New potential and applications of contrast-enhanced ultrasound of the breast: Own investigations and review of the literature. Eur J Radiol. 2009;69:14-23. [PMID: 18977102 DOI: 10.1016/j.ejrad.2008.07.037]

Meta-analysis of contrast-enhanced ultrasound in differential diagnosis of breast adenosis and breast cancer

This systematic review and meta-analysis study aimed to determine the total capacity of contrast-enhanced ultrasound (CEUS) in the differential diagnosis of breast lesions and breast cancer. For collecting papers, four groups of keywords were searched in five databases. The required information was extracted from the selected papers. In addition to the descriptive findings, a meta-analysis was also conducted. Thirty-three of thirty-six studies (91.67%) on the differential diagnosis of various degrees and types of breast lesions showed that CEUS has proper performance. The pooled values related to the sensitivity and specificity of CEUS were computed by 88.00 and 76.17.

Current status and future perspectives of contrast-enhanced ultrasound diagnosis of breast lesions

Advances in various imaging modalities for breast lesions have improved diagnostic capabilities not only for tumors but also for non-tumorous lesions. Contrast-enhanced ultrasound (CEUS) plays a crucial role not only in the differential diagnosis of breast lesions, identification of sentinel lymph nodes, and diagnosis of lymph node metastasis but also in assessing the therapeutic effects of neoadjuvant chemotherapy (NAC). In CEUS, two image interpretation approaches, i.e., qualitative analysis and quantitative analysis, are employed and applied in various clinical settings. In this paper, we review CEUS for breast lesions, including its various applications.

A Prospective Multicenter Study on the Additive Value of Contrast-Enhanced Ultrasound for Biopsy Decision of Ultrasound BI-RADS 4 Breast Lesions

OBJECTIVE

The main aim of this study was to determine whether the use of contrast-enhanced ultrasound (CEUS) could improve the categorization of suspicious breast lesions based on the Breast Imaging Reporting and Data System (BI-RADS), thereby reducing the number of benign breast lesions referred for biopsy.

METHODS

This prospective study, conducted between January 2017 and December 2018, enrolled consenting patients from eight teaching hospitals in China, who had been diagnosed with solid breast lesions classified as BI-RADS 4 using conventional ultrasound. CEUS was performed within 1 wk of diagnosis for reclassification of breast lesions. Histopathological results obtained from core needle biopsies or surgical excision samples served as the reference standard. The simulated biopsy rate and cancer-to-biopsy yield were used to compare the accuracy of CEUS and conventional ultrasound (US).

RESULTS

Among the 1490 lesions diagnosed as BI-RADS 4 with conventional ultrasound, 486 malignant and 1004 benign lesions were confirmed based on histology. Following CEUS, 2, 395, and 211 lesions were reclassified as CEUS-based BI-RADS 2, 3, and 5, respectively, while 882 (59%) remained as BI-RADS 4. The actual cancer-to-biopsy yield based on US was 32.6%, which increased to 43.4% when CEUS-based BI-RADS 4A was used as the cut-off point to recommend biopsy. The simulated biopsy rate decreased to 73.4%. Overall, in this preselected BI-RADS 4 population, only 2.5% (12/486) of malignant lesions would have been miscategorized as BI-RADS 3 using CEUS-based reclassification. The diagnostic accuracy, sensitivity, and specificity of contrast-enhanced ultrasound reclassification were 57.65%, 97.53%, and 38.35%, respectively.

CONCLUSION

Our collective findings indicate that CEUS is a valuable tool in further triage of BI-RADS category 4 lesions and facilitates a reduction in the number of biopsies while increasing the cancer-to-biopsy yield.

A retrospective study on adverse events of intravenous administration of sulfur hexafluoride microbubbles in abdominal and superficial applications in 83,778 patients

OBJECTIVES

To investigate the rate of adverse events (AEs) caused by intravenous administration of sulfur hexafluoride microbubbles in abdominal and superficial applications retrospectively and to explore practical measures for prevention and treatment of them.

MATERIALS AND METHODS

This study enrolled 83,778 contrast-enhanced ultrasound (CEUS) examinations using sulfur hexafluoride microbubbles intravenously performed during 11 years. Age, gender, and target organs of all CEUS patients were recorded. For cases of AEs, their medical history and laboratory results were also collected. The process of AEs was assessed and categorized. Besides, the management of AEs were recorded.

RESULTS

Twenty patients had sulfur hexafluoride microbubbles-related AEs. The AE rate was 0.024%. No significant difference was observed between patients with AEs and the whole group for age and sex distribution. All AEs happened in liver examinations. Among them, 7 (35%) were mild, 8 (40%) were moderate, and 5 (25%) were severe. They were categorized into 15 allergic-like reactions and 5 physiologic reactions. The manifestations of mild and moderate AEs mainly include urticaria, chills, and mild hypoxia, which could be eased by simple management. Severe cases had anaphylactic shock, generalized convulsions, and diffuse erythema with hypotension respectively. They need close monitoring and oxygen inhalation with anti-shock and anti-anaphylactic treatment. Most cases started within 30 min and recovered within 1 day.

CONCLUSIONS

Intravenous administration of sulfur hexafluoride microbubbles in abdominal and superficial applications was safe with rare AEs. AEs were more likely to happen in abdominal applications than superficial ones. A well-designed emergency plan should be available for clinical use of sulfur hexafluoride microbubbles to reduce AEs and to deal with AEs properly.

CRITICAL RELEVANCE STATEMENT

Intravenous administration of sulfur hexafluoride microbubbles in abdominal and superficial applications reported few AEs and could be considered safe but severe AEs are life-threatening. We analyzed the influence factors of AEs and propose some methods for prevention and treatment of them, which can further improve the safety of sulfur hexafluoride microbubbles in clinical practice.

KEY POINTS

• The AE rate of sulfur hexafluoride microbubbles in abdominal and superficial applications was 0.024%. • Patients were more likely to have AEs in abdominal applications than superficial ones. • Severe AEs are life-threatening and need prompt identification and treatment. • We summarized some detailed suggestions for clinical prevention and treatment of AEs.

A Nomogram for Enhancing the Diagnostic Effectiveness of Solid Breast BI-RADS 3-5 Masses to Determine Malignancy Based on Imaging Aspects of Conventional Ultrasonography and Contrast-Enhanced Ultrasound

BACKGROUND

To establish and validate a nomogram model, which can incorporate clinical data, and imaging features of ultrasound (US) and contrast-enhanced ultrasound (CEUS), for improving the diagnostic efficiency of solid breast lesions.

PATIENTS AND METHODS

A total of 493 patients with solid breast lesions were randomly divided into training (n = 345) and validation (n = 148) cohorts with a ratio of 7:3 and, clinical data and image features of US and CEUS were reviewed and retrospectively analyzed. The breast lesions in both the training and validation cohorts were analyzed using the BI-RADS and nomogram models.

RESULTS

Five variables, including the shape and calcification features of conventional US, enhancement type and size after enhancement features of CEUS, and BI-RADS, were selected to construct the nomogram model. As compared to the BI-RADS model, the nomogram model demonstrated satisfactory discriminative function (area under the receiver operating characteristic [ROC] curves [AUC], 0.940; 95% confidence interval [CI], 0.909 to 0.971; sensitivity, 0.905; and specificity, 0.902 in the training cohort and AUC, 0.968; 95% CI, 0.941 to 0.995; sensitivity, 0.971; and specificity, 0.867 in the validation cohort). In addition, the nomogram model showed good consistency and clinical potential according to the calibration curve and DCA.

CONCLUSION

The nomogram model could identify benign from malignant breast lesions with good performance.

