the three levels between the left and right sides or in SD between males and females. However, the CSA of males at different levels was slightly larger than those of females (P < .05). In most volunteers, AN visibility at different levels was excellent or good, and AN was best displayed anterior to subscapular muscle. Rank correlation analysis revealed that the degree of AN visibility had correlation with height, weight, and BMI. A total of 15 patients diagnosed with AN injury, 12 patients showed diffuse swelling or focal thickening in AN, and 3 patients showed AN discontinuity. CONCLUSION: HRUS is able to reliably visualize AN, and it could be considered as the first choice for diagnosing AN injury.

Ultrasound Assessment of Hip Subspine Bone Morphology Soft-tissue Correlates with Clinical Diagnosis of Impingement.

PURPOSE: To determine the ultrasound imaging manifestations associated with subspine impingement (SSI), including the osseous and soft-tissue injuries adjacent to anterior inferior iliac spine (AIIS) and to investigate the diagnostic value of ultrasound for SSI. METHODS: We retrospectively evaluated patients who attended the sports medicine department of our hospital and underwent arthroscopic treatment for femoroacetabular impingement (FAI) between September 2019 and October 2020, with preoperative hip joint ultrasound and computed tomography (CT) examination within 1 month before surgery. All of the FAI patients were divided into the SSI group and non-SSI group, according to the clinical and intraoperative findings. The preoperative ultrasound and CT findings were assessed. The sensitivity, specificity, and positive predictive value (PPV) of some indicators were calculated and compared. Multivariable logistic regression and receiver operating characteristic curve (ROC) were also used. RESULTS: A total of 71 hips were included, with a mean age of 35.4 ± 10.4 years, 56.3% were women. Of these, 40 hips had clinically confirmed SSI. The bone morphology type III, heterogeneous hypoecho in anterosuperior joint capsule and the direct head of rectus femoris (dRF) tendon adjacent to AIIS on the Standard Section of the dRF in ultrasound were associated with SSI. Among them, the heterogeneous hypoecho in the anterosuperior joint capsule had the best diagnostic value for the SSI (85.0% sensitivity, 58.1% specificity, AUC = 0.681). The AUC of the ultrasound composite indicators was 0.750. The AUC and PPV of CT low-lying AIIS for the SSI diagnosis was 0.733 and 71.7%, which could be improved when CT was combined with the ultrasound composite indicators with AUC = 0.831 and PPV = 85.7%. CONCLUSIONS: Bone morphology abnormalities and soft-tissue injuries adjacent to the AIIS through sonographic evaluation were associated with SSI. Ultrasound could be used as a feasible method to predict SSI. The diagnostic value for SSI could be improved when ultrasound is combined with CT. LEVEL OF EVIDENCE: Level IV, case series.

Evaluation of Supratrochlear, Supraorbital and Angular Artery Course Variations and Depth by Doppler Ultrasound.

BACKGROUND: Supratrochlear (STA), supraorbital (SOA), and dorsal nasal artery (DNA) branches from the ophthalmic artery and angular artery (AA) from the facial artery are the primary suppliers of blood to the upper face. Filler injection without precise knowledge of its vascular topography poses a risk of severe complications. METHODS: Seventy-four hemifaces from 37 subjects with a median age of 25.0 (21.0, 35.0) years and a median body mass index of 21.2 (20.0, 25.4) kg/m2 underwent high-frequency ultrasound tests between March 2022 and April 2022. The bilateral location, depth, peak systolic velocity (PSV), and inner diameter (ID) of the four periorbital arteries (STA, SOA, DNA, AA) were measured. RESULTS: The average ID ranges from 0.6~1.0 mm, and the average PSV ranges from 9.2~24.9 cm/s. All arteries detected passed through the superficial subcutaneous fascia. Most subjects' STAs traveled within 1.0 to 2.0 cm from the midline (left 96.8%, right 93.8%), while SOAs were mainly concentrated within 2.0 to 4.0 cm (left 83.9%, right 81.3%). STAs were more superficial and had a larger internal ID and PSV than SOAs (p<0.001). Except for the ID of the right SOA2 being significantly larger than that of the left SOA2 (p<0.05), no dominant side was found. The depth of STAs and SOAs was moderately correlated with BMI (p<0.05), except for STA1 on the left side. The course of AAs presented a high variability. CONCLUSION: These findings emphasize that the periorbital arteries carry with it a likelihood of ocular complication risks during injection. Targeting the supraperiosteal layer in the STA area and the supramuscular layer in the SOA area of the inferior forehead during injection seems reasonable, and an area within 1.0~2.0 cm from the midline should be avoided. Additionally, the high variability of AAs will enhance the understanding of the anatomy of the facial artery terminals. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Study on multiplanar measurements of infant hips with three-dimensional ultrasonography.

