The value of microvascular Doppler ultrasound technique, qualitative or quantitative shear-wave elastography of breast lesions for predicting axillary nodal burden in patients with breast cancer.

Background: The status of the axillary lymph node (ALN) in patients with breast cancer can critically inform clinical decision-making and prognosis. Preoperative evaluation of limited nodal burden (0-2 metastatic ALNs) and high nodal burden (≥3 metastatic ALNs) is vital for individual treatment in patients with breast cancer. Thus, this study aimed to evaluate the value of Angio-PLUS (AP; Aixplorer, SuperSonic Imagine) and the qualitative and quantitative shear-wave elastography (SWE) of breast lesions to predict limited or high axillary nodal burden and to develop a model for predicting limited or high axillary nodal burden. Methods: From March 2020 to November 2022, a total of 232 consecutive patients with breast cancer comprising 232 breast lesions were enrolled retrospectively from Yueyang Central Hospital. The sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), accuracy, and area under the receiver operating characteristic curve (AUC) of AP, qualitative SWE, quantitative SWE, and the predictive model for evaluating limited or high axillary nodal burden were compared. Results: There was no significant difference in AP patterns between the limited nodal burden group and high nodal burden group. The best cutoff values of Emin (the minimal value of the first Q-box), Emean (the mean value of the first Q-box), Emax (the maximum value of the first Q-box), Eratio (ratio of the first Q-Box and the second Q-Box) and standard deviation for predicting limited or high nodal burden were 80.85 KPa, 133.45 KPa, 153.40 KPa, 9.95, and 19.25 KPa, respectively. The Emax had the highest AUC, and its sensitivity, specificity, PPV, NPV, accuracy, and AUC were 71.64%, 56.36%, 40.00%, 83.04%, 60.78%, and 0.640 [95% confidence interval (CI): 0.575-0.702], respectively. The sensitivity, specificity, PPV, NPV, accuracy, and AUC of seven color patterns for qualitative SWE were 71.64%, 74.55%, 53.33%, 86.62%, 73.71%, and 0.731 (95% CI: 0.669-0.787), respectively, which was significantly higher than all the other quantitative SWE parameters. ALN evaluation in ultrasound and qualitative SWE were independent risk factors for predicting limited or high nodal burden according to a binary logistics regression analysis. The AUC of the predictive model based on independent risk factors was 0.820 (95% CI: 0.765-0.867), which was significantly higher than that of the other independent risk factors. Conclusions: The seven color patterns in the qualitative SWE of breast lesions were valuable for predicting limited or high nodal burden for patients with breast cancer. Compared with quantitative SWE, qualitative SWE exhibited a better diagnostic performance. Breast lesions present no findings, vertical stripes, and spot patterns were important indicators for limited nodal burden. The predictive model developed in this study could be a simple, noninvasive, and convenient method for predicting limited or high nodal burden, which would be beneficial for clinical decision-making and individual treatment to improve prognosis.

The value of quantitative and a new qualitative color pattern shear wave elastography for the differentiation of ACR TI-RADS 4 or 5 category thyroid nodules measuring ≤10 mm.

Objective: This study aims to evaluate the diagnostic performance of quantitative shear wave elastography (SWE) and a new qualitative color pattern SWE for the differentiation of benign and malignant American College of Radiology Thyroid Imaging, Reporting, and Data System (ACR TI-RADS) 4 or 5 category thyroid nodules measuring ≤10 mm. Materials and methods: From May 2020 to July 2022, a total of 237 patients with 270 thyroid nodules were enrolled, and conventional ultrasound and SWE examinations were performed for each patient. Each ACR TI-RADS 4 or 5 category thyroid nodule measuring ≤10 mm was evaluated by quantitative SWE and a new qualitative color pattern SWE. The diagnostic performance of quantitative SWE parameters, the new qualitative color pattern SWE, and the combination of SWE with ACR TI-RADS, respectively, for the differentiation of benign and malignant ACR TI-RADS 4 or 5 category thyroid nodules measuring ≤10 mm was evaluated and compared. Results: Among 270 thyroid nodules in 237 patients, 72 (26.67%) thyroid nodules were benign and 198 (73.33%) thyroid nodules were malignant. The qualitative color pattern SWE showed better diagnostic performance than the quantitative SWE parameters. When combining the qualitative color pattern SWE with ACR TI-RADS scores, with the optimal cutoff value of the total points ≥8, the thyroid nodules were considered malignant. The sensitivity, specificity, accuracy, and AUC were 89.90%, 56.94%, 81.11%, and 0.820 (95% CI: 0.768-0.864), respectively. Compared with using qualitative color pattern SWE alone, the combination of qualitative color pattern SWE and ACR TI-RADS had better diagnostic performance, which was significantly different (p < 0.05). Conclusion: The combination of qualitative SWE color patterns and ACR TI-RADS had high sensitivity and accuracy, which might be a convenient and useful method to differentiate benign and malignant ACR TI-RADS 4 or 5 category thyroid nodules measuring ≤10 mm. It would be helpful for the management of thyroid nodules and improving prognosis.