Multimodal Ultrasonography Features of Breast Lymphomas: 3 Cases Report

To investigate the multimodal ultrasonography (US) features of breast lymphomas (BLs). Multimodal ultrasonography was performed on three patients who had been diagnosed BLs by pathology in our hospital. Two cases of primary BLs appeared hyper hyperechoic and hypoechoic, and one case of second BL appeared isoechoic and hypoechoic. Elastography of two lesions was soft elasticity and the elasticity score was 2 points. Contrast-enhanced ultrasound (CEUS) revealed rapid uniform high enhancement with clearly defined after injection. There are some common features in ultrasound. Combined with those features can help to improve the sonographer's understanding and diagnosis of the BLs.

Medical Imaging of Inflammations and Infections of Breast Implants

Breast implants are widely used for reconstructive and/or cosmetic purposes. Inflammations and infections of breast implants represent important complications in clinical practice. The proper management of complications is necessary: diagnostic imaging plays a key role in detecting sites of inflammation and/or infection. The present review aims to illustrate the radiological findings of these conditions with different imaging techniques, such as mammography (MX), ultrasound (US), magnetic resonance imaging (MRI), and nuclear medicine imaging. A knowledge of these findings is essential for radiologists and nuclear medicine physicians to provide helpful information for the clinical management of these complications.

Ultrasound-based radiomics analysis for differentiating benign and malignant breast lesions: From static images to CEUS video analysis

Background

Continuous contrast-enhanced ultrasound (CEUS) video is a challenging direction for radiomics research. We aimed to evaluate machine learning (ML) approaches with radiomics combined with the XGBoost model and a convolutional neural network (CNN) for discriminating between benign and malignant lesions in CEUS videos with a duration of more than 1 min.

Methods

We gathered breast CEUS videos of 109 benign and 81 malignant tumors from two centers. Radiomics combined with the XGBoost model and a CNN was used to classify the breast lesions on the CEUS videos. The lesions were manually segmented by one radiologist. Radiomics combined with the XGBoost model was conducted with a variety of data sampling methods. The CNN used pretrained 3D residual network (ResNet) models with 18, 34, 50, and 101 layers. The machine interpretations were compared with prospective interpretations by two radiologists. Breast biopsies or pathological examinations were used as the reference standard. Areas under the receiver operating curves (AUCs) were used to compare the diagnostic performance of the models.

Results

The CNN model achieved the best AUC of 0.84 on the test cohort with the 3D-ResNet-50 model. The radiomics model obtained AUCs between 0.65 and 0.75. Radiologists 1 and 2 had AUCs of 0.75 and 0.70, respectively.

Conclusions

The 3D-ResNet-50 model was superior to the radiomics combined with the XGBoost model in classifying enhanced lesions as benign or malignant on CEUS videos. The CNN model was superior to the radiologists, and the radiomics model performance was close to the performance of the radiologists.

Contrast-Enhanced Ultrasound Parameters and D-Dimer: New Prognostic Parameters for Diffuse Large B-Cell Lymphoma

Objective

To investigate the predictive role of contrast-enhanced ultrasonography (CEUS) plus D-dimer levels in the prognosis of patients with diffuse large B-cell lymphoma (DLBCL).

Methods

CEUS was applied to assess lymph nodes in 186 patients with confirmed DLBCL. The clinical data and laboratory indicators were collected from these patients, and a retrospective analysis was conducted on the relationship between the quantitative parameters of CEUS (TTP, PI, AUC, WOT), D-dimer levels, and clinical features of the DLBCL patients. The Cox regression model was used for univariate and multivariate analyses for the risk factors associated with the prognosis.

Results

There was an increase of D-dimer levels in advanced DLBCL patients, who were combined with a significant reduction in TTP and WOT and a significant increase in PI and AUC. D-dimer levels and quantitative parameters of CEUS were strongly correlated with the Ann Arbor, B symptoms, International Prognostic Index (IPI), LDH and CRP levels. The results of the Cox regression model indicated that D-dimer levels, TTP and PI, the quantitative parameters of CEUS, were important prognostic factors for DLBCL.

Conclusion

CEUS results and D-dimer levels can be used as independent prognostic factors for DLBCL.

Four-quadrant fast compressive tracking of breast ultrasound videos for computer-aided response evaluation of neoadjuvant chemotherapy in mice

BACKGROUND AND OBJECTIVE

Neoadjuvant chemotherapy (NAC) is a valuable treatment approach for locally advanced breast cancer. Contrast-enhanced ultrasound (CEUS) potentially enables the assessment of therapeutic response to NAC. In order to evaluate the response accurately, quantitatively and objectively, a method that can effectively compensate motions of breast cancer in CEUS videos is urgently needed.

METHODS

We proposed the four-quadrant fast compressive tracking (FQFCT) approach to automatically perform CEUS video tracking and compensation for mice undergoing NAC. The FQFCT divided a tracking window into four smaller windows at four quadrants of a breast lesion and formulated the tracking at each quadrant as a binary classification task. After the FQFCT of breast cancer videos, the quantitative features of CEUS including the mean transit time (MTT) were computed. All mice showed a pathological response to NAC. The features between pre- (day 1) and post-treatment (day 3 and day 5) in these responders were statistically compared.

RESULTS

When we tracked the CEUS videos of mice with the FQFCT, the average tracking error of FQFCT was 0.65 mm, reduced by 46.72% compared with the classic fast compressive tracking method (1.22 mm). After compensation with the FQFCT, the MTT on day 5 of the NAC was significantly different from the MTT before NAC (day 1) (p = 0.013).

CONCLUSIONS

The FQFCT improves the accuracy of CEUS video tracking and contributes to the computer-aided response evaluation of NAC for breast cancer in mice.

Imaging of Benign and Malignant Breast Lesions Using Contrast-Enhanced Ultrasound: A Pictorial Essay

ABSTRACT

Contrast-enhanced ultrasound is a promising noninvasive imaging technique for evaluating benign and malignant breast lesions, as contrast provides information about perfusion and microvasculature. Contrast-enhanced ultrasound is currently off-label use in the breast in the United States, but its clinical and investigational use in breast imaging is gaining popularity. It is important for radiologists to be familiar with the imaging appearances of benign and malignant breast masses using contrast-enhanced ultrasound. This pictorial essay illustrates enhancement patterns of various breast masses from our own experience. Pathologies include subtypes of invasive breast cancer, fibroadenomas, papillary lesions, fibrocystic change, and inflammatory processes. Contrast-enhanced ultrasound pitfalls and limitations are discussed.

Contrast-enhanced ultrasound perfusion imaging of organs

In multimodal radiologic imaging, contrast-enhanced ultrasound (CEUS) is increasingly used. One of the advantages of CEUS is the possibility of repeated application of contrast media without decreasing renal function or affecting the thyroid gland. Small solid liver lesions can be diagnosed and detected with high accuracy. Moreover, solid lesions in other abdominal organs can also be characterized. Frequent applications for solid lesions in the near field concern thyroid tumors and lymph nodes. For prostate diagnostics, CEUS can be used with an endorectal probe and perfusion imaging. This review explains how the additional (semi-)quantitative perfusion analysis, especially time-intensity curve (TIC) analyses, and wash-in/wash-out kinetics of integrated or external perfusion software programs facilitate new options in dynamic assessment of microvascularization during tumor follow-up care and even minimally invasive tumor therapy.