PURPOSE: An automatic evaluation technology based on artificial intelligence and three-dimensional ultrasonography (3D US) is proposed for hip US inspection plane selection. This study aimed to evaluate the consistency of the α angle as measured using 3D US to select the section plane and two-dimensional ultrasonography (2D US) to manually select the Graf image, as well as to explore the feasibility of diagnosing developmental dysplasia of the hip (DDH) using 3D US and reconstruction technology. METHODS: A total of 216 infant hips were included and assessed by doctors using 3D US layer-by-layer. The researchers used a computer to identify the coronal images that met the Graf standard and then compared the αX values obtained with the αG values measured artificially by 2D US. RESULTS: Compared with 2D US, 3D US more clearly showed the relative positions of the ilium, ischia, and pubis. The measured α value of the optimal section obtained by 3D US showed good agreement with the measured α value of the standard Graf section. CONCLUSION: The artificial intelligence and 3D US-based automatic evaluation technology for section selection and inspection for DDH showed good agreement with the Graf method based on standard sections.

Factors Influencing the Sample Adequacy of Ultrasound-Guided Fine-Needle Aspiration from Solid Thyroid Nodules for Liquid-Based Cytology: A Demographic, Sonographic, and Technical Perspective.

Background and Objectives: To identify factors that influence the sample adequacy of solid thyroid nodules based on ultrasound-guided fine-needle aspiration (FNA) with subsequent liquid-based cytology. Materials and Methods: We retrospectively reviewed 855 patients who underwent ultrasound-guided FNA at our hospital between July 2019 and July 2020. The final analysis included 801 solid thyroid nodules in 801 patients. After reviewing the demographic data, ultrasonic features, and FNA technique-related factors, we defined 14 potential variables. For cytological results, the Bethesda categories II−VI were defined as adequate sample results. Univariate and multivariate analyses were performed to identify factors that influenced sample adequacy. Results: The adequate sample rate was 87.1%. The univariate analysis showed that four factors were related to adequate sampling in patients with thyroid FNA. These factors included age (p < 0.001), nodule orientation (p = 0.0232), calcification (p = 0.0034), and operator experience (p = 0.0286). After the multivariate analysis, five independent factors were identified to improve the diagnostic results of FNA for solid thyroid nodules: (1) the presence of Hashimoto's thyroiditis (odds ratio (OR) = 1.810; 95% confidence interval (CI): 1.076−3.045; p = 0.0254), (2) a taller-than-wide orientation (OR = 2.038; 95% CI: 1.260−3.296; p = 0.0037), (3) the presence of calcification (OR = 1.767; 95% CI: 1.115−2.799; p = 0.0153), (4) four needle passes to obtain material (OR = 1.750; 95% CI: 1.094−2.799; p = 0.0196), and (5) an experienced operator (OR = 0.561; 95% CI: 0.319−0.987; p = 0.0451). Conclusions: A taller-than-wide orientation, the presence of calcification, and the presence of Hashimoto's thyroiditis were found to affect the sample adequacy of ultrasound-guided FNA with liquid-based cytology. The sample adequacy could be improved when FNA is performed with four needle passes by experienced doctors.

Percutaneous Sonazoid-enhanced ultrasonography combined with in vitro verification for detection and characterization of sentinel lymph nodes in early breast cancer.

