Does Lesion Size Affect the Value of Shear Wave Elastography for Differentiating Between Benign and Malignant Thyroid Nodules?

Associations of Real-Time Ultrasound and Strain and Shear Wave Elastography with Gastrointestinal Organs: A Systematic Review

Ultrasound elastography is gaining attention for its diagnostic potential across various medical fields, and its physical properties make it valuable in modern clinical medicine. However, its specific attributes, especially in the context of recent medical advancements, remain relatively unexplored. This study aimed to identify instrument-specific characteristics and applications of real-time ultrasound elastography, shear wave elastography, and strain elastography, particularly within gastroenterology. Following PRISMA guidelines, the study examined elastography articles on databases like PubMed, resulting in 78 included articles. Data on patient demographics, organ involvement, specificity, sensitivity, accuracy, positive predictive value, and negative predictive value were extracted. Statistical analysis involved SPSS version 21, with significance set at p < 0.05. The majority of patients were male (50.50%), with a mean age of 42.73 ± 4.41 years. Shear wave elastography was the most prevalent technique (48.7%), and liver investigations were predominant in gastroenterology (34.6%). Gastrointestinal applications showed higher sensitivity, positive predictive value, and negative predictive values (p < 0.05) but lower specificity (p < 0.05). Real-time ultrasound elastography exhibited increased specificity, accuracy, and predictive values (p < 0.05). Ultrasound elastography appears more accurate and effective in gastroenterological settings. Nonetheless, its performance depends on instrument-specific and operator-dependent factors. While promising, further studies are necessary to ascertain optimal utilization in both gastrointestinal and non-gastrointestinal conditions.

Diagnostic efficacy of a combination of the Chinese thyroid imaging reporting and data system and shear wave elastography in detecting category 4a and 4b thyroid nodules

Objectives

Differential diagnosis of benign and malignant thyroid imaging reporting and data system (TIRADS) category 4a and 4b nodules can be difficult using conventional ultrasonography (US). The objective of this study was to evaluate the diagnostic efficacy of a combination of the Chinese-TIRADS (C-TIRADS) and shear wave elastography (SWE) in detecting malignant nodules among category 4a and 4b thyroid nodules.

Methods

Among 409 thyroid nodules in 332 patients that we included in this study, 106 thyroid nodules were diagnosed as category 4a and 4b using C-TIRADS. We used SWE to measure the maximum Young's modulus (Emax) values of category 4a and 4b thyroid nodules. We calculated the diagnostic efficacy of only the C-TIRADS, only SWE, and a combination of C-TIRADS with SWE, and compared these, while taking the pathology results as the gold standard.

Results

The area under the ROC curve (AUC), sensitivity, and accuracy values of the combination of C-TIRADS and SWE (0.870, 83.3%, and 84.0%, respectively) were all higher when compared with the values of only the C-TIRADS (0.785, 68.5%, and 78.3%, respectively) or only SWE (0.775, 68.5%, and 77.4%, respectively) in the diagnosis of category 4a and 4b thyroid nodules.

Conclusion

In this study, we found that the combination of C-TIRADS and SWE significantly improved the diagnostic efficacy in detecting malignant nodules among category 4a and 4b thyroid nodules, and this could provide a reference for further use of this combination by clinicians for diagnosis and treatment.

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.

Combined Shear Wave Elastography and EU TIRADS in Differentiating Malignant and Benign Thyroid Nodules

Although multimodal ultrasound approaches have been suggested to potentially improve the diagnosis of thyroid cancer; the diagnostic utility of the combination of SWE and malignancy-risk stratification systems remains vague due to the lack of standardized criteria. The purpose of the study was to assess the diagnostic value of the combination of grey scale ultrasound assessment using EU TIRADS and shear wave elastography. 121 patients (126 nodules−81 benign; 45 malignant) underwent grey scale ultrasound and SWE imaging of nodules between 0.5 cm and 5 cm prior to biopsy and/or surgery. Nodules were analyzed based on size stratifications: <1 cm (n = 43); 1−2 cm (n = 52) and >2 cm (n = 31) and equivocal cytology status (n = 52), and diagnostic performance assessments were conducted. The combination of EU TIRADS with SWE using the SD parameter; maintained a high sensitivity and significantly improved the specificity of sole EU TIRADS for nodules 1−2 cm (SEN: 72.2% vs. 88.9%, p > 0.05; SPEC: 76.5% vs. 55.9%, p < 0.01) and >2 cm (SEN: 71.4% vs. 85.7%, p > 0.05; SPEC: 95.8% vs. 62.5%, p < 0.01). For cytologically-equivocal nodules; the combination with the SWE minimum parameter resulted in a significant reduction in sensitivity with increased specificity (SEN: 60% vs. 80%; SPEC: 83.4% vs. 37.8%; all p < 0.05). SWE in combination with EU TIRADS is diagnostically efficient in discriminating nodules > 1 cm but is not ideal for discriminating cytologically-equivocal nodules.