A Review of the Role of the S-Detect Computer-Aided Diagnostic Ultrasound System in the Evaluation of Benign and Malignant Breast and Thyroid Masses

Computer-aided diagnosis (CAD) systems have attracted extensive attention owing to their performance in the field of image diagnosis and are rapidly becoming a promising auxiliary tool in medical imaging tasks. These systems can quantitatively evaluate complex medical imaging features and achieve efficient and high-diagnostic accuracy. Deep learning is a representation learning method. As a major branch of artificial intelligence technology, it can directly process original image data by simulating the structure of the human brain neural network, thus independently completing the task of image recognition. S-Detect is a novel and interactive CAD system based on a deep learning algorithm, which has been integrated into ultrasound equipment and can help radiologists identify benign and malignant nodules, reduce physician workload, and optimize the ultrasound clinical workflow. S-Detect is becoming one of the most commonly used CAD systems for ultrasound evaluation of breast and thyroid nodules. In this review, we describe the S-Detect workflow and outline its application in breast and thyroid nodule detection. Finally, we discuss the difficulties and challenges faced by S-Detect as a precision medical tool in clinical practice and its prospects.

Quantification of dynamic contrast-enhanced ultrasound (CEUS) in non-cystic breast lesions using external perfusion software

The aim of this present clinical pilot study is the display of typical perfusion results in patients with solid, non-cystic breast lesions. The lesions were characterized using contrast enhanced ultrasound (CEUS) with (i) time intensity curve analyses (TIC) and (ii) parametric color maps. The 24 asymptomatic patients included were genetically tested for having an elevated risk for breast cancer. At a center of early detection of familial ovary and breast cancer, those patients received annual MRI and grey-scale ultrasound. If lesions remained unclear or appeared even suspicious, those patients also received CEUS. CEUS was performed after intravenous application of sulfur hexafluoride microbubbles. Digital DICOM cine loops were continuously stored for one minute in PACS (picture archiving and communication system). Perfusion images and TIC analyses were calculated off-line with external perfusion software (VueBox). The lesion diameter ranged between 7 and 15 mm (mean 11 ± 3 mm). Five hypoechoic irregular lesions were scars, 6 lesions were benign and 12 lesions were highly suspicious for breast cancer with irregular enhancement at the margins and a partial wash out. In those 12 cases, histopathology confirmed breast cancer. All the suspicious lesions were correctly identified visually. For the perfusion analysis only Peak Enhancement (PE) and Area Under the Curve (AUC) added more information for correctly identifying the lesions. Typical for benign lesions is a prolonged contrast agent enhancement with lower PE and prolonged wash out, while scars are characterized typically by a reduced enhancement in the center. No differences (p = 0.428) were found in PE in the center of benign lesions (64.2 ± 28.9 dB), malignant lesions (88.1 ± 93.6 dB) and a scar (40.0 ± 17.0 dB). No significant differences (p = 0.174) were found for PE values at the margin of benign lesions (96.4 ± 144.9 dB), malignant lesions (54.3 ± 86.2 dB) or scar tissue (203.8 ± 218.9 dB). Significant differences (p < 0.001) were found in PE of the surrounding tissue when comparing benign lesions (33.6 ± 25.2 dB) to malignant lesions (15.7 ± 36.3 dB) and scars (277.2 ± 199.9 dB). No differences (p = 0.821) were found in AUC in the center of benign lesions (391.3 ± 213.7), malignant lesions (314.7 ± 643.9) and a scar (213.1 ± 124.5). No differences (p = 0.601) were found in AUC values of the margin of benign lesions (313.3 ± 372.8), malignant lesions (272.6 ± 566.4) or scar tissue (695.0 ± 360.6). Significant differences (p < 0.01) were found in AUC of the surrounding tissue for benign lesions (151.7 ± 127.8), malignant lesions (177.9 ± 1345.6) and scars (1091 ± 693.3). There were no differences in perfusion evaluation for mean transit time (mTT), rise time (RT) and time to peak (TTP) when comparing the center to the margins and the surrounding tissue. The CEUS perfusion parameters PE and AUC allow a very good assessment of the risk of malignant breast lesions and thus a downgrading of BI-RADS 4 lesions. The use of the external perfusion software (VueBox, Bracco, Milan, Italy) did not lead to any further improvement in the diagnosis of suspicious breast lesions and does appears not to have any additional diagnostic value in breast lesions.

Contrast-enhanced ultrasound of breast fibromatosis: a case report

We herein present a rare case of breast fibromatosis, the contrast-enhanced ultrasonography (CEUS) findings of which we believe have never been described. The high similarity between the clinical and imaging manifestations of breast cancer makes its differential diagnosis difficult. In this report, we describe the CEUS findings of a less common type of fibromatosis, discuss the potential value of CEUS to differentiate it from malignant breast lesions, and briefly review the literature.

Value of contrast-enhanced ultrasound area ratio in identifying benign and malignant small breast masses

Background

Tumor size affects clinical staging and is closely related to prognosis. Therefore, early diagnosis of breast cancer is one of the most important methods to reduce mortality and improve prognosis. However, minimal breast cancer is difficult to differentiate from small benign breast masses due to insufficient typical malignant signs. The significantly increased range of enhancement can be an important indication for the prediction of malignancy; however, quantitative studies on the extent of enhancement are rarely reported. The purpose of this study was to investigate the value of contrast-enhanced ultrasound (CEUS) area ratio in finding benign and malignant small breast masses.

Methods

A retrospective analysis was conducted on 88 patients with breast masses confirmed by surgery or needle biopsy (the maximal diameter not over 1 cm). 88 breast masses were divided into the younger age group (not over 40 years old) and older age group (over 40 years old) according to the patient's age. The receiver operating characteristic (ROC) curve was used to determine the cutoff values of CEUS area ratio in diagnosing benign or malignant small breast masses in each group. The efficiency of different cutoff values in finding benign and malignant small breast masses of the distinct groups was analyzed.

Results

The CEUS area ratio of malignant mass was larger than benign masses (P<0.05). The CEUS area ratio of malignant masses in the younger age group was larger than that in the older age group (P<0.05). The results of the ROC curve analysis showed that the area under the curve (AUC) and the cutoff values of the entire group, the younger age group, and the older age group were 0.887, 1.65; 0.909, 1.95; and 0.908, 1.22, respectively. When the cutoff value of the older age group was reduced from 1.65 to 1.22, its diagnostic sensitivity was improved significantly (P<0.05).

Conclusions

CEUS area ratio has specific application value in finding benign and malignant small breast masses. Proper reduction of the cutoff value of elderly patients can further improve its diagnostic sensitivity without significantly reducing the specificity.

Immunohistochemical index prediction of breast tumor based on multi-dimension features in contrast-enhanced ultrasound

Breast cancer is the leading killer of Chinese women. Immunohistochemistry index has great significance in the treatment strategy selection and prognosis analysis for breast cancer patients. Currently, histopathological examination of the tumor tissue through surgical biopsy is the gold standard to determine immunohistochemistry index. However, this examination is invasive and commonly causes discomfort in patients. There has been a lack of noninvasive method capable of predicting immunohistochemistry index for breast cancer patients. This paper proposes a machine learning method to predict the immunohistochemical index of breast cancer patients by using noninvasive contrast-enhanced ultrasound. A total of 119 breast cancer patients were included in this retrospective study. Each patient implemented the pathological examination of immunohistochemical expression and underwent contrast-enhanced ultrasound imaging of breast tumor. The multi-dimension features including 266 three-dimension features and 837 two-dimension dynamic features were extracted from the contrast-enhanced ultrasound sequences. Using the machine learning prediction method, 21 selected multi-dimension features were integrated to generate a model for predicting the immunohistochemistry index noninvasively. The immunohistochemical index of human epidermal growth factor receptor-2 (HER2) was predicted based on multi-dimension features in contrast-enhanced ultrasound sequence with the sensitivity of 71%, and the specificity of 79% in the testing cohort. Therefore, the noninvasive contrast-enhanced ultrasound can be used to predict the immunohistochemical index. To our best knowledge, no studies have been reported about predicting immunohistochemical index by using contrast-enhanced ultrasound sequences for breast cancer patients. Our proposed method is noninvasive and can predict immunohistochemical index by using contrast-enhanced ultrasound in several minutes, instead of relying totally on the invasive and biopsy-based histopathological examination. Graphical abstract Immunohistochemical index prediction of breast tumor based on multi-dimension features in contrast-enhanced ultrasound.

