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.

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.

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.

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.

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.

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 .

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.

Trichilemmal Cyst: Clinical and Sonographic Features.

OBJECTIVES: In this study, we retrospectively reviewed the clinical and sonographic features of patients with trichilemmal cysts. METHODS: Sonographic findings of 54 cases of trichilemmal cysts were retrospectively analyzed from 50 patients, including 4 cases of proliferating trichilemmal cysts. Associated factors of internal calcification-positive cases were also evaluated. RESULTS: The mean age of the 50 patients was 43.4 years (range, 15-80 years) and the female-to-male ratio was 1.3. Overall, 68% of the trichilemmal cysts in the 54 lesions were located in the scalp, and 15% were located in the extremities. All 54 lesions were preoperatively examined by sonography and showed well-defined, oval-shaped structures located in subcutaneous soft tissues close to the dermis. Of the 54 lesions, 72% were hypoechoic masses, 89% were heterogeneous, and 65% had internal calcification. Among the internal calcification-positive cases, the mean age of the patients was 43.4 years, and the female-to-male ratio was 0.6. Of these lesions, 83% were located in the scalp. We did not find any significant association between calcification, age, or sex (P = .993 and P = .99); however, lesions present in the scalp were significantly associated with internal calcification (P = .005). 81% of the 54 lesions displayed posterior enhancement. but the color Doppler sonography of all lesions revealed no vascularization. CONCLUSIONS: Trichilemmal cysts should be considered to diagnose of well-defined, hypoechoic lesions with internal calcification and posterior sound enhancement in the subcutaneous soft tissues of the scalp or extremities upon sonography.

A Multicenter Large-Sample Shear Wave Ultrasound Elastographic Study of the Achilles Tendon in Chinese Adults.

OBJECTIVES: The changes in the viscoelasticity of the Achilles tendon are related to tendinopathy. Therefore, constructing a data model in the healthy population is essential to understanding the key factors affecting the viscoelasticity of the Achilles tendon. The purpose of our research was to obtain large sample data, construct a data model, and determine parameters that affect the elastic modulus of the Achilles tendon in healthy Chinese adults. METHODS: We designed a prospective multicenter clinical trial to evaluate the viscoelasticity of the Achilles tendon by using shear wave elastography. A total of 1165 healthy adult participants from 17 Chinese hospitals were recruited for the assessment. The necessary parameters (age, height, weight, and body mass index) were recorded. The elastic modulus (Young modulus) was obtained from the middle of the Achilles tendon and calculated with feet in naturally relaxed, dorsal, and plantar positions. The thickness and perimeter of the Achilles tendon were measured via cross section on the same site. A multiple linear regression was performed to find the key factors affecting the Young modulus of the Achilles tendon. RESULTS: The Young modulus of the left Achilles tendon in the natural relaxed position followed a normal distribution (P > .05) with a mean ± SD of 374.24 ± 106.12 kPa. The regression equations showed a positive correlation between the Young modulus and weight and a negative correlation between the Young modulus and the circumference or thickness of the left Achilles tendon (P < .05). CONCLUSIONS: The Young modulus of the Achilles tendon as measured by shear wave elastography is related to body weight as well as the perimeter or thickness of the tendon.

[Values of Longitudinal and Transverse Plane Ratios in Predicting the Risk of Malignant Thyroid Nodules].

Objective To compare the predictive value of different ratio measurement in predicting the risk of malignant thyroid nodules and to determine the best value of ratio in diagnosing thyroid nodules.Methods The clinical data of 342 thyroid nodules diagnosed by ultrasonography and confirmed by histology in our hospital from January 2018 to August 2018 were analyzed.The ratio of nodules in different sections,including longitudinal plane ratio(A/TL)and transverse plane ratio(A/TC),was obtained through the maximum head-foot diameter(TL),the maximum left-right diameter(TC),and the anterior-posterior diameter(A)of transverse section measured by ultrasonography.The correlation of histological diagnosis of benign or malignant nodule with longitudinal ratio and transverse ratio were analyzed.Results The A/TC and A/TL of malignant nodules were 1.00(0.83,1.17)and 0.81(0.65,1.00),respectively,which were significantly higher than those of benign nodules [0.81(0.67,0.93)(Z=-6.567,P=0.000)and 0.63(0.52,0.75)(Z=-7.239,P=0.000)].The area under the ROC curve of A/TC and A/TL was 0.734 and 0.712,respectively,showing no significant difference(area difference:0.0210,standard error:0.0213,95% CI:-0.0207-0.0627,Z=0.987,P=0.3235).The threshold values of A/TC and A/TL for predicting malignant nodules were 0.784 161 5 and 0.985 714 5,respectively.Conclusions Both A/TL and A/TC has similar diagnostic value in predicting the risk of malignant nodules.The best cutoff value of the above two ratios are 0.78 and 0.99 respectively.