OBJECTIVES: To assess the efficacy of percutaneous Sonazoid-enhanced ultrasound and in vitro verification for identification sentinel lymph nodes (SLNs) and diagnosis of metastatic SLNs in patients with early breast cancer (BC). METHODS: Sixty-eight patients with early BC were enrolled finally. After the induction of general anesthesia, 0.4 ml of Sonazoid (SNZ), a new second-generation tissue-specific ultrasound contrast agent (UCA), mixed with 0.6 ml of methylene blue, was injected intradermally. The lymphatic vessels and connected SLNs were immediately observed and marked. After being resected, these SLNs were soaked in saline water and examined still in the mode of contrast-enhanced ultrasound (CEUS) in vitro. This procedure could ensure that all the enhanced nodes had been removed as much as possible. The numbers of SLNs detected by UCA and blue dye were recorded. The enhancement patterns of SLNs were compared with the final pathological results. RESULTS: SLNs detection rate by SNZ-CEUS was 100%, which was higher than that by blue dye (95.59%). CEUS identified a median of 1.5 nodes, while blue dye identified a median of 1.9 nodes per case (p = 0.0012). When homogeneous high perfusion and complete annular high perfusion were regarded as negative nodes, the sensitivity and negative predictive value were 92.31% and 96.79% respectively, while the specificity was 84.21%. CONCLUSIONS: Percutaneous SNZ-enhanced ultrasonography combined with in vitro verification is a feasible and reliable method for SLNs identification intraoperatively. Enhancement patterns can be helpful in determining the status of SLNs. KEY POINTS: • CEUS with percutaneous injection of Sonazoid can successfully identify SLNs with the rate of 100% in early breast cancer patients, higher than 95.59% of blue dye. • Sonazoid, with high affinity with reticuloendothelial cells, increases the imaging time of SLNs and facilitates biopsy intraoperatively better than Sonovue as a lymphatic tracer. • Homogenous high and complete annular high perfusions have a sensitivity of 92.31% and a negative predictive value of 96.79% in the prediction of uninvolved SLNs.

Lung Ultrasound Findings in Patients With Coronavirus Disease (COVID-19).

OBJECTIVE. Although chest CT is the standard imaging modality in early diagnosis and management of coronavirus disease (COVID-19), the use of lung ultrasound (US) presents some advantages over the use of chest CT and may play a complementary role in the workup of COVID-19. The objective of our study was to investigate US findings in patients with COVID-19 and the relationship of the US findings with the duration of symptoms and disease severity. MATERIALS AND METHODS. From March 3, 2020, to March 30, 2020, consecutive patients with a positive reverse transcriptase polymerase chain reaction test result for the virus that causes COVID-19 were enrolled in this study. Lung US was performed, and the imaging features were analyzed. The Fisher exact test was used to compare the percentages of patients with each US finding between groups with different symptom durations and disease severity. RESULTS. Our study population comprised 28 patients (14 men and 14 women; mean age ± SD, 59.8 ± 18.3 years; age range, 21-92 years). All 28 patients (100.0%, 28/28) had positive lung US findings. The most common findings were the following: B-lines (100.0%, 28/28), consolidation (67.9%, 19/28), and a thickened pleural line (60.7%, 17/28). A thickened pleural line was observed in a higher percentage of patients with a longer duration of the disease than in those with a shorter duration of the disease, and pulmonary consolidations were more common in severe and critical cases than in moderate cases. CONCLUSION. Typical lung US findings in patients with COVID-19 included B-lines, pulmonary consolidation, and a thickened pleural line. In addition, our results indicate that lung US findings can be be used to reflect both the infection duration and disease severity.

Ultrasound and Ultrasound-Guided Hip Injection Have High Accuracy in the Diagnosis of Femoroacetabular Impingement With Atypical Symptoms.