Breast non-mass-like lesions on contrast-enhanced ultrasonography: Feature analysis, breast image reporting and data system classification assessment

BACKGROUND

Breast non-mass-like lesions (NMLs) account for 9.2% of all breast lesions. The specificity of the ultrasound diagnosis of NMLs is low, and it cannot be objectively classified according to the 5^th Edition of the Breast Imaging Reporting and Data System (BI-RADS). Contrast-enhanced ultrasound (CEUS) can help to differentiate and classify breast lesions but there are few studies on NMLs alone.

AIM

To analyze the features of benign and malignant breast NMLs in grayscale ultrasonography (US), color Doppler flow imaging (CDFI) and CEUS, and to explore the efficacy of the combined diagnosis of NMLs and the effect of CEUS on the BI-RADS classification of NMLs.

METHODS

A total of 51 breast NMLs verified by pathology were analyzed in our hospital from January 2017 to April 2019. All lesions were examined by US, CDFI and CEUS, and their features from those examinations were analyzed. With pathology as the gold standard, binary logic regression was used to analyze the independent risk factors for malignant breast NMLs, and a regression equation was established to calculate the efficiency of combined diagnosis. Based on the regression equation, the combined diagnostic efficiency of US combined with CEUS (US + CEUS) was determined. The initial BI-RADS-US classification of NMLs was adjusted according to the independent risk factors identified by CEUS, and the diagnostic efficiency of CEUS combined with BI-RADS (CEUS + BI-RADS) was calculated based on the results. ROC curves were drawn to compare the diagnostic values of the three methods, including US, US + CEUS, and CEUS + BI-RADS, for benign and malignant NMLs.

RESULTS

Microcalcification, enhancement time, enhancement intensity, lesion scope, and peripheral blood vessels were significantly different between benign and malignant NMLs. Among these features, microcalcification, higher enhancement, and lesion scope were identified as independent risk factors for malignant breast NMLs. When US, US + CEUS, and CEUS + BI-RADS were used to identify the benign and malignant breast NMLs, their sensitivity rates were 82.6%, 91.3%, and 87.0%, respectively; their specificity rates were 71.4%, 89.2%, and 92.9%, respectively; their positive predictive values were 70.4%, 87.5%, and 90.9%, respectively; their negative predictive values were 83.3%, 92.6%, and 89.7%, respectively; their accuracy rates were 76.5%, 90.2%, and 90.2%, respectively; and their corresponding areas under ROC curves were 0.752, 0.877 and 0.903, respectively. Z tests showed that the area under the ROC curve of US was statistically smaller than that of US + CEUS and CEUS + BI-RADS, and there was no statistical difference between US + CEUS and CEUS + BI-RADS.

CONCLUSION

US combined with CEUS can improve diagnostic efficiency for NMLs. The adjustment of the BI-RADS classification according to the features of contrast-enhanced US of NMLs enables the diagnostic results to be simple and intuitive, facilitates the management of NMLs, and effectively reduces the incidence of unnecessary biopsy.

Factors influencing the performance of a diagnostic model including contrast-enhanced ultrasound in 1023 breast lesions: comparison with histopathology

Background

We aimed to investigate the influence of patient and lesion characteristics on our diagnostic model for contrast-enhanced ultrasound (CEUS) of the breast, comparing its accuracy with that of histopathology.

Methods

Conducting a study with eight medical centers, we compared 1,023 breast lesions categorized as BI-RADS 4 or 5 with the score from our newly-established CEUS-based diagnostic model, comparing the results with pathological outcomes. Univariate and multivariate logistic regression analyses were conducted to determine the influence of clinicopathological characteristics on the performance of this CEUS model.

Results

Logistic regression analysis showed that patients' age, maximum lesion diameter, and distance from the lesion's deep edge to the pectoralis major were significant independent influencing factors. The model's diagnostic accuracy was greater for patients >35 y (P=0.005), for maximum lesion diameter >20 mm, and for distance from the lesion's deep edge to the pectoralis major ≤3.05 mm. There was no significant difference in accuracy between lesions with maximum lesion diameter 10-20 and <10 mm (P=0.393).

Conclusions

The diagnostic performance of the proposed CEUS model for breast lesions is influenced by patients' age, maximum lesion diameter, and distance from the lesion's deep edge to the pectoralis major. Consideration of influencing factors is required to optimize clinical use of the CEUS model.

Contrast-Enhanced Ultrasound Imaging of Breast Masses: Adjunct Tool to Decrease the Number of False-Positive Biopsy Results

OBJECTIVES

This pilot study evaluated use of contrast-enhanced ultrasound (CEUS) to reduce the number of benign breast masses recommended for biopsy.

METHODS

This prospective study included 131 consenting women, from October 2016 to June 2017, with American College of Radiology Breast Imaging Reporting and Data System category 4a, 4b, and 4c masses detected by mammography, conventional ultrasound (US), or both. Contrast-enhanced US examinations (using intravenous injection of perflutren lipid microspheres or sulfur hexafluoride lipid-type A microspheres) were performed before biopsy. Qualitative and quantitative CEUS parameters were compared with reference standard histopathologic results from biopsy of 131 masses.

RESULTS

There were 109 benign, 6 high-risk, and 16 malignant masses, with a median size of 12 mm (range, 4 to 48 mm) on conventional US imaging. Of 131 masses, 93 (71%) enhanced on CEUS imaging, including 73 of 109 (67%) benign, 6 of 6 (100%) high-risk, and 14 of 16 (87.5%) malignant. Thirty-eight lesions did not enhance, including 36 of 109 (33%) benign and 2 of 16 (12.5%) malignant. Prediction models using recursive petitioning revealed that CEUS may reduce 31% (95% confidence interval, 23%, 40%) of benign biopsies for masses that are: nonenhancing with circumscribed margins or enhancing with an oval shape and homogeneous enhancement. Quantitative parameters indicated that benign masses had the longest time to peak (P = .078), highest time-to-peak ratio of mass to background (P = .036), lowest peak intensity (P = .021), and smallest difference in peak intensity between the mass and background (P = .079) compared to high-risk and malignant lesions.

CONCLUSIONS

Contrast-enhanced US may be a valuable modality that can be used to predict benign pathologic results of breast masses, thereby reducing the number of biopsies.

Correlation Between Contrast-enhanced Ultrasound Characteristics (Qualitative and Quantitative) and Pathological Prognostic Factors in Breast Cancer

BACKGROUND/AIM

Little is known about the correlation between contrast-enhanced ultrasound (CEUS) characteristics and pathological prognostic factors in breast cancer. The aim of this study was to explore the correlation between CEUS characteristics and pathological prognostic factors.

PATIENTS AND METHODS

A retrospective study with 34 malignant breast lesions was conducted. CEUS characteristics included qualitative characteristics (e.g. lesion's enhancement degree and order, internal lesion homogeneity etc.) and quantitative characteristics (e.g. peak intensity, time to peak etc.). Also, pathological prognostic factors were included (e.g. tumor grade, estrogen receptor status etc.).

RESULTS

Blurred lesion margins were observed more often in tumors of high histological grade (p=0.01) and in estrogen receptor-negative tumors (p=0.049). Furthermore, perilesional enhancement was associated with positive Ki-67 expression (p=0.049), while heterogeneous internal sentinel lymph node enhancement was associated with malignant infiltration of the node (p=0.002).

