Clinical application of breast elastography: State of the art

Breast elastography is a new sonographic imaging technique for the characterization of focal breast lesions in addition to conventional ultrasonography (US) and mammography. Elastography provides a non-invasive evaluation of the stiffness of a lesion. Two different technical approaches are available for clinical use: free-hand elastography (USE) and shear wave elastography (SWE). Initial results of these techniques in clinical trials suggest that elastography substantially improves the US capability in differentiating benign from malignant breast lesions, thus reducing the number of breast biopsies in benign nodules. This review paper, based on an extensive literature search, highlights the basics of breast elastography, including main technical features, how to do suggestions, limit and pitfalls, and presents the results of major clinical studies. © 2013 Elsevier Ireland Ltd. All rights reserved

Neuroendocrine lung cancer presenting as a breast lump

We report the case of a 54-year-old woman presenting to our attention for a palpable breast lump. The mammographic examination showed multiple round/oval areas of increased opacity spread on both breasts. The ultrasonographic examination showed multiple hypo-anechoic nodularities without retro-tumor acoustic shadowing. The mammo/ultrasonographic findings were worthy of histological analysis, thus we performed a ultrasound (US)-guided core-biopsy, obtaining a histological diagnosis of neuroendocrine carcinoma, probably originating from the lungs. The subsequent whole body CT scan, performed to search the primary neoplasm, put in evidence a neoplasm in the left lung, involving the pulmonary hilum, and infiltrating the bronchial branches. Moreover, there were multiple secondary lesions involving adrenal glands, brain and bowel. A review of the literature confirmed that breast lumps may be the first manifestation of a metastatic disease

Prospective evaluation of acoustic radiation force impulse technology in the differentiation of thyroid nodules: accuracy and interobserver variability assessment

PURPOSE: The aim of this study is to assess the diagnostic efficacy and interobserver agreement of acoustic radiation force impulse (ARFI) elasticity imaging in differentiating thyroid nodules. METHODS: In our study, 74 consecutive patients (52 females, 22 males; age range 27–77 years, mean: 41 years) with 82 thyroid nodules (60 benign nodules, and 22 malignant) were examined by two radiologists with different experience. Patients underwent either cytology using fine needle aspiration cytology or thyroid surgery. The diagnostic performance of the two operators at ARFI with sensitivity, specificity, positive predictive and negative predictive value, and ROC curves was estimated. Inter-reader variability between the two operators was defined using Cohen’s k. RESULTS: According to receiver operating characteristics ROC curves (AUROC = 0.86 for observer 1; 0.81 for observer 2) sensitivity, specificity, PPV and NPV of reader 1 and 2 were respectively: 90, 75, 90.91 and 96.55 %; (cut-off value of shear wave: 2.455 m/s); 90, 72, 90 and 96.90 % (cut-off value shear wave: 2.365 m/s). Concordance between the two operators was good (k = 0.755). CONCLUSIONS: This work is a feasibility study evaluating ARFI imaging. Its results suggest that ARFI imaging is a reproducible method which can be utilized with good diagnostic performance in the thyroid for discriminating benign and malignant nodules using the cut-off value of 2.455 m/s. However, larger studies are needed to validate this method

Skin thickening as unique pathologic sign of an inflammatory breast cancer: a case report and review of the literature.

We report the case of a 42-year-old woman with inflammatory cancer of the right breast treated with neoadjuvant chemotherapy, surgery, additional chemotherapy, and consolidative radiotherapy (RT), that has metastatized to the chest wall and presented a resumption of disease on the contralateral breast. Magnetic Resonance (MR), performed after the second phase's fourth round of additional chemotherapy, showed a modest reduction of scar metastases on the right and a contralateral anomalous skin thickening with high signal intensity in T2 weighted images (WI) with multiple mass-like enhancements located in a wide area of the central region at the union of higher quadrants. These findings were suggestive for resumption of contralateral disease; the biopsy confirmed an inflammatory breast cancer (IBC) infiltrating lobular type with high mitotic rate. A retrospective evaluation of the previous MR exam, performed 5 months before, was conducted: on the left side only a modest skin thickening was found as an early sign. A careful review of the literature has confirmed that skin thickening, increased density and clinical signs of inflammation are the most common findings in inflammatory cancer. We report the case of a patient affected by IBC whose unique early sign of resumption on the contralateral breast was skin thickening