Analysis of the Influence of Thyroid Nodule Characteristics on the Results of Shear Wave Elastography

OBJECTIVE

To analyze the ultrasonic characteristics of false-negative and false-positive results of shear wave elastography (SWE) in the diagnosis of thyroid nodules to clarify the influence of nodular characteristics on SWE and to guide the clinical application of SWE.

METHODS

A total of 435 thyroid nodules from 343 patients with the diagnosis confirmed by surgical pathology were analyzed. Preoperative ultrasonography and SWE were conducted. The conventional ultrasound characteristics of thyroid nodules and the maximum Young's modulus were recorded. The false negativity and false positivity of SWE for the diagnosis of thyroid nodules were calculated. The ultrasonic characteristics of thyroid nodules with SWE false results were analyzed, and logistic regression analysis was adopted to determine the ultrasonic characteristics associated with SWE false results of thyroid nodules.

RESULTS

Among 323 malignant nodules, the SWE false negativity was 27.2% (88/323). The false positivity of SWE in 112 benign nodules was 19.6% (22/112). Regression analysis showed that an increase in the nodule volume increased the risk of SWE false-positive results (odds ratio [OR] 3.286; 95% confidence interval [CI]: 1.572-6.871; P = 0.002) and decreased the risk of false-negative results (OR 0.238; 95% CI: 0.115-0.493; P < 0.001). Nodules with coarse calcification had an increased risk of SWE false-positive results compared with those without calcification (OR 5.303; 95% CI: 1.098-25.619; P = 0.038). However, nodules with scattered hyperechoic foci had a reduced risk of SWE false-negative results (OR 0.515; 95% CI: 0.280-0.951; P = 0.034).

CONCLUSION

Nodular size and calcification were correlated with SWE false results, and the clinical application of SWE should be combined with conventional ultrasound features. Fine needle aspiration or a puncture biopsy should be conducted if necessary.

Influence of lesion size on shear wave elastography in the diagnosis of benign and malignant thyroid nodules

In shear wave elastography (SWE) studies, the optimal cutoff value of Young's modulus for the diagnosis of benign and malignant thyroid nodules varies greatly, which affects the clinical application of the method. The objective of this study was to evaluate the influence of thyroid nodule size on the clinical diagnostic efficacy of SWE. A total of 356 thyroid nodules of 280 patients were divided into three groups according to size (Group A: ≤ 1 cm; Group B: 1-2 cm; Group C: ≥ 2 cm). SWE was used to measure the maximum Young's modulus (Emax) values of all thyroid nodules. Receiver operating characteristic (ROC) curves were drawn with pathological results as the gold standard. For all nodules, the optimal cutoff value of Emax in SWE for diagnosing malignant thyroid nodules was 36.2 kPa. The sensitivity and specificity were 76.5% and 78.4%, respectively. Groups A, B, and C had different optimal Emax cutoff values of 33.7 kPa, 37.7 kPa, and 55.1 kPa, respectively. The area under the ROC curve (AUC) values of Groups A, B, and C (0.844, 0.886, and 0.935, respectively) were all greater than the values for all lesions (0.830). The specificity values of Groups A, B, and C (86.4%, 82.6%, and 88.2%, respectively) were all increased, and the sensitivity values of Groups B and C (89.7% and 96.4%, respectively) were also increased compared with the values for all lesions. Thyroid nodule size affects the optimal Emax cutoff value of SWE. We suggest that different cutoff values be used to diagnose benign and malignant thyroid nodules according to lesion size.

The Value of Shear Wave Elastography in Predicting the Risk of Endometrial Cancer and Atypical Endometrial Hyperplasia

OBJECTIVES

To evaluate shear wave elastography (SWE) technology diagnosis value of endometrial cancer (EC) and atypical endometrial hyperplasia (AEH), and to establish predictive logistic regression models for the diagnosis of EC and AEH.