CONCLUSION

CEUS has the potential to provide a prevision of pathological prognostic factors in malignant breast lesions, helping in the better early patient management.

Upcoming imaging concepts and their impact on treatment planning and treatment response in radiation oncology

For 2018, the American Cancer Society estimated that there would be approximately 1.7 million new diagnoses of cancer and about 609,640 cancer-related deaths in the United States. By 2030 these numbers are anticipated to exceed a staggering 21 million annual diagnoses and 13 million cancer-related deaths. The three primary therapeutic modalities for cancer treatments are surgery, chemotherapy, and radiation therapy. Individually or in combination, these treatment modalities have provided and continue to provide curative and palliative care to the myriad victims of cancer.

Today, CT-based treatment planning is the primary means through which conventional photon radiation therapy is planned. Although CT remains the primary treatment planning modality, the field of radiation oncology is moving beyond the sole use of CT scans to define treatment targets and organs at risk. Complementary tissue scans, such as magnetic resonance imaging (MRI) and positron electron emission (PET) scans, have all improved a physician’s ability to more specifically identify target tissues, and in some cases, international guidelines have even been issued. Moreover, efforts to combine PET and MR to define solid tumors for radiotherapy planning and treatment evaluation are also gaining traction.

Keeping these advances in mind, we present brief overviews of other up-and-coming key imaging concepts that appear promising for initial treatment target definition or treatment response from radiation therapy.

Ultrasound Imaging Technologies for Breast Cancer Detection and Management: A Review

Ultrasound imaging is a commonly used modality for breast cancer detection and diagnosis. In this review, we summarize ultrasound imaging technologies and their clinical applications for the management of breast cancer patients. The technologies include ultrasound elastography, contrast-enhanced ultrasound, 3-D ultrasound, automatic breast ultrasound and computer-aided detection of breast ultrasound. We summarize the study results seen in the literature and discuss their future directions. We also provide a review of ultrasound-guided, breast biopsy and the fusion of ultrasound with other imaging modalities, especially magnetic resonance imaging (MRI). For comparison, we also discuss the diagnostic performance of mammography, MRI, positron emission tomography and computed tomography for breast cancer diagnosis at the end of this review. New ultrasound imaging techniques, ultrasound-guided biopsy and the fusion of ultrasound with other modalities provide important tools for the management of breast patients.

Quantitative [18F]FMISO PET Imaging Shows Reduction of Hypoxia Following Trastuzumab in a Murine Model of HER2+ Breast Cancer

PURPOSE

Evaluation of [¹⁸F]fluoromisonidazole ([¹⁸F]FMISO)-positron emission tomography (PET) imaging as a metric for evaluating early response to trastuzumab therapy with histological validation in a murine model of HER2+ breast cancer.

PROCEDURES

Mice with BT474, HER2+ tumors, were imaged with [¹⁸F]FMISO-PET during trastuzumab therapy. Pimonidazole staining was used to confirm hypoxia from imaging.

RESULTS

[¹⁸F]FMISO-PET indicated significant decreases in hypoxia beginning on day 3 (P < 0.01) prior to changes in tumor size. These results were confirmed with pimonidazole staining on day 7 (P < 0.01); additionally, there was a significant positive linear correlation between histology and PET imaging (r ²  = 0.85).

CONCLUSIONS

[¹⁸F]FMISO-PET is a clinically relevant modality which provides the opportunity to (1) predict response to HER2+ therapy before changes in tumor size and (2) identify decreases in hypoxia which has the potential to guide subsequent therapy.

Computer-Aided Diagnosis of Focal Liver Lesions Using Contrast-Enhanced Ultrasonography With Perflubutane Microbubbles

This paper proposes an automatic classification method based on machine learning in contrast-enhanced ultrasonography (CEUS) of focal liver lesions using the contrast agent Sonazoid. This method yields spatial and temporal features in the arterial phase, portal phase, and post-vascular phase, as well as max-hold images. The lesions are classified as benign or malignant and again as benign, hepatocellular carcinoma (HCC), or metastatic liver tumor using support vector machines (SVM) with a combination of selected optimal features. Experimental results using 98 subjects indicated that the benign and malignant classification has 94.0% sensitivity, 87.1% specificity, and 91.8% accuracy, and the accuracy of the benign, HCC, and metastatic liver tumor classifications are 84.4%, 87.7%, and 85.7%, respectively. The selected features in the SVM indicate that combining features from the three phases are important for classifying FLLs, especially, for the benign and malignant classifications. The experimental results are consistent with CEUS guidelines for diagnosing FLLs. This research can be considered to be a validation study, that confirms the importance of using features from these phases of the examination in a quantitative manner. In addition, the experimental results indicate that for the benign and malignant classifications, the specificity without the post-vascular phase features is significantly lower than the specificity with the post-vascular phase features. We also conducted an experiment on the operator dependency of setting regions of interest and observed that the intra-operator and inter-operator kappa coefficients were 0.45 and 0.77, respectively.

Modulation of mammary tumor vascularization by mast cells: Ultrasonographic and histopathological approaches

AIMS

The inhibition of mast cells' degranulation may be an approach to prevent the formation of new vessels during the mammary carcinogenesis.

MATERIALS AND METHODS

Female Sprague-Dawley rats were randomly divided into five experimental groups. Mammary tumors were induced by intraperitoneal injection of N-methyl-N-nitrosourea (MNU). Animals from group II were treated with ketotifen for 18weeks immediately after the MNU administration, while animals from group III only received the ketotifen after the development of the first mammary tumor. Mammary tumors vascularization was assessed by ultrasonography (Doppler, B Flow and contrast-enhanced ultrasound) and immunohistochemistry (vascular endothelial growth factor-A).

KEY FINDINGS AND SIGNIFICANCE

Similar to what occurs in women with breast cancer, the majority of MNU-induced mammary tumors exhibited a centripetal enhancement order of the contrast agent, clear margin and heterogeneous enhancement. Ultrasonographic and immunohistochemical data suggest that the inhibition of mast cells' degranulation did not change the mammary tumors vascularization.

Quantitative contrast-enhanced ultrasonography for the differential diagnosis of endometrial hyperplasia and endometrial neoplasms

The present study aimed to investigate the feasibility of applying contrast-enhanced ultrasonography (CEUS) imaging technology for distinguishing between benign and malignant endometrial lesions, and to screen markers that could be correlated with the pathological results. In this study, endometrial diseases were diagnosed by biopsy under hysteroscopy and CEUS examinations. The intensity and time parameters of the time-intensity curve (TIC) were analyzed. The mean arrival time (AT), time-to-peak (TTP), rise time (RT), washout half-time and clearance half-time of malignant lesions were shorter than those of benign lesions (P<0.05), whereas the average peak intensity (PI) and enhancement intensity (EI) of malignant lesions were higher than those of benign lesions (P<0.05). The receiver operating characteristic curve showed the following cut-off values: PI, 29.2 dB; EI, 21.35 dB; AT, 12.75 sec; TTP, 26.75 sec; RT, 13.2 sec; clearance half-time, 89.3 sec; and washout half-time, 75.45 sec. The lesions with PI, an EI higher than that of the cut-off and lesions with an AT, TTP, RT, half clearing time and washout half-time shorter than the cut-off were considered malignant. The TTP, RT and half clearing time were negatively correlated with microvessel density (MVD), i.e., MVD was higher when the TTP, RT and half clearing time were shorter. Overall, changes in the enhancement and clearing of lesions could be quantitatively analyzed by CEUS TIC and further discriminate benign from malignant lesions. In the present study, CEUS appeared to indirectly reflect blood vessel changes inside the lesions and provided a pre-operative non-invasive fast imaging method for the diagnosis of endometrial disease.