PURPOSE: To evaluate the diagnostic value of ultrasound and ultrasound-guided hip injection in the diagnosis of femoroacetabular impingement (FAI) with atypical symptoms. METHODS: We evaluated consecutive patients diagnosed with FAI and with atypical symptoms who underwent ultrasound-guided hip injection between January 2017 and February 2019. All patients underwent systematic physical examination, ultrasound examination, magnetic resonance imaging (MRI) examination, and ultrasound-guided injection before surgery. Patients with positive response to ultrasound-guided hip injection were recommended to undergo arthroscopic surgery to treat intra-articular pathology. Sensitivity, specificity, accuracy, and positive predictive value (PPV) of ultrasound and MRI were calculated by using arthroscopic surgery as the gold standard. The accuracy of ultrasound-guided hip injection was recorded. Preoperative and postoperative patient-reported outcomes included visual analog scale for pain and modified Harris Hip Score. RESULTS: A total of 78 patients with atypical symptoms were diagnosed with FAI. Among these 78 patients, 50 patients had positive responses to injection and 28 patients had negative responses to injection. A total of 36 patients finally underwent arthroscopic surgery. Response to the ultrasound-guided intra-articular injection was 91.7% accurate for detecting the presence of intra-articular abnormality. There were no complications of injection in any of the patients. The sensitivity, PPV, and accuracy by ultrasound diagnosis of cam impingement were 82.9%, 96.7%, and 80.6%, respectively. The sensitivity and accuracy by ultrasound diagnosis of anterosuperior labral tear were both 72.2%. For MRI diagnosis of cam impingement, the sensitivity, PPV and accuracy were 72.2%, 96.3%, and 74.3%, respectively. For MRI diagnosis of labral tear, the sensitivity and accuracy were both 88.9%. Thirty-four patients (94.4%) surpassed the minimal clinically important difference, and 33 patients (91.7%) achieved the patient acceptable symptomatic state. CONCLUSIONS: Ultrasound and ultrasound-guided hip injection have high accuracy in the diagnosis of femoroacetabular impingement with atypical symptoms. LEVEL OF EVIDENCE: IV, case series.

Diagnosing Muscle Atrophy by Use of a Comprehensive Method of Assessing the Elastic Properties of Muscle During Passive Stretching.

OBJECTIVE. The purpose of this study was to apply a new method for quantitatively assessing atrophied muscles by use of sonoelastography. SUBJECTS AND METHODS. B-mode sonography and shear-wave elastography of the gastrocnemius muscle (GM) were performed on 12 patients and 32 healthy control volunteers during passive stretching induced by ankle rotation from 40° plantar flexion to 30° dorsiflexion. The GM length and corresponding elastic moduli were measured consecutively per frame. The elastic modulus-length curve was created by plotting the elastic modulus against the GM length during passive stretching. Three physiologically significant parameters-slack elasticity modulus (E0), slack length (l0), and passive elastic coefficient (k)-were estimated from the measured elasticity modulus-length curve to quantify the elastic properties of the GM. RESULTS. All results showed a smooth exponential curve. In the state of relaxation, atrophied GM was softer than GM of healthy control subjects. However, when the muscles were passively stretched from a state of slack to tension, k was significantly greater for the patients with atrophied GMs than for the control subjects. Furthermore, the diagnostic accuracy of k for muscle atrophy was greater than that of E0. CONCLUSION. Increased elastic stiffness may be considered a positive finding for the characterization of muscle atrophy. Because of its high diagnostic accuracy and reproducibility, the elastic modulus-length curve can provide new insights into the diagnosis of muscle disease and allows monitoring of muscle function in rehabilitation.

Distinguishing a Trichilemmal Cyst From a Pilomatricoma With Ultrasound.