[Direct and Indirect Methods of High-frequency Ultrasound in Imaging Distal Biceps Brachii Tendon].

Objective To explore convenient and effective ultrasound scanning methods and skills for imaging the distal biceps tendon.Methods Totally 80 distal biceps tendons of 40 healthy volunteers were scanned and evaluated with high-frequency ultrasound using the direct and the indirect methods. The scanning time and the subjective comfort scores of each subject were recorded. The imaging clarity of the tendon and its insertion onto the radial tuberosity was evaluated.Results The scanning time of the indirect method was shorter than that of the direct method in all volunteers,male volunteers,and female volunteers,although the differences were not statistically significant(all P> 0.05). The mean scanning time was longer on the left side than on the right side regardless of the scanning method (all P> 0.05). The scanning time in women was significantly shorter than in men when the scan was performed by using indirect method on the left side (t=-2.33,P=0.025),direct method on the right side (t=-3.35,P=0.002),or indirect method on the right side (t=-2.67,P=0.011). However,the scanning time was not significantly different between women and men when using the direct method on the left side (t=-1.27,P=0.213). The subjective comfort score was not significantly different between direct and indirect methods in each group (all P>0.05). However,the subjective comfort score was higher on the right side than on the left side regardless of the methods used. In particular,the subjective comfort scores showed significant difference when using the direct method in all subjects (t=2.32,P=0.026),the indirect method in all subjects (t=3.08,P=0.004),and indirect method in females (t=2.52,P=0.021). The overall subjective comfort score of females was higher than that of males,and the difference was statistically significant when the direct method was used on the right side (t=2.33,P=0.025),although no significant difference was observed for the indirect method on the right side (t=2.00,P=0.053),direct method on the left side (t=0.34,P=0.739),and indirect method on the left side (t=-0.15,P=0.884). The clarity rates of the indirect method for the insertions were 100.0% and 95.0%,which were significantly higher than those of the direct method(right side:100.0% vs. 85.0%,P=0.026;left side:95.0% vs.60.0%,P=0.000). The clarity rates of the main trunk of the tendon showed no significant difference between direct and indirect methods on both sides (right side:100.0% vs.95.0%,P=0.494;left side:92.5% vs.87.5%,P=0.712).Conclusions When high-frequency ultrasound is applied for scanning the distal biceps tendon,the scanning time and the subjective comfort are similar when either the direct method or the indirect method is used. The indirect method has higher clarity in imaging the insertion and may be used as the preferred scanning method,whereas the direct method may serve as a supplementary method.

Utility of 360° Real-time Endoanal Sonography for Evaluation of Perianal Fistulas.

OBJECTIVES: To assess the diagnostic accuracy and performance of 360° endoanal sonography for preoperative evaluation of perianal fistulas using surgical results as a reference standard. METHODS: Between January 2012 and May 2016, 122 patients with suspicious anal fistulas and perianal abnormalities had real-time endoanal sonographic examinations using a 360° cross-sectional endoanal transducer (5-13 MHz) for preoperative evaluation of the disease. All patients underwent surgical interventions. The sonographic findings, including the fistulas and other inflammatory lesions, were correlated with surgical results. The types of fistulas on endoanal sonography were compared with the surgical classification of Parks et al (Br J Surg 1976; 63:1-2), and the internal opening of the fistula on endoanal sonography was confirmed by surgical results as a reference standard. RESULTS: The 122 patients studied included 111 male and 11 female patients. Endoanal sonography was able to show and track hypoechoic lesions, their locations, and internal openings of the fistulas. Compared with surgical results, endoanal sonography had sensitivity of 92.2%, specificity of 100%, and accuracy of 93.4% for the diagnosis of perianal fistulas. Also, endoanal sonography had accuracy of 87.4% for determining fistula types based on the Parks classification and 94.6% for identifying internal openings of the fistulas. CONCLUSIONS: Endoanal sonography is an accurate and noninvasive imaging modality for evaluation of fistulas. It is a very useful tool for preoperative management and surgical planning by providing precise and detailed information on fistulas.

[Value of Elasticity Contrast Index of Ultrasonography in Differentiating Benign and Malignant Cervical Lymph Nodes].