Ultrasound elastography in the evaluation of thyroid pathology. Current status

Thyroid pathology including thyroid nodules and diffuse thyroid diseases represents often a diagnosing challenge for clinicians. US, although highly accurate in identifying thyroid nodules and diffuse thyroid diseases, is still not sufficiently accurate to evaluate them. US-elastography has been introduced in order to further increase US accuracy in many fields and eventually for thyroid disease. The aim of the present paper it to provide an update of the literature on different available techniques and the results reported both for thyroid nodules differentiation and for diffuse thyroid disease evaluation. Advantages and limitations of elastography are also discussed. (C) 2013 Published by Elsevier Ireland Ltd

Feasibility of 3.0 T pelvic MR imaging in the evaluation of endometriosis

Introduction: Endometriosis represents an important clinical problem in women of reproductive age with high impact on quality of life, work productivity and health care management. The aim of this study is to define the role of 3 T magnetom system MRI in the evaluation of endometriosis. Materials and methods: Forty-six women, with transvaginal (TV) ultrasound examination positive for endometriosis, with pelvic pain, or infertile underwent an MR 3.0 T examination with the following protocol: T2 weighted FRFSE HR sequences, T2 weighted FRFSE HR CUBE 3D sequences, T1 w FSE sequences, LAVA-flex sequences. Pelvic anatomy, macroscopic endometriosis implants, deep endometriosis implants, fallopian tube involvement, adhesions presence, fluid effusion in Douglas pouch, uterus and kidney pathologies or anomalies associated and sacral nervous routes were considered by two radiologists in consensus. Laparoscopy was considered the gold standard. Results: MRI imaging diagnosed deep endometriosis in 22/46 patients, endometriomas not associated to deep implants in 9/46 patients, 15/46 patients resulted negative for endometriosis, 11 of 22 patients with deep endometriosis reported ovarian endometriosis cyst. We obtained high percentages of sensibility (96.97%), specificity (100.00%), VPP (100.00%), VPN (92.86%). Conclusion: Pelvic MRI performed with 3 T system guarantees high spatial and contrast resolution, providing accurate information about endometriosis implants, with a good pre-surgery mapping of the lesions involving both bowels and bladder surface and recto-uterine ligaments. (C) 2011 Elsevier Ireland Ltd. All rights reserved

Beyond laparoscopy: 3-T magnetic resonance imaging in the evaluation of posterior cul-de-sac obliteration

Objectives: Endometriosis is the ectopic localization of endometrial glands. Symptoms include a wide variety of chronic pelvic pain. Ovarian endometriosis represents the most frequent site of implantation followed by the Douglas pouch which is undepicted unless peritoneal fluid is present. Pelvic exams may be reported as normal in 40% of evaluations, although multiple nodularities are located in this region. Nowadays, laparoscopy represents the standard technique for endometriosis evaluation. However, magnetic resonance imaging (MRI) remains the best noninvasive technique for the evaluation of pelvic lesions. According to the importance of a precise preoperative diagnosis of deep infiltrative endometriosis involving the Douglas pouch, we evaluated feasibility of a 3-T system in the evaluation of this particular region. Methods: We enrolled 19 women coming with either ultrasound or anamnestic suspicion of endometriosis. Pelvic MRI examination was performed on the 3-T system. We applied a standard exam protocol including pulse sequences [single-shot fast spin echo (FSE)] and high-resolution T2W and T1W FSE sequences with and without FS. Results: MRI diagnosed posterior cul-de-sac obliteration in 15/19 patients. MRI findings were compared with laparoscopy, thus obtaining the following statistical values: mean sensitivity, specificity, positive predictive value and negative predictive value, respectively, of 93%, 75%, 93% and 75%. Moreover, we calculated an interobserver agreement k value of 0.72 with a substantial degree of agreement between two radiologists of a sensitivity value of 93% and specificity value of 75%. Conclusions: Precise preoperative mapping of posterior cul-de-sac region is essential for a preoperative planning. In our work, the 3-T MRI was shown to be excellent in the evaluation of posterior cul-de-sac obliteration associated to an optimal evaluation of the uterosacral ligaments due to the higher contrast spatial resolution. (C) 2012 Elsevier Inc. All rights reserved

Diagnostic accuracy and interobserver agreement of quasistatic ultrasound elastography in the diagnosis of thyroid nodules