OBJECTIVES: To determine whether ultrasound (US) could distinguish a trichilemmal cyst from a pilomatricoma preoperatively. METHODS: Ultrasound images of 61 pathologically proven trichilemmal cysts and 90 pathologically proven pilomatricomas were analyzed retrospectively. Two radiologists evaluated several US features. The sensitivity, specificity, Youden index, and predictive values of statistically significant US features were assessed. Parallel combined tests, serial combined tests, or both were performed to identify US features with high statistical significance. RESULTS: Results from individual US features were not satisfactory; however, serial combined tests that included absence of complete internal echogenic foci, absence of a hypoechoic rim, absence of peritumoral hyperechogenicity, and absence of vascularity showed higher diagnostic utility. The sensitivity, specificity, Youden index, positive predictive value, and negative predictive value for correctly identifying a trichilemmal cyst were 74%, 88%, 0.62, 80%, and 83%, respectively. If 1 of these 4 US features was not a match for a trichilemmal cyst, pilomatricoma was considered. CONCLUSIONS: It may be possible to distinguish trichilemmal cysts from pilomatricomas preoperatively using US. A combined test is superior to using any individual US feature.

The Possible Role of Color Doppler and Pulse Wave Doppler Ultrasound in the Diagnosis of Cutaneous Lymphangioma Circumscriptum.

Cutaneous lymphangioma circumscriptum (CLC) is an uncommon congenital lymphatic malformation. Its dermoscopic features have been reported, however, if blood has infiltrated the lacunas, a pink hue overwhelms the lacunar structures, rendering dermoscopic features indistinguishable. In addition, dermoscopy cannot assess the subcutaneous extent of the lesion before surgery. The high-frequency array transducer Sonography with a high-frequency transducer is excellent in its resolution to evaluate skin lesions and is unaffected by infiltration of blood. Here, the authors report the use of ultrasound (color Doppler and pulse wave Doppler) for the diagnosis and management of CLC.An 18-year-old man presented 10 years previously with an asymptomatic 0.5 × 0.7 cm cluster of dark reddish vesicular lesions on his buttock. The lesions had recently increased in size and number. There was associated pachyderma. The lesions were hyperechoic and well defined on grayscale ultrasound and hypervascular on color Doppler ultrasound. Cluster cystics of lymphatic spaces were found throughout the whole dermis, especially in the papillary dermis. The lymphatic channels extended downwards to the reticular dermis and the superficial layer of the subcutaneous tissue. The pathological findings revealed lymphangiomas invading the subcutaneous tissue. The flat endothelial cells were partly positive for D2-40, which is a marker of lymphatic endothelial cells. Ultrasound was able to delineate the margins of the lesions. Diagnosis of CLC using preoperative color Doppler and pulse wave Doppler could reduce unnecessary repeated pre- and postoperative biopsies.

Can Contrast-Enhanced Ultrasound Increase or Predict the Success Rate of Testicular Sperm Aspiration in Patients With Azoospermia?

OBJECTIVE. The objective of our study was to determine whether contrast-enhanced ultrasound (CEUS) perfusion measurements obtained before testicular sperm aspiration (TESA) can improve or predict sperm retrieval (SR) outcomes of TESA in patients with azoospermia. SUBJECTS AND METHODS. Between May 2017 and January 2018, 70 patients with azoospermia (mean age, 29 years; age range, 22-41 years) underwent testes CEUS within 10 days before TESA. Major perfusion areas were visually chosen, and their ranges were recorded. The other areas were defined as minor perfusion. CEUS quantitative features were acquired for both the main perfusion area and whole testis. Testis tissue biopsies were taken for both major and minor perfusion areas by cognitive fusion, and SR outcomes were compared. Associations between testicular volume, quantitative CEUS features, and SR outcomes were analyzed. RESULTS. Twenty-four men were found to have obstructive azoospermia (OA), and the remaining 46 had nonobstructive azoospermia (NOA). All patients with OA had spermatozoa in biopsy. Only one patient with NOA had spermatozoa in the major perfusion area but not the minor perfusion area; the other patients with NOA had the same SR outcomes in both major and minor perfusion areas. In patients with NOA, both wash-in and washout CEUS features were correlated with the success of SR in TESA. CONCLUSION. CEUS-guided TESA with cognitive fusion cannot yield improved SR outcomes of TESA in patients with NOA, possibly because of imprecise correlation between biopsy sites and main perfusion area analyzed by CEUS; however, quantitative CEUS features can be useful predictors of the success of SR.