A model based on clinical data and multi-modal ultrasound for predicting cervical lymph node metastasis in patients with thyroid papillary carcinoma.

Objective: The aim of this study was to explore diagnostic performance based on clinical characteristics, conventional ultrasound, Angio PLUS (AP), shear wave elastography (SWE), and contrast-enhanced ultrasound (CEUS) for the preoperative evaluation of cervical lymph node metastasis (CLNM) in patients with papillary thyroid carcinoma (PTC) and to find a reliable predictive model for evaluating CLNM. Materials and methods: A total of 206 thyroid nodules in 206 patients were included. AP, SWE, and CEUS were performed for all thyroid nodules. Univariate analysis and multivariate logistic regression analysis were performed to ascertain the independent risk factors. The sensitivity, specificity, and the area under the curve (AUC) of independent risk factors and the diagnostic model were compared. Results: Sex, age, nodule size, multifocality, contact extent with adjacent thyroid capsule, Emax, and capsule integrity at CEUS were independent risk predictors for CLNM in patients with PTC. A predictive model was established based on the following multivariate logistic regression: Logit (p) = -2.382 + 1.452 × Sex - 1.064 × Age + 1.338 × Size + 1.663 × multifocality + 1.606 × contact extent with adjacent thyroid capsule + 1.717 × Emax + 1.409 × capsule integrity at CEUS. The AUC of the predictive model was 0.887 (95% CI: 0.841-0.933), which was significantly higher than using independent risk predictors alone. Conclusion: Our study found that male presence, age < 45 years, size ≥ 10 mm, multifocality, contact extent with adjacent thyroid capsule > 25%, Emax ≥ 48.4, and interrupted capsule at CEUS were independent risk predictors for CLNM in patients with PTC. We developed a diagnostic model for predicting CLNM, which could be a potentially useful and accurate method for clinicians; it might be beneficial to surgical decision-making and patient management and for improving prognosis.

Z-score model of foetal ascending aorta diameter distensibility.

Objective: The purpose of this study is to establish Z-scores models of normal fetal ascending aorta diameter and diameter distensibility. Methods: The maximum systolic diameter (Dmax), minimum diastolic diameter (Dmin), and diameter distensibility of the sinotubular junction were measured and taken as dependent variables in 490 normal fetuses at 18-40 gestational weeks, and gestational age (GA), biparietal diameter (BPD), and femoral length (FL) were taken as independent variables. The data were subjected to regression analysis, and the best-fitting equations for the dependent variables based on the independent variables were determined. The fitting equations were then applied to construct the Z-scores models. Results: The Dmax, Dmin and Diameter Distensibility in normal fetuses between 18 and 40 weeks of GA could be evaluated by utilizing the Z-scores models. Dmax and Dmin increased significantly with increasing GA, BPD, and FL. Diameter distensibility, assessed as (Dmax-Dmin)/Dmin, decreased significantly with increasing GA, BPD, and FL. Conclusion: The Z-scores are valuable, and can be utilized as a potent supplement to the conventional approach as they can indirectly reflect the development of fetal ascending aortic elastic property.

Combined Use of Shear Wave Elastography, Microvascular Doppler Ultrasound Technique, and BI-RADS for the Differentiation of Benign and Malignant Breast Masses.