Purpose: To assess the best technique and the diagnostic accuracy of Quasistatic Ultrasound Elastography (QUE) in thyroid nodules. Interobserver agreement was also evaluated. Materials and Methods: A preliminary study of 50 patients with 54 thyroid nodules was performed with quantitative software in order to define the best cut-off value of different imaging methods. All patients underwent total thyroidectomy and histopathology findings served as the standard of reference. Thereafter, 154 nodules in 137 consecutive patients were prospectively evaluated by three operators. Findings at fine-needle aspiration cytology and histopathology (N = 60) served as the standard of reference. Results: The most accurate technique was the axial peri-intranodular measurement method which achieved an area under the ROC curve of 0.961 (95 %CI 0.848 - 1.00) and had an optimal cut-off value of 3.00. QUE in the differentiation of thyroid nodules showed for operator 1: sensitivity 90 % (95 %CI 73.5 - 97.9 %), specificity 92.7 % (95 %CI 86.7 - 96.6 %), LR+ 12.40 (6.54 - 23.50), LR- 0.11 (0.04 - 0.32) and accuracy 91.4 % (95 %CI 85.4 - 97.3 %); for operator 2: sensitivity 86.7 % (95 %CI 69.3 - 96.2 %), specificity 87.1 % (95 %CI 79.9 - 92.4 %), LR+ 6.72 (4.16 - 10.80), LR- 0.15 (0.06 - 0.38) and accuracy 86.9 % (95 %CI 80.0 - 93.7 %); for operator 3: sensitivity 80 % (95 %CI 61.4 - 92.3 %), specificity 83.9 % (95 %CI 76.2 - 89.9 %), LR+ 4.96 (3.20 - 7.70), LR- 0.24 (0.12 - 0.49) and accuracy 81.9 % (95 %CI 74.0 - 89.9 %). Interobserver agreement values between operator 1 and operator 2 (k = 0.79) (p < 0.05, 95 %CI 0.684 - 0.904), between operator 1 and operator 3 (k = 0.73, 95 %CI: 0.607 - 0.854) and between operator 2 and operator 3 (k = 0.71, 95 %CI: 0.584 - 0.835) were significant. Conclusion: QUE provides accurate quantitative evaluation of thyroid nodules with low interobserver variability. © Georg Thieme Verlag KG Stuttgart · New York

Ultrasound evaluation of liver fibrosis: preliminary experience with acoustic structure quantification (ASQ) software

The aim of our study was to assess the diagnostic accuracy of acoustic structure quantification (ASQ) ultrasound software in estimating the degree of hepatic fibrosis compared to Fibroscan and liver biopsy. Seventy-seven patients with chronic viral hepatitis B and C underwent standard ultrasound examination, ASQ, Fibroscan and liver biopsy. ASQ analysis was conducted by placing a single region of interest (ROI) on each image captured, and calculating mode, average and standard deviation. The sonographic technique was developed through a preliminary evaluation of 20 healthy volunteers. The area under the receiver operating characteristic (AUROC) curve for the diagnosis of cirrhosis (Fa parts per thousand yen4) with ASQ was 0.77, whereas for the diagnosis of any degree of fibrosis (Fa parts per thousand yen1) it was 0.71. The AUROC for the diagnosis of cirrhosis (Fa parts per thousand yen4) with Fibroscan was 0.98, while for the diagnosis of any degree of fibrosis (Fa parts per thousand yen1) it was 0.94. The difference between the AUROC was statistically significant (p < 0.05). ASQ is a promising new ultrasound software programme which offers encouraging results in the diagnosis of both liver cirrhosis (F=4) and fibrosis (Fa parts per thousand yen1). However, to date it has not attained the same level of diagnostic performance as Fibroscan

Prospective evaluation in 123 patients of strain ratio as provided by quantitative elastosonography and multiparametric ultrasound evaluation (ultrasound score) for the characterisation of thyroid nodules.

This study was done to compare quantitative elastosonography and ultrasound analysis in the characterisation of thyroid nodules. From July 2009 to September 2011, 123 patients with 147 thyroid nodules were included in our study. All patients enrolled had to undergo thyroidectomy because of nodular thyroid disease (goitre or nodules). After preliminary examination with conventional ultrasound (US) and colour Doppler US, the patients were examined with elastosonography, using high-level equipment (Toshiba Aplio XG) and quantitative software (Elasto-Q). Each lesion was characterised using an US score (echogenicity, borders, microcalcifications and colour Doppler pattern), and then by elastosonographic strain ratio. Each patient subsequently underwent thyroidectomy. Histological results were used as the gold standard. Histological examination demonstrated 89 benign and 58 malignant lesions. On average, the strain ratio value was 2.84±2.69 (range, 0.05-14.5; p=0.001). Sensitivity and specificity of the US score were about 56% and 72%, respectively, whereas those of the strain ratio were 93% and 89%, using a cut-off of 2 obtained with receiver operating characteristic (ROC) curve analysis. Elastosonography was more accurate than US and colour Doppler US in characterising thyroid nodules (p=0.002). Quantitative elastosonography is a useful diagnostic tool in the evaluation of thyroid lesions, and can be used to limit fine-needle aspiration cytology and improve the selection of patients for thyroidectomy