Predictive model for contrast-enhanced ultrasound of the breast: Is it feasible in malignant risk assessment of breast imaging reporting and data system 4 lesions?

AIM: To build and evaluate predictive models for contrast-enhanced ultrasound (CEUS) of the breast to distinguish between benign and malignant lesions.

METHODS: A total of 235 breast imaging reporting and data system (BI-RADS) 4 solid breast lesions were imaged via CEUS before core needle biopsy or surgical resection. CEUS results were analyzed on 10 enhancing patterns to evaluate diagnostic performance of three benign and three malignant CEUS models, with pathological results used as the gold standard. A logistic regression model was developed basing on the CEUS results, and then evaluated with receiver operating curve (ROC).

RESULTS: Except in cases of enhanced homogeneity, the rest of the 9 enhancement appearances were statistically significant (P < 0.05). These 9 enhancement patterns were selected in the final step of the logistic regression analysis, with diagnostic sensitivity and specificity of 84.4% and 82.7%, respectively, and the area under the ROC curve of 0.911. Diagnostic sensitivity, specificity, and accuracy of the malignant vs benign CEUS models were 84.38%, 87.77%, 86.38% and 86.46%, 81.29% and 83.40%, respectively.

CONCLUSION: The breast CEUS models can predict risk of malignant breast lesions more accurately, decrease false-positive biopsy, and provide accurate BI-RADS classification.

Intraoperative high-resolution ultrasound and contrast-enhanced ultrasound of peripheral nerve tumors and tumorlike lesions

The diagnostic workup and surgical therapy for peripheral nerve tumors and tumorlike lesions are challenging. Magnetic resonance imaging is the standard diagnostic tool in the preoperative workup. However, even with advanced pulse sequences such as diffusion tensor imaging for MR neurography, the ability to differentiate tumor entities based on histological features remains limited. In particular, rare tumor entities different from schwannomas and neurofibromas are difficult to anticipate before surgical exploration and histological confirmation. High-resolution ultrasound (HRU) has become another important tool in the preoperative evaluation of peripheral nerves. Ongoing software and technical developments with transducers of up to 17-18 MHz enable high spatial resolution with tissue-differentiating properties. Unfortunately, high-frequency ultrasound provides low tissue penetration. The authors developed a setting in which intraoperative HRU was used and in which the direct sterile contact between the ultrasound transducer and the surgically exposed nerve pathology was enabled to increase structural resolution and contrast. In a case-guided fashion, the authors report the sonographic characteristics of rare tumor entities shown by intraoperative HRU and contrast-enhanced ultrasound.

Adjunctive targeted contrast-enhanced ultrasonography for the work-up of Breast Imaging Reporting and Data System category 3 and 4 lesions

INTRODUCTION

The assessment and management of Breast Imaging Reporting and Data System category 3 and 4 lesions (BI-RADS 3 and 4 lesions respectively) present numerous challenges for breast radiologists and physicians due to the ambiguity in the classification guidelines. Different imaging modalities have been investigated for their ability to provide additional aid in classification and management. The aim of this study was to evaluate the utility of targeted contrast-enhanced ultrasonography (CEUS) as an adjunctive modality to mammography plus conventional ultrasound (MG + US) in the decision of whether further diagnostic work-up is needed for BI-RADS 3 and 4 lesions.

METHODS

A total of 37 MG + US-detected BI-RADS 3 lesions and 60 MG + US-detected BI-RADS 4 lesions were analysed by targeted CEUS and biopsied. The effectiveness of CEUS in distinguishing benign from malignant entities among the breast lesions was evaluated by using the histological results of biopsied samples as the gold standard.

RESULTS

Two BI-RADS 3 and 14 BI-RADS 4 lesions were diagnosed as true-positive findings by targeted CEUS, with negative predictive values (NPVs) of 100% and 89.2% respectively.

CONCLUSIONS

Owing to the high NPV of targeted CEUS, a negative diagnosis of MG + US-detected BI-RADS 3 lesions by targeted CEUS can be helpful in avoiding unnecessary biopsies. However, targeted CEUS cannot be used to exclude patients with BI-RADS 4 lesions from further diagnostic work-up.

Evaluation of Malignancy Grade of Breast Cancer Using Perflubutane-Enhanced Ultrasonography

Whether the contrast effects of perflubutane on contrast-enhanced ultrasonography can predict the malignancy grade of breast cancer is unknown. We analyzed associations between perfusion parameters created from time-intensity curves based on enhancement intensity and temporal changes in contrast-enhanced ultrasonography and clinicopathologic factors in 100 consecutive patients with invasive breast cancer. Values of perfusion parameters were significantly greater in estrogen receptor-negative than -positive tumors (peak intensity, p = 0.0002; ascending slope, p = 0.006; area under the curve, p = 0.0006). Variations in the peak intensity of Ki-67 were significantly correlated in all tumors (r = 0.54, p < 0.0001) and in luminal (r = 0.43, p = 0.0002), human epidermal growth factor receptor type 2-positive (r = 0.47, p = 0.047) and triple-negative (r = 0.55, p = 0.043) tumors. Perfusion parameters on contrast-enhanced ultrasonography can provide excellent predictive value for high-grade malignancy and might help to determine appropriate therapeutic strategies.

Ability of contrast-enhanced ultrasonography to determine clinical responses of breast cancer to neoadjuvant chemotherapy

OBJECTIVE

We aimed to determine whether contrast-enhanced ultrasonography can predict the effects of neoadjuvant chemotherapy on breast cancer.

METHODS

The clinical responses of 63 consecutive patients with breast cancer (T1-4, N0-1, M0) to neoadjuvant chemotherapy between October 2012 and May 2015 were assessed using contrast-enhanced magnetic resonance imaging, positron emission tomography/computed tomography and contrast-enhanced ultrasonography. Perfusion parameters for contrast-enhanced ultrasonography were created from time-intensity curves based on enhancement intensity and temporal changes to objectively evaluate contrast-enhanced ultrasonography findings. The sensitivity, specificity and accuracy of contrast-enhanced ultrasonography, magnetic resonance imaging and positron emission tomography/computed tomography to predict a pathological complete response were compared after confirming the pathological findings of surgical specimens.

RESULTS

Twenty-three (36.5%) of the 63 patients achieved pathological complete response. The sensitivity, specificity and accuracy of contrast-enhanced ultrasonography for predicting pathological complete response were 95.7% (82.5-99.2%), 77.5% (69.9-79.5%) and 84.1% (74.5-86.7%). The sensitivity of contrast-enhanced ultrasonography was significantly greater than that of magnetic resonance imaging (95.7 vs. 69.6%, P = 0.047). The specificity and accuracy were significantly greater and tended to be greater, respectively, for contrast-enhanced ultrasonography than positron emission tomography/computed tomography (specificity, 77.5 vs. 52.5%, P = 0.02; accuracy, 84.1 vs. 69.8%, P = 0.057).

CONCLUSIONS

Contrast-enhanced ultrasonography might serve as a new diagnostic modality when planning therapeutic strategies for patients with breast cancer after neoadjuvant chemotherapy.

The role of ultrasound in the management of breast disease

Surgeon‐performed ultrasound has also been increasingly utilised by breast surgeons in particular, who find ultrasound an invaluable tool in the office to assist in the management of breast patients, and also in the operating room where it can be used to directly guide excision of impalpable breast lesions without the use of hookwires^2,3. In the future, the role of ultrasound will continue to grow, particularly with the advent of 3‐D ultrasound, and in the evolving area of breast lesion ablation techniques using modalities such as radiofrequency ablation or laser therapy. Ultrasound is a very important tool in the assessment and management of breast disease and it has dramatically changed the way breast cancer patients are managed.