Objective To investigate the diagnostic value of elasticity contrast index(ECI)in the differential diagnosis between benign and malignant cervical lymph nodes.Methods Cervical lymph nodes of 48 patients were examined by traditional ultrasound and ECI in Peking University Third Hospital between December 2016 and April 2017. Patients were further divided into free-hand group and non-free-hand group according to the use of manual compression or not. With pathological or clinical follow-up results as the gold standard,we compared the diagnostic values of traditional ultrasound,ECI,and their combination in the differential diagnosis between benign and malignant lymph nodes.Results Totally 138 lymph nodes were collected from 46 patients,among which 76 were benign and 62 were malignant. The ECI value of malignant lymph nodes(1.69±0.89)were significantly higher than that of benign lymph nodes(1.32±0.87)(t=-2.46,P=0.015).The area under receiver operating characteristic(ROC)curve for traditional ultrasound in discrimination of malignant cervical lymph nodes with benign ones was 0.899,with an optimal cut-off value of 7,which had a sensitivity of 93.5% and a specificity of 84.2%. The area under ROC curve for ECI was 0.649,with an optimal cut-off value of 1.25,which had a sensitivity of 59.7% and a specificity of 60.5%. For their combination,the area under ROC curve was 0.724,with a sensitivity of 93.5% and a specificity of 51.3%. In the group without using free-hand technique,the mean ECI value was 1.77±0.94 for malignant nodes,which was significantly higher than that(1.26±0.81)for benign nodes(t=-3.09,P=0.003). In the group requiring free-hand technique,the ECI value for malignant nodes was 1.33(1.01,1.44),showing no significant difference with benign ones[1.32(0.78,2.18);z=-0.20,P=0.843].Conclusions Conventional ultrasound has higher diagnostic value than ECI and their combination in differentiating benign and malignant lymph nodes. The role of ECI in evaluating other organs requires further investigations.

[Persistent hypertension for two months in a preterm infant].

A boy aged 2 months (born at 36 weeks of gestation) was admitted due to cough and dyspnea. After admission, he was found to have persistent hypertension, proteinuria, and persistent convulsion, and imaging examination showed extensive calcification of the aorta and major branches and stenosis of local lumens of the abdominal aorta and the right renal artery with increased blood flow velocity. The boy was admitted during the neonatal period due to wet lung and pulmonary arterial hypertension and was found to have hypertension and proteinuria. High-throughput whole-exome sequencing was performed and found two compound heterozygous mutations in the ENPP1 gene from his parents, c.130C>T (p.Q44X) and c.1112A>T (p.Y371F). c.130C>T was a nonsense mutation, which could cause partial deletion of protein from 44 amino acids, and was defined as a primary pathogenic mutation. c.1112A>T was a missense mutation which had been reported as a pathogenic mutation associated with idiopathic infantile arterial calcification (IIAC). Therefore, he was diagnosed with IIAC. He was given phosphonate drugs, antihypertensive drugs, anticonvulsion treatment, and respiratory support. Blood pressure was maintained at the upper limit of normal value. There was no deterioration of arterial calcification. It is concluded that IIAC should be considered for infants with persistent hypertension and extensive vascular calcification, and imaging and genetic examinations should be performed as early as possible to make a confirmed diagnosis.

Value of Shear Wave Elastography Versus Contrast-Enhanced Sonography for Differentiating Benign and Malignant Superficial Lymphadenopathy Unexplained by Conventional Sonography.

OBJECTIVES: This study aimed to compare the efficacy of shear wave elastography (SWE) and contrast-enhanced sonography in the differential diagnosis of superficial lymphadenopathy with abnormal imaging findings, which could not be otherwise confirmed by conventional sonography. METHODS: Forty-two enlarged superficial lymph nodes in 42 patients who met the screening criteria for this study were evaluated by both contrast-enhanced sonography and SWE. All lymph nodes underwent both methods using biopsy pathologic findings as a reference standard. RESULTS: The maximum elastic modulus, mean elastic modulus, and standard deviation of the elastic modulus were the main distinguishing features on SWE; they were significantly higher in malignant lesions than benign ones. The threshold value for the maximum elastic modulus was set at 37.9 kPa, and the sensitivity, specificity, and accuracy of differential diagnosis of superficial lymph nodes were 81.8%, 80.0%, and 81.0%, respectively. The diagnosis of benignity and malignancy by this index was statistically significant (P < .001). The lymph nodes were divided into benign and malignant groups according to different types based on the degree and range of intensity on contrast-enhanced sonography: intense or moderate homogeneous enhancement (n = 26) and heterogeneous, low homogeneous, or absent enhancement (n = 16). The sensitivity, specificity, and accuracy of contrast-enhanced sonography were 27.3%, 50.0%, and 38.1%. There was no statistically significant difference in the values between the benign and malignant groups (χ2 = 2.295; P = .130). CONCLUSIONS: Compared with contrast-enhanced sonography, SWE has better diagnostic value and efficiency in differentiation of superficial lymph nodes unexplained by conventional sonography. When conventional sonography cannot differentiate malignant superficial lymph nodes from benign ones, SWE is a useful adjunctive tool for assessment of lymph nodes.