Objective: To evaluate the value of the combined use of Breast Imaging Reporting and Data System (BI-RADS), qualitative shear wave elastography (SWE), and AngioPLUS microvascular Doppler ultrasound technique (AP) for distinguishing benign and malignant breast masses. Materials and Methods: A total of 210 pathologically confirmed breast lesions in 210 patients were reviewed using BI-RADS, qualitative SWE, and AP. The sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), accuracy, and area under the receiver operating characteristic curve (AUC) of BI-RADS and the combination of qualitative SWE and/or AP with BI-RADS were compared, respectively. Results: Compared with using BI-RADS alone, the use of combined qualitative SWE and/or AP with BI-RADS had higher AUC values (P < 0.001). Besides this, the combination of qualitative SWE and AP with BI-RADS had the best diagnostic performance for differentiating between benign and malignant masses. When AP and SWE were combined with BI-RADS, 49/76 benign masses were downgraded from BI-RADS category 4a into BI-RADS category 3, while no benign masses were upgraded from BI-RADS category 3 into BI-RADS category 4a. Three sub-centimeter malignant masses were downgraded from BI-RADS category 4a into BI-RADS category 3, while three malignant masses remain in BI-RADS category 3 due to a benign manifestation in both AP and qualitative SWE. Moreover, 5/6 of them were sub-centimeter masses, and 4/6 of them were intraductal carcinoma. The sensitivity, specificity, PPV, NPV, accuracy, and AUC were 91.0%, 81.1%, 69.3%, 95.1%, 84.3%, and 0.861 (95% confidence interval, 0.806-0.916; P < 0.001), respectively. Compared with BI-RADS alone, the sensitivity slightly decreased, while the specificity, PPV, NPV, and accuracy were significantly improved. Conclusion: Combination of qualitative SWE and AP with BI-RADS improved the diagnostic performance in differentiating benign from malignant breast lesions, which is helpful for avoiding unnecessary biopsies. However, we should be careful about the downgrading of sub-centimeter BI-RADS 4a category lesions.

Ultrasound elastography.

Physicians have used palpation as a diagnostic examination to understand the elastic properties of pathology for a long time since they realized that tissue stiffness is closely related to its biological characteristics. US elastography provided new diagnostic information about elasticity comparing with the morphological feathers of traditional US, and thus expanded the scope of the application in clinic. US elastography is now widely used in the field of diagnosis and differential diagnosis of abnormality, evaluating the degree of fibrosis and assessment of treatment response for a range of diseases. The World Federation of Ultrasound Medicine and Biology divided elastographic techniques into strain elastography (SE), transient elastography and acoustic radiation force impulse (ARFI). The ARFI techniques can be further classified into point shear wave elastography (SWE), 2D SWE, and 3D SWE techniques. The SE measures the strain, while the shear wave-based techniques (including TE and ARFI techniques) measure the speed of shear waves in tissues. In this review, we discuss the various techniques separately based on their basic principles, clinical applications in various organs, and advantages and limitations and which might be most appropriate given that the majority of doctors have access to only one kind of machine.

Contrast-enhanced ultrasound and shear wave elastography in the diagnosis of ACR TI-RADS 4 and 5 category thyroid nodules coexisting with Hashimoto's thyroiditis.

Objective: This study aims to evaluate the value of contrast-enhanced ultrasound (CEUS), shear wave elastography (SWE), and their combined use in the differentiation of American College of Radiology (ACR) thyroid imaging reporting and data system (TI-RADS) 4 and 5 category thyroid nodules coexisting with Hashimoto's thyroiditis (HT). Materials and methods: A total of 133 pathologically confirmed ACR TI-RADS 4 and 5 category nodules coexisting with HT in 113 patients were included; CEUS and SWE were performed for all nodules. The sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), accuracy, and the area under the receiver operating characteristic curve (AUC) of the SWE, CEUS, and the combined use of both for the differentiation of benign and malignant nodules were compared, respectively. Results: Using CEUS alone, the sensitivity, specificity, PPV, NPV, and accuracy were 89.2%, 66.0%, 81.3%, 78.6%, and 80.5%, respectively. Using SWE alone, Emax was superior to Emin, Emean, and Eratio for the differentiation of benign and malignant nodules with the best cutoff Emax >46.8 kPa, which had sensitivity of 65.1%, specificity of 90.0%, PPV of 91.5%, NPV of 60.8%, and accuracy of 74.4%, respectively. Compared with the diagnostic performance of qualitative CEUS or/and quantitative SWE, the combination of CEUS and SWE had the best sensitivity, accuracy, and AUC; the sensitivity, specificity, PPV, NPV, accuracy, and AUC were 94.0%, 66.0%, 82.1%, 86.8%, 83.5%, and 0.80 (95% confidence interval: 0.713, 0.886), respectively. Conclusion: In conclusion, CEUS and SWE were useful for the differentiation of benign and malignant ACR TI-RADS 4 and 5 category thyroid nodules coexisting with HT. The combination of CEUS and SWE could improve the sensitivity and accuracy compared with using CEUS or SWE alone. It could be a non-invasive, reliable, and useful method to differentiate benign from malignant ACR TI-RADS 4 and 5 category thyroid nodules coexisting with HT.

Ultrasound Elastography for the Evaluation of Lymph Nodes.

The differential diagnosis of lymphadenopathy is important for predicting prognosis, staging, and monitoring the treatment, especially for cancer patients. Conventional computed tomography and magnetic resonance imaging characterize lymph node (LN) with disappointing sensitivity and specificity. Conventional ultrasound with the advantage of high resolution has been widely used for the LN evaluation. Ultrasound elastography (UE) using color map or shear wave velocity can non-invasively demonstrate the stiffness and homogeneity of both the cortex and medulla of LNs and can detect early circumscribed malignant infiltration. There is a need of a review to comprehensively discuss the current knowledge of the applications of various UE techniques in the evaluation of LNs. In this review, we discussed the principles of strain elastography and shear wave-based elastography, and their advantages and limitations in the evaluation of LNs. In addition, we comprehensively introduced the applications of various UE techniques in the differential diagnosis of reactive LNs, lymphoma, metastatic LNs, and other lymphadenopathy. Moreover, the applications of endoscopic UE and endobronchial UE are also discussed, including their use for improving the positive rate of diagnosis of fine-needle aspiration biopsy.

Fetal double aortic arch: prenatal sonographic and postnatal computed tomography angiography features, associated abnormalities and clinical outcomes.

BACKGROUND: Fetal double aortic arch (DAA) malformation is a rare congenital heart disease with few reported cases in the literature. We aimed to investigate the characteristics of prenatal ultrasound and postnatal computed tomography angiography (CTA) of DAA and to describe the associated anomalies and clinical outcomes to improve prenatal diagnosis and assist in perinatal management. METHODS: The obstetric ultrasound imaging databases of seven tertiary referral centers were reviewed retrospectively to identify fetuses with a prenatal diagnosis of DAA between January 2013 and December 2018. Ultrasonographic findings, associated anomalies, genetic abnormalities, postnatal CTA images, and long-term postnatal outcomes were evaluated. RESULTS: A total of 36 cases out of 40 prenatally diagnosed DAA fetuses were confirmed by postnatal diagnosis (fetal autopsy, CTA, and surgery). In this cohort of 36 confirmed cases, 24 (67%) were isolated anomalies, while 12 (33%) were associated with intracardiac or extracardiac anomalies, and 2 (6%) had a 22q11.2 chromosome deletion. Among nine cases of pregnancy termination with a fetal autopsy, 7 had other abnormalities. Among the remaining 27 live births, 16 (59%) were asymptomatic and 11 (41%) received surgical treatment due to tracheal or esophageal compression symptoms, all with satisfactory outcomes. Prenatal echocardiography showed that DAA was mainly characterized by a bifurcation of the ascending aorta into the right and left aortic arch and the formation of a complete O-shaped vascular ring around the trachea on the three-vessel tracheal view. A variant in the aortic arch branching pattern was found for the first time. The airway obstruction, branching pattern, and atretic arch of DAA were clearly shown by postnatal CTA. CONCLUSIONS: Fetal DAA has unique features on prenatal echocardiography and postnatal CTA, and systematic prenatal examination and timely postnatal CTA evaluation are required. A certain proportion of intracardiac and extracardiac abnormalities are associated with DAA, but the probability of chromosome abnormalities is low, especially for isolated DAA.The clinical outcomes of isolated DAA are favorable, even if surgery is performed due to symptoms. Determining whether other malformations or chromosomal anomalies exist is crucial for prognosis evaluation and prenatal counseling.

Comparison of Contrast-Enhanced Ultrasound versus Contrast-Enhanced Magnetic Resonance Imaging for the Diagnosis of Focal Liver Lesions Using the Liver Imaging Reporting and Data System.