Contrast-enhanced ultrasonography in differential diagnosis of benign and malignant ovarian tumors

Objective

To evaluate the accuracy of contrast-enhanced ultrasonography (CEUS) in differential diagnosis of benign and malignant ovarian tumors.

Methods

The scientific literature databases PubMed, Cochrane Library and CNKI were comprehensively searched for studies relevant to the use of CEUS technique for differential diagnosis of benign and malignant ovarian cancer. Pooled summary statistics for specificity (Spe), sensitivity (Sen), positive and negative likelihood ratios (LR⁺/LR⁻), and diagnostic odds ratio (DOR) and their 95%CIs were calculated. Software for statistical analysis included STATA version 12.0 (Stata Corp, College Station, TX, USA) and Meta-Disc version 1.4 (Universidad Complutense, Madrid, Spain).

Results

Following a stringent selection process, seven high quality clinical trials were found suitable for inclusion in the present meta-analysis. The 7 studies contained a combined total of 375 ovarian cancer patients (198 malignant and 177 benign). Statistical analysis revealed that CEUS was associated with the following performance measures in differential diagnosis of ovarian tumors: pooled Sen was 0.96 (95%CI = 0.92∼0.98); the summary Spe was 0.91 (95%CI = 0.86∼0.94); the pooled LR⁺ was 10.63 (95%CI = 6.59∼17.17); the pooled LR− was 0.04 (95%CI = 0.02∼0.09); and the pooled DOR was 241.04 (95% CI = 92.61∼627.37). The area under the SROC curve was 0.98 (95% CI = 0.20∼1.00). Lastly, publication bias was not detected (t = −0.52, P = 0.626) in the meta-analysis.

Conclusions

Our results revealed the high clinical value of CEUS in differential diagnosis of benign and malignant ovarian tumors. Further, CEUS may also prove to be useful in differential diagnosis at early stages of this disease.

Contrast-enhanced ultrasound using real-time contrast harmonic imaging in invasive breast cancer: comparison of enhancement dynamics with three different doses of contrast agent

BACKGROUND

In the last few years new potential applications have been developed for contrast-enhanced ultrasound (CEUS) and the management of breast diseases, but there is still some debate concerning the optimal dose to evaluate breast lesions, especially as a diagnostic tool.

PURPOSE

To compare different CEUS doses of injected contrast agent in order to establish an optimal dose for the diagnosis of invasive breast cancer.

MATERIAL AND METHODS

In Group A we compared the bolus dose of 1.2 mL vs. 2.4 mL and in Group B we compared the bolus dose of 2.4 mL vs. 4.8 mL (26 and 25 invasive carcinomas, respectively). CEUS was performed in real-time contrast harmonic imaging (CHI) using a L9-3 MHz probe. All examinations were recorded in a contrast side/side imaging mode loop for 120 s. Wash-in and wash-out patterns of the contrast agent were analyzed with advanced US quantification software and kinetic curves were used for statistical analysis.

RESULTS

In Group B (2.4 mL vs. 4.8 mL), more and stronger correlation was found among kinetic parameters (area under the curve, P < 0.00001; lognormal model parameters, μ, P = 0.0007 and σ, P < 0.0001; mean transit time, P < 0.0001; model-based wash-out ratios, W21m, P = 0.0002; W50m, P = 0.0001; time-to-peak, P = 0.005) as compared to Group A (1.2 mL vs. 2.4 mL).

CONCLUSION

The optimal way to evaluate kinetic features of invasive breast tumors using real-time CEUS is with an injection of contrast agent of either 2.4 mL or 4.8 mL.

Meta-analysis of contrast-enhanced ultrasound for the differentiation of benign and malignant breast lesions

BACKGROUND

Contrast-enhanced ultrasound (CEUS) is a non-invasive method for the assessment of breast lesions. The accuracy of CEUS in diagnosing of breast cancer has never been systematically assessed.

PURPOSE

To determine the overall performance of CEUS in the differentiation of benign and malignant breast lesions using meta-analysis.

MATERIAL AND METHODS

PubMed, Embase, Cochrane Library, and article references published before October 2012 were searched. Published studies that used histopathologic results as golden reference to assess the diagnostic performance of CEUS in patients suspected of having breast cancer and the data necessary to calculate the diagnostic results were included. The qualities of eligible studies for final meta-analysis were assessed by using the quality assessment of diagnostic studies (QUADAS) instrument. Sensitivity, specificity, summary receiver-operating characteristic (sROC) curves, and area under the curve were calculated to examine the diagnostic performance of CEUS.

RESULTS

Of 16 eligible studies, 957 breast lesions were included in the original meta-analysis, among which heterogeneity arising from factors other than threshold effect was explored. Meta-regression analysis confirmed the contrast agent was the most significant factor cause of heterogeneity (P = 0.0012, relative diagnostic odds ratio [DOR] = 7.06). The use of perfluoro containing microbubbles (Sonovue or Optison) significantly increased the diagnostic precision compared with Levovist. The pooled weighted estimates of sensitivity and specificity for CEUS in the diagnosis of breast lesions were 0.86 (95% confidence interval [CI], 0.83, 0.89) and 0.79 (95% CI, 0.75, 0.83), respectively.

CONCLUSION

CEUS has good sensitivity and specificity in the characterization of breast lesions and can potentially help to select suspicious breast mass for surgery.

Breast contrast-enhanced ultrasound: is a scoring system feasible? A preliminary study in China

OBJECTIVES

Although many studies about breast contrast-enhanced ultrasound had been conducted, clear diagnostic criteria for evaluating enhancement patterns are still lacking. This study aims to identify significant indicators for breast contrast-enhanced ultrasound and to establish an initial scoring system.

MATERIALS AND METHODS

Totally 839 patients were included in the study. This study was divided into two parts. 364 patients were included in part 1 while 475 in part 2. Conventional ultrasound and contrast-enhanced ultrasound were used to examine each lesion. Only the cases in part 2 were also examined by elastography. In part 1, Logistic regression analysis was performed to predict significant variables. A 5-point scoring system was developed based on the results. In part 2, the scoring system was used to evaluate all the breast lesions. To evaluate the diagnostic efficacy of the new scoring system, it was compared with the system established for elastography and conventional ultrasound (BI-RADS).

RESULTS

Three independent variables, namely, lesion scope, margin, and shape were selected in the final step of the logistic regression analysis in part 1. In part 2, the area under the ROC (receiver operating characteristic) curve for the contrast-enhanced scoring system was 0.912. The difference in the diagnostic capabilities of the contrast-enhanced scoring system and elastography was not statistically significant (P = 0.17). The difference in the diagnostic capabilities of the contrast-enhanced scoring system and BI-RADS was statistically significant (P<0.001).

CONCLUSIONS

The contrast-enhanced patterns of benign and malignant breast tumors are different. The application of a 5-point scoring system for contrast-enhanced ultrasound is clinically promising.

Recent advances in molecular, multimodal and theranostic ultrasound imaging

Ultrasound (US) imaging is an exquisite tool for the non-invasive and real-time diagnosis of many different diseases. In this context, US contrast agents can improve lesion delineation, characterization and therapy response evaluation. US contrast agents are usually micrometer-sized gas bubbles, stabilized with soft or hard shells. By conjugating antibodies to the microbubble (MB) surface, and by incorporating diagnostic agents, drugs or nucleic acids into or onto the MB shell, molecular, multimodal and theranostic MBs can be generated. We here summarize recent advances in molecular, multimodal and theranostic US imaging, and introduce concepts how such advanced MB can be generated, applied and imaged. Examples are given for their use to image and treat oncological, cardiovascular and neurological diseases. Furthermore, we discuss for which therapeutic entities incorporation into (or conjugation to) MB is meaningful, and how US-mediated MB destruction can increase their extravasation, penetration, internalization and efficacy.