[Sonographic fingdings of pectoralis major and its tears].

OBJECTIVE: To investigate the normal sonographic anatomic characteristics of the pectoralis major and the clinical value of ultrasound in diagnosing the extent and location of the pectoralis major tears. METHODS: High frequency transducer was used in scanning the pectoralis major. The ultrasonographic images of 40 normal pectoralis major were obtained from 20 healthy volunteers with both sides. Longitudinal and transversal views were performed and stored. The distal tendon was identified in the transverse plane coursing superficially to the long head of the biceps brachii tendon inferior to the level of the subscapularis tendon. Eighteen cases of pectoralis major tears were analyzed retrospectively,with MRI, surgical and ultrasound follow -up RESULTS correlation respectively. RESULTS: High-frequency ultrasound could clearly show the anatomic orientation of the normal pectoralis major. The fibers converge was like a fan into three laminae that twisted upon each other at 90° before coalescing into a single tendon of insertion. In the study, 18 patients of pectoralis major muscle tears [average age: (37.2 ± 15.6) years] sustained injuries during weightlifting, basketball and impact. Three of the eighteen patients had MRI results; nine had surgical correlation; six were followed by ultrasound. Eleven were injured on the left side, and 7 on the right side. Seven were involved in the distal tendon (1 in sternal head, 2 in clavicular head, 4 in both sternal and clavicular head), five were involved the musculotendinous junction, 6 were involved muscle belly. Twelve cases were partial-thickness petoralis major tears (4 in the distal tendon, four in the muscle tendon junction,4 in the muscle belly),with the partial fiber intact, echogenicity decreased and the internal structure disordered; 6 cases (3 in the distal tendon, 1 in the muscle tendon junction, 2 in pectoralis major muscle belly) were completely disrupted, with fiber fracture and retraction, accompanied with or without hematoma formation. CONCLUSION: High-frequency ultrasound can clearly show the anatomic structure of the pectoralis major. Ultrasonography can diagnose the pectoralis major tears with the extent and location of injuries,and can be used to help the clinical treatment.

Evaluation of the Morphology and Function of Medial Collateral Ligament afterTotal Knee Arthroplasty with High-frequency Ultrasound.

Objective To explore the feasibility and clinical value of ultrasonography in evaluating the morphology and function of medial collateral ligaments (MCL) after total knee arthroplasty (TKA). Methods Totally 38 patients undergoing routine KTA (group A) and 22 patients undergoing constrained condylar knee arthroplasty KTA with MCL injury (group B) were included. Long axis views of MCL were taken and the MCL thickness was measured on femur side and tibial side 1 cm away from the joint line, respectively. The thicknesses were compared between the two groups. Subsequently, the gap between the metal part of the femoral prosthesis and the spacer after dynamic valgus stress was measured. The distribution and composition of the gap between the two groups were compared. Results High-frequency ultrasound clearly showed the prosthesis and MCL after TKA. MCL fiber structures of both groups were intact. The MCL thickness on the tibial side in group B was (0.25±0.06)cm, which was significantly thinner than group A [(0.32±0.14)cm] (t=2.12, P=0.040).For the femur side, there was no significant difference (t=1.65, P=0.110) between these two groups [(0.37±0.09) cm in group B versus (0.42±0.12)cm in group A]. Under the condition of valgus stress, the gaps between the metal part of the femoral prosthesis and the spacer could be found in 11 cases in group B but only in 1 case in group A. The proportion of gaps in group B was significantly higher than that in group A (Fisher's exact test, P=0.000). Conclusions High-frequency ultrasound can clearly show the prosthesis and MCL after TKA. The injured MCL can be well joined but the thickness is thinner. Under the condition of valgus stress of the knee, the stability of the TKA can be evaluated according to the gap between the prosthesis and the spacer.