METHODS

Clinical information collection, transvaginal conventional ultrasonography, and SWE check were performed on 122 patients, who were perimenopausal or postmenopausal vaginal bleeding with ≥4.5 mm thick endometrium. The maximal (Emax) and mean (Emean) of Young's modulus for the endometrium were obtained. Using pathology as the gold standard, ROC curves were plotted to evaluate Young's modulus on the diagnostic effectiveness of EC and AEH. Single-factor analysis and bivariate logistic regression methods were applied to assess the clinical variables, transuaginal conventional ultrasonography variables, and Young's modulus on the identification of EC and AEH.

RESULTS

Out of 122 cases of endometrial lesions, 85 cases were benign lesions, and the remaining 37 cases were EC and AEH. The Emax and Emean for the benign group were 29.80 ± 11.40 and 17.96 ± 8.05 kPa, respectively. The Emax and Emean values for EC and AEH group were 59.49 ± 16.95 and 38.46 ± 17.10 kPa, respectively. Emax and Emean for both groups were statistically significant, with p <.001. In the logistical regression analysis, endometrial thickness, Color score, and Young's modulus were identified as independent risk factors for EC and AEH.

CONCLUSIONS

SWE technology plays an important role in the diagnosis of EC and AEH, and the diagnostic effectiveness would be higher when combined with conventional ultrasonography.

Elastography for the diagnosis of high-suspicion thyroid nodules based on the 2015 American Thyroid Association guidelines: a multicenter study

BACKGROUND

An accurate diagnosis for high-suspicion nodules based on the 2015 American Thyroid Association (ATA) guidelines would reduce unnecessary invasive examinations. Elastography is a useful tool for discriminating benign and malignant thyroid nodules. The aim of this study is to investigate the diagnostic efficiency of elastography for high-suspicion thyroid nodules based on the 2015 ATA guidelines in the Chinese population.

METHODS

Thyroid nodules with high-suspicion characteristics based on the 2015 ATA guidelines were subjected to conventional ultrasound (US) and ultrasound strain elastography (USE) examinations at 12 hospitals from 4 geographic regions across China. Cytology/histology of thyroid nodules was used as a reference method. Receiver operating characteristic (ROC) curves were plotted to evaluate the diagnostic performance of the elasticity score (ES) and strain ratio (SR). Logistic regression analysis was used to determine the predictors of malignancy.

RESULTS

Overall, a total of 1445 thyroid nodules (834 malignant, 611 benign) from 12 centers were included in the final analysis. The areas under the curve of the ES and SR were 0.828 and 0.732, respectively. The sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) of the ES were 92.4, 60.7, 79.0, 76.3 and 85.5%, respectively, and those of the SR were 81.1, 50.1, 68.9, 65.9 and 67.9%, respectively. The combination of the Thyroid Imaging Reporting and Data System (TI-RADS) and ES led to a significant increase in the sensitivity and NPV (97.1 and 91.9%, respectively) compared with the TI-RADS alone. Logistic regression analysis showed that microcalcifications (OR = 5.290), taller than wide (OR = 12.710), irregular margins (OR = 10.117), extrathyroidal extension (ETE; OR = 6.412), the ES (OR = 3.741) and the SR (OR = 1.083) were independent predictors of malignant thyroid nodules. The sensitivity, specificity, accuracy, PPV and NPV of the ES were all superior in nodules ≥1 cm than in those < 1 cm (95.0% vs 90.4, 68.8% vs 56.8, 85.9% vs 74.4, 85.2% vs 69.9, and 87.8% vs 84.2%, respectively).

CONCLUSIONS

Elastography combined with the ES is a valuable tool for the assessment of high-suspicion thyroid nodules based on the 2015 ATA guidelines, especially in nodules ≥1 cm.

Shear wave elasticity by tracing total nodule showed high reproducibility and concordance with fibrosis in thyroid cancer

Background

Although shear wave elastography (SWE) is reported to be useful in detecting malignant thyroid nodules, it shows a wide range of cut-off values of elasticity index (EI) in detecting malignant nodules. The cause of discrepancy remains unclear. Fibrosis of the tumors is known to increase the EI in SWE, and matching of SWE and surgical histopathology has not been fully illustrated in thyroid cancer. We aimed to evaluate the reproducibility of the new total nodular region of interest (ROI) method excluding the subjective features of focal circular ROI placement and to determine the lesion that causes the elevation of EI on SWE and on histopathology.