CEUS helps to rerate small breast tumors of BI-RADS category 3 and category 4

PURPOSE

The primary aim of this study was to explore if classification, whether using the BI-RADS categories based on CEUS or conventional ultrasound, was conducive to the identification of benign and malignant category 3 or 4 small breast lesions.

MATERIAL AND METHODS

We evaluated 30 malignant and 77 benign small breast lesions using CEUS. The range of enhancement, type of enhancement strength, intensity of enhancement, and enhancement patterns were independent factors included to assess the BI-RADS categories.

RESULTS

Of the nonenhanced breast lesions, 97.8% (44/45) were malignant, while, of the hyperplasic nodules, 96.8% (30/31) showed no enhancement in our study. Category changes of the lesions were made according to the features determined using CEUS. The results showed that these features could improve diagnostic sensitivity (from 70.0 to 80.0, 80.0, 90.0, and 90.0%), reduce the negative likelihood ratio (from 0.33 to 0.22, 0.25, 0.11, and 0.12), and improve the NPV (from 88.8 to 92.2, 91.2, 96.2, and 95.5%). However, this was not conducive to improve diagnostic specificity or the PPV.

CONCLUSION

The vast majority of nonenhanced small breast lesions were malignant and most of the hyperplasic nodules showed no contrast enhancement. As a reference, CEUS was helpful in identifying BI-RADS category 3 or 4 small breast lesions.

A semi-automated 3-D annotation method for breast ultrasound imaging: system development and feasibility study on phantoms

Spatial annotation is an essential step in breast ultrasound imaging, because the follow-up diagnosis and treatment are based on this annotation. However, the current method for annotation is manual and highly dependent on the operator's experience. Moreover, important spatial information, such as the probe tilt angle, cannot be indicated in the clinical 2-D annotations. To solve these problems, we developed a semi-automated 3-D annotation method for breast ultrasound imaging. A spatial sensor was fixed on an ultrasound probe to obtain the image spatial data. Three-dimensional virtual models of breast and probe were used to annotate image locations. After the reference points were recorded, this system displayed the image annotations automatically. Compared with the conventional manual annotation method, this new annotation system has higher accuracy as indicated by the phantom test results. In addition, this new annotation method has good repeatability, with intra-class correlation coefficients of 0.907 (average variation: ≤3.45%) and 0.937 (average variation: ≤2.85%) for the intra-rater and inter-rater tests, respectively. Breast phantom experiments simulating clinical breast scanning further indicated the feasibility of this system for clinical applications. This new annotation method is expected to facilitate more accurate, intuitive and rapid breast ultrasound diagnosis.

Doppler ultrasonography reveals blood flow signals within the masses of invasive moles in subjects with normal hCG levels after chemotherapy: Three case reports

A consensus has formed that patients with invasive moles should continue with one to three cycles of chemotherapy after human chorionic gonadotropin (hCG) levels have decreased to a normal level. However, the management plan has not been agreed for cases where Doppler ultrasonography (DU) indicates blood-flow signals within the tumor mass after one to three cycles of chemotherapy when the hCG concentration has returned to normal. The present study describes the clinical and therapeutic courses of three patients with invasive moles with confirmed blood-flow signals (by DU) after their hCG levels had normalized. One patient underwent surgery to remove the mass within the uterine muscle, while the other two patients decided to cease chemotherapy and were managed by follow-up appointments; all three patients had good outcomes. These data illustrate that patients with invasive moles should be followed up if DU indicates blood-flow signals in the tumor mass after one to three cycles of chemotherapy when the hCG level has decreased back to a normal level.

Diagnostic efficacy of contrast-enhanced sonography by combined qualitative and quantitative analysis in breast lesions: a comparative study with magnetic resonance imaging

OBJECTIVES

The purpose of this study was to evaluate the diagnostic efficacy of contrast-enhanced sonography for differentiation of breast lesions by combined qualitative and quantitative analyses in comparison to magnetic resonance imaging (MRI).

METHODS

Fifty-six patients with American College of Radiology Breast Imaging Reporting and Data System category 3 to 5 breast lesions on conventional sonography were evaluated by contrast-enhanced sonography and MRI. A comparative analysis of diagnostic results between contrast-enhanced sonography and MRI was conducted in light of the pathologic findings.

RESULTS

Pathologic analysis showed 26 benign and 30 malignant lesions. The predominant enhancement patterns of the benign lesions on contrast-enhanced sonography were homogeneous, centrifugal, and isoenhancement or hypoenhancement, whereas the patterns of the malignant lesions were mainly heterogeneous, centripetal, and hyperenhancement. The detection rates for perfusion defects and peripheral radial vessels in the malignant group were much higher than those in the benign group (P < .05). As to quantitative analysis, statistically significant differences were found in peak and time-to-peak values between the groups (P < .05). With pathologic findings as the reference standard, the sensitivity, specificity, and accuracy of contrast-enhanced sonography and MRI were 90.0%, 92.3%, 91.1% and 96.7%, 88.5%, and 92.9%, respectively. The two methods had a concordant rate of 87.5% (49 of 56), and the concordance test gave a value of κ = 0.75, indicating that there was high concordance in breast lesion assessment between the two diagnostic modalities.

CONCLUSIONS

Contrast-enhanced sonography provided typical enhancement patterns and valuable quantitative parameters, which showed good agreement with MRI in diagnostic efficacy and may potentially improve characterization of breast lesions.

Novel use of contrast-enhanced sonography in the diagnosis of central uterine necrosis following embolization for postpartum hemorrhage

Since 2007, we have identified 2 cases of central uterine necrosis after uterine arterial embolization for postpartum hemorrhage. Contrast-enhanced sonography showed an absence of enhancement of the internal myometrium. Magnetic resonance imaging with gadolinium confirmed the diagnosis. The images obtained for the first case were corroborated by histologic analysis from a hysterectomy done for sepsis. For the second case, contrast-enhanced sonography performed during a follow-up period of conservative treatment revealed a reduction of necrosis. Our study shows that contrast-enhanced sonography seems to be a useful examination as an adjunct to grayscale and power Doppler imaging in the diagnosis and follow-up of uterine necrosis.

Diagnostic value of contrast-enhanced ultrasound parametric imaging in breast tumors

PURPOSE

This study aimed to evaluate the diagnostic value of SonoLiver software for parametric imaging in breast tumors.

METHODS

Contrast-enhanced ultrasound (CEUS) was performed in 216 breast lesions (113 malignant, 103 benign). The CEUS parameters were compared between benign and malignant lesions. The rise time, the time to peak, the mean transit time and dynamic vessel pattern (DVP) were analyzed using SonoLiver software.

RESULTS

Quantitative analysis showed that the rise time was 16.52±4.15 seconds in the benign group vs. 13.86±3.36 seconds in the malignant group (p=0.007), and the time to peak was 19.86±4.87 seconds in the benign group vs. 16.52±4.85 seconds in the malignant group (p=0.009). The mean transit time was 80.55±18.65 seconds in the benign group vs. 65.16±20.28 seconds in the malignant group (p=0.006). The difference between the distribution of DVP in benign and malignant tumors was statistically significant. One hundred one malignant tumors (89.4%) performed an irregular red/yellow fill in the region of interest (ROI) and 85 benign tumors (82.5%) performed a single blue/green fill in the ROI. The sensitivity, specificity, and accuracy of parametric imaging in breast tumors were 84.1%, 85.4%, 84.7%, respectively.

CONCLUSION

The CEUS parametric imaging can distinguish differences between malignant and benign breast tumors as well as provide diagnostic information on breast lesions.