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Ito T, Manabe H, Kubota M, Komoike Y. Current status and future perspectives of contrast-enhanced ultrasound diagnosis of breast lesions. J Med Ultrason (2001) 2024:10.1007/s10396-024-01486-0. [PMID: 39174799 DOI: 10.1007/s10396-024-01486-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 06/28/2024] [Indexed: 08/24/2024]
Abstract
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.
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Affiliation(s)
- Toshikazu Ito
- Division of Breast and Endocrine Surgery and Department of Surgery, Kindai University Faculty of Medicine, Osaka, Japan.
| | - Hironobu Manabe
- Division of Breast and Endocrine Surgery and Department of Surgery, Kindai University Faculty of Medicine, Osaka, Japan
| | - Michiyo Kubota
- Division of Breast and Endocrine Surgery and Department of Surgery, Kindai University Faculty of Medicine, Osaka, Japan
| | - Yoshifumi Komoike
- Division of Breast and Endocrine Surgery and Department of Surgery, Kindai University Faculty of Medicine, Osaka, Japan
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Li X, Zhang J, Zhang G, Liu J, Tang C, Chen K, Chen P, Tan L, Guo Y. Contrast-Enhanced Ultrasound and Conventional Ultrasound Characteristics of Breast Cancer With Different Molecular Subtypes. Clin Breast Cancer 2024; 24:204-214. [PMID: 38102010 DOI: 10.1016/j.clbc.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 11/09/2023] [Accepted: 11/13/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Identifying molecular subtypes of breast cancer (BC) is of great significance in selecting optimal treatment strategy. Different molecular subtypes of BC have various vascular distribution characteristics. Contrast-enhanced ultrasound (CEUS) can dynamically display the microcirculation of tumor. This study intends to explore the conventional ultrasound and CEUS characteristics of different molecular subtypes of BC. METHODS During this prospective study, 86 patients with BC who were divided into Luminal A (LA), Luminal B (LB), HER2 over-expression (H2), and triple-negative (TN). The CEUS qualitative and quantitative characteristics of BC with different molecular subtypes was explored, as well as the conventional ultrasound features. In addition, the diagnostic efficiency of CEUS quantitative parameters in differentiating molecular subtypes of BC was analyzed. RESULTS Our study found that the Adler grade differed significantly among 4 molecular subtypes (P < .05). The enhancement speed, enhancement degree and size after enhancement of 4 molecular subtypes were statistically different (P < .05). The wash in slope (WIS), peak intensity (PI), and wash-in area under the curve (WiAUC) differed significantly among 4 subtypes (P < .05). The diagnostic efficiency of PI was better for detecting LA and H2 subtype with the areas under the receiver operating characteristic curve was 0.778 and 0.734, respectively. CONCLUSION Different molecular subtypes of BC have different CEUS and conventional ultrasound characteristics. CEUS can provide valuable imaging basis for precise clinical diagnosis and individualized therapy of BC with different molecular subtypes.
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Affiliation(s)
- Xin Li
- Department of Ultrasound, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jun Zhang
- Department of Ultrasound, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Guozhi Zhang
- Department of Breast and Thyroid Surgery, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Juan Liu
- Department of Ultrasound, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Chunlin Tang
- Department of Ultrasound, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Kaixuan Chen
- Department of Ultrasound, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Ping Chen
- Department of Ultrasound, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Lin Tan
- Department of Ultrasound, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Yanli Guo
- Department of Ultrasound, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China.
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Li LL, Su QL, Deng YX, Guo WW, Lun HM, Hu Q. Contrast-enhanced ultrasound for the preoperative prediction of pathological characteristics in breast cancer. Front Oncol 2024; 14:1320714. [PMID: 38487727 PMCID: PMC10937469 DOI: 10.3389/fonc.2024.1320714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 02/13/2024] [Indexed: 03/17/2024] Open
Abstract
Objective We aimed to investigate the value of contrast-enhanced ultrasound (CEUS) in the preoperative prediction of the histological grades and molecular subtypes of breast cancer. Methods A total of 183 patients with pathologically confirmed breast cancