Yu-Lan Peng

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

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

Ultrasound Elastography of Breast Lesions in Chinese Women: A Multicenter Study in China

PURPOSE Through analysis, the elastograms characteristics of breast lesions of Chinese women, a suitable diagnostic standard of quasistatic ultrasound elastography (UE) for Chinese women was proposed. METHODS From June 2010 to March 2012, 1036 consecutive female patients (mean age, 44 years old) with breast lesions were recruited into a multicenter retrospective study, which involved 8 centers across China. Each institutional ethic review board approved the study, and all the patients gave written informed consent. All breast lesions underwent ultrasound and UE examination. Two radiologists analyzed the elastograms and separated the elastograms into 10 types. A final diagnosis was made on the basis of histologic findings. The characteristics of the elastograms were analyzed. Receiver operating characteristic curves were plotted for evaluating the diagnostic performance. Sensitivity, specificity, and accuracy were calculated. Differences in sensitivity, specificity, and accuracy were tested by using the McNemar test. RESULTS There were 1150 lesions (593 benign, 557 malignant). There was a highly significant correlation between the elastogram color distribution and the percentage of malignant lesions, with a value of 0.92 (2P < .0001). Through analysis the different malignant percentages in different elastogram types, UE diagnostic standard was proposed, which was correlated with the blue percentage in the elastogram. The specificity, sensitivity, and accuracy of UE were 86.4%, 80.8%, and 83.5%, respectively. The specificity and accuracy of UE were higher than with ultrasound. The area under the curve was 0.86. CONCLUSION UE could give valuable assessment in the diagnosis of breast lesions. The proposed UE diagnostic standard was suitable for Chinese women.

CHARACTERIZATION AND DIAGNOSTIC CONFIDENCE OF CONTRAST-ENHANCED ULTRASOUND FOR SOLID RENAL TUMORS

The objective was to determine whether contrast-enhanced ultrasound (CEUS) could improve the diagnostic confidence of solid renal masses. CEUS examinations were performed on 51 patients with renal tumors. Histologic findings from surgical specimens (n = 24) or magnetic resonance imaging follow-up (n = 27) were used as reference procedures for definitive diagnosis. Diffuse heterogeneous/homogeneous enhancement and quick peripheralnodularenhancement were found to be characteristic patterns in renal cell carcinoma (RCC). Dotlike or diffuse heterogeneous/homogeneous enhancement and slow peripheral nodular enhancement were observed as typical enhancement patterns in angiomyolipoma. The results show that CEUS combined with conventional ultrasound significantly improves diagnostic confidence. The sensitivity for RCC diagnosis with this imaging approach was 86% and the specificity was 93%. Both positive and negative predictive values of detection were 90% and the overall accuracy was 90%.

Value of Contrast-Enhanced Ultrasonography in the Differential Diagnosis of Enlarged Lymph Nodes: a Meta-Analysis of Diagnostic Accuracy Studies

OBJECTIVE To evaluate the diagnostic accuracy of contrast-enhanced ultrasonography (CEUS) in differentiating between benign and malignant enlarged lymph nodes using meta-analysis. MATERIALS AND METHODS Pubmed, Embase, SCI and Cochrane databases were searched for studies (up to September 1, 2014) reporting the diagnostic performance of CEUS in discriminating between benign and malignant lymph nodes. Inclusion criteria were: prospective study; histopathology as the reference standard; and sufficient data to construct 2?2 contingency tables. Methodological quality was assessed using Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). Patient clinical characteristics, sensitivity and specificity were extracted. The summary receiver operating characteristic curve was used to examine the accuracy of CEUS. A meta-analysis was performed to evaluate the clinical utility in identification of benign and malignant lymph nodes. Sensitivity analysis was performed after omitting outliers identified in a bivariate boxplot and publication bias was assessed with Egger testing. RESULTS The pooled sensitivity, specificity and AUROC were 0.92 (95%CI, 0.85-0.96), 0.91 (95%CI, 0.82-0.95) and 0.97 (95%CI, 0.95-0.98), respectively. After omitting 3 outlier studies, heterogeneity decreased. Sensitivity analysis demonstrated no disproportionate influences of individual studies. Publication bias was not significant. CONCLUSIONS CEUS is a promising diagnostic modality in differentiating between benign and malignant lymph nodes and can potentially reduce unnecessary fine-needle aspiration biopsies of benign nodes.

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

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

Sonography of Dermatofibrosarcoma Protuberans in the Skin Over Breast

We describe here the sonographic manifestation of the soft tissue neoplasm, dermatofibrosarcoma protuberans, which rarely occurs in the breast. Four patients had clinical features of breast mass. Sonography was performed with a high-frequency transducer (7.5-12.0MHz). Distribution of blood flow inside the tumor was studied by color Doppler. All the cases of dermatofibrosarcoma protuberans observed on the sonograms were hypoechoic, with a heterogeneous internal echo. An oval-shaped and circumscribed margin was seen in two of the tumors, whereas a lobulated shape and slightly obscured margin was noted in the other two tumors. On color Doppler, arterial blood flow signals were noted inside the tumor in three of the cases, and no significant flow signal was noticed in the remaining case. In three of the cases, the masses were in the dermal region, without infiltrating the mammary tissue, and they were diagnosed as a dermal mass. However, in the remaining case, the mass infiltrated the mammary tissue and was thus misdiagnosed as a breast mass.

Fasciitis Ossificans of the Breast

CLINICAL PRESENTATION A 62-year-old woman who incidentally found a painless lump in the upper area of the right breast for 1 week came to our hospital for examination. Physical examination revealed a mass of size 3 cm located 3 cm away from the nipple. The mass was hard and movable. Mammography examination on Mediolateral Oblique view revealed a circumscribed mass having globuse contour with prominent popcorn calcification at the 12 o9clock position of right breast (Figure 1, black arrow). Sonography examination revealed a superficial hyperechoic heterogenous mass with irregular acoustic interface and angulated margins. The angulated margin indicated possible extension of mass into the adipose tissue. Doppler examination was unremarkable. With the highly suggestive of malignancy (Breast Imaging-Report and Data System-4C), the patient went for ultrasound-guided core needle biopsy. Biopsy specimens suggested mesenchymoma, with large amounts of bone-like tissue and a small amount of fat, fiber and myxoid stroma. The diagnosis of benign breast tumor was made, but breast cancer still remained a possibility. The intraoperative frozen section also suggested benign tumor, which is consistent with the prior report. Local excision of the tumor was performed. Excised mass histopathology examination confirmed fasciitis ossificans of the breast. Fasciitis ossificans of the breast is extremely rare. Clinically, hard texture with obscure margin and a temporary course are potential pitfalls that can lead to the incorrect diagnosis of malignancy. Radiologically, mammography and ultrasonography can show an infiltrative margin and a prominent calcification mimicking breast malignancy, such as fibrosarcoma, phyllodes tumor, malignant mesenchymoma, osteosarcoma or osteochondrosarcoma. Ultrasound-guided biopsy is mandatory for preoperative diagnosis for further management. Local excision is the choice of surgical treatment. Follow-up for 12 months did not show any complications or recurrence.