Methods

A total of 29 thyroid cancers from 28 patients were included. We evaluated the reproducibility of EI in the new total nodular ROI using Q-Box Trace program and compared the EI in focal nodular ROI using a 3-mm circular area. We analyzed the correlation between fibrosis and EI.

Result

The coefficient of variation (CV) of the intrarater assay was significantly lower in total nodular ROI than in focal nodular ROI within the image in rater 1 (1.7% vs. 13.4%, p < 0.001) and in rater 2 (1.4% vs. 16.9%, p < 0.001) and in different images in rater 1 (7.6% vs. 12.3%, p = 0.040) and in rater 2 (7.5% vs. 19.8%, p = 0.004). Moreover, CV of the interrater assay showed similar results (14.9% vs. 19%, p = 0.030). Interrater intraclass correlation coefficient showed better agreement in total nodular ROI than in focal nodular ROI (0.863 vs. 0.783). The degree of fibrosis on histopathology showed significant correlations with EI (E_Mean, p < 0.001; E_Max, p = 0.027), and the location of fibrosis was concordant with the high EI area on SWE.

Conclusion

Our study revealed that the new total nodular ROI method showed higher reproducibility and better agreement in intra- and interrater assay than the focal nodular ROI method, suggesting a valuable and standardized method in clinical practice. Moreover, our results showed that fibrosis in the histopathology increased EI on SWE and might lead to the discrepancy of the cut-off values in detecting thyroid cancer.

2-D Shear Wave Elastography for Focal Lesions in Liver Phantoms: Effects of Background Stiffness, Depth and Size of Focal Lesions on Stiffness Measurement

The aim of this study was to determine the factors influencing stiffness and conspicuity of focal lesions in deep organs by focusing on target properties using 2-D shear wave elastography (SWE). Two normal (4 ± 1 kPa) and cirrhotic (16 ± 2 kPa) liver-mimicking phantoms with spherical inclusions (23 ± 3 kPa) were used. Inclusions of three sizes (20, 15 and 10 mm in diameter) were arranged in a row at depths of 3, 5 and 7 cm. Two observers acquired quantitative stiffness values and a qualitative five-grade morphologic score at each inclusion using SWE. The coefficients of variation (CVs) of stiffness were calculated to assess measurement reliability. The generalized estimating equation was used to identify whether stiffness, CV and morphologic score were independent of background stiffness, depth and size of inclusions and observer. In the quantitative assessment, stiffness of the inclusion and CV were dependent on the type of phantom and depth of inclusion (p < 0.001). There were no significant differences in stiffness and CV according to the observer. Morphologic score differed significantly only in the size of the inclusion (p < 0.001). When the depth of the inclusion was 7 cm, the stiffness was the highest, and the 10 mm-sized inclusions had lower morphologic scores than the other inclusions (all p values < 0.001). In conclusion, 2-D SWE assessment of focal lesions could be affected by background stiffness and depth of focal lesions, and may be limited in evaluating focal hepatic lesions.

Which Is the Best Reference Tissue for Strain Elastography in Predicting Malignancy in Thyroid Nodules, the Sternocleidomastoid Muscle or the Thyroid Parenchyma?

OBJECTIVES

This study aimed to compare 2 types of strain ratios (SRs) in thyroid nodules. Two reference points were used: the sternocleidomastoid (SCM) muscle and the thyroid parenchyma.

METHODS

A total of 101 nodules in 83 patients were prospectively enrolled in the study. For the semiquantitative analysis, 2 types of SRs were used: SR1, the ratio of the SCM muscle strain to the thyroid nodule strain; and SR2, the ratio of the surrounding normal thyroid tissue strain to the thyroid nodule strain. For each nodule, the SR1 and SR2 elastographic values were calculated, and their averages were compared.

RESULTS

Eighty-one (80.2%) of 101 thyroid nodules were benign, and 20 (19.8%) were malignant. In both benign and malignant histopathologic types, the SR1 averages were significantly higher than the SR2 averages (P = .001; P < .001, respectively). Both the SR1 and SR2 values were found to be significantly successful in differentiating benign from malignant histopathologic types (P < .001 for both). The areas under the curve were then compared for the methods, and the difference was found to be statistically significant (P = .046). The diagnostic accuracy of the SR1 was superior to that of the SR2.

CONCLUSIONS

The SR1 and SR2 are effective adjunctive diagnostic tools for identifying malignant thyroid nodules. Using the SCM muscle as a reference point instead of thyroid tissue may be a more valuable way to measure SRs.