The aim of this retrospective study was to evaluate the Liver Imaging Reporting and Data System (LI-RADS) categorization of focal liver lesions (FLLs) on contrast-enhanced ultrasound (CEUS) in comparison with contrast-enhanced magnetic resonance imaging (CE-MRI). A total of 63 patients with 84 FLLs were included in the final study population, after review of the electronic medical records and clinical data. Two trained radiologists evaluated all CEUS and CE-MRI images independently. They assigned a LI-RADS category to each FLL and assessed major features based on CEUS LI-RADS Version 2017 and computed tomography/MRI LI-RADS Version 2018. The generalized estimating equation method was used to compare the diagnostic performance of the LI-RADS algorithm between CEUS and CE-MRI. The sensitivity of LR-5/LR-TIV (tumor in vein) categories for diagnosing hepatocellular carcinoma (HCC) differed significantly between CEUS and CE-MRI (88.9% [40/45], 95% confidence interval [CI]: 76.5%-95.2%), versus 64.4% (29/45; 95% CI: 49.8%-76.8%), p = 0.006; 82.2% (37/45; 95% CI: 68.7%-90.7%), versus 62.2% (28/45; 95% CI: 47.6%-74.9%), p = 0.034. Inter-observer agreement was substantial for assigning LR-5 on both CEUS and CE-MRI. For both reviewers, there was a higher frequency of LR-5 (44.0% vs. 25.0%, p = 0.009; 42.9% vs. 26.2%, p = 0.023) in CEUS compared with CE-MRI. Arterial phase hyper-enhancement (APHE) was less frequently observed on CEUS than on CE-MRI (46.4% vs. 61.9%, p = 0.044). However, the washout appearance was observed more frequently on CEUS than on CE-MRI (50.0% vs. 28.6%, p = 0.004). Inter-observer agreement between the two reviewers on APHE and washout appearance was excellent for both CEUS and CE-MRI. These findings suggest that CEUS had a much higher sensitivity than CE-MRI in the diagnosis of HCC using LI-RADS, and although the frequencies of major features differed, inter-observer agreement between the two reviewers on major features of HCC was excellent for both CEUS and CE-MRI.

Nomogram Based on Shear-Wave Elastography Radiomics Can Improve Preoperative Cervical Lymph Node Staging for Papillary Thyroid Carcinoma.

Background: Accurate preoperative prediction of cervical lymph node (LN) metastasis in patients with papillary thyroid carcinoma (PTC) provides a basis for surgical decision-making and the extent of tumor resection. This study aimed to develop and validate an ultrasound radiomics nomogram for the preoperative assessment of LN status. Methods: Data from 147 PTC patients at the Wuhan Tongji Hospital and 90 cases at the Hunan Provincial Tumor Hospital between January 2017 and September 2019 were included in our study. They were grouped as the training and external validation set. Radiomics features were extracted from shear-wave elastography (SWE) images and corresponding B-mode ultrasound (BMUS) images. Then, the minimum redundancy maximum relevance algorithm and the least absolute shrinkage and selection operator regression were used to select LN status-related features and construct the SWE and BMUS radiomics score (Rad-score). Multivariate logistic regression was performed using the two radiomics scores together with clinical data, and a nomogram was subsequently developed. The performance of the nomogram was assessed with respect to discrimination, calibration, and clinical usefulness in the training and external validation set. Results: Both the SWE and BMUS Rad-scores were significantly higher in patients with cervical LN metastasis. Multivariate analysis indicated that the SWE Rad-scores, multifocality, and ultrasound (US)-reported LN status were independent risk factors associated with LN status. The radiomics nomogram, which incorporated the three variables, showed good calibration and discrimination in the training set (area under the receiver operator characteristic curve [AUC] 0.851 [CI 0.791-0.912]) and the validation set (AUC 0.832 [CI 0.749-0.916]). The significantly improved net reclassification improvement and index-integrated discrimination improvement demonstrated that SWE radiomics signature was a very useful marker to predict the LN metastasis in PTC. Decision curve analysis indicated that the SWE radiomics nomogram was clinically useful. Furthermore, the nomogram also showed favorable discriminatory efficacy in the US-reported LN-negative (cN0) subgroup (AUC 0.812 [CI 0.745-0.860]). Conclusions: The presented radiomics nomogram, which is based on the SWE radiomics signature, shows a favorable predictive value for LN staging in patients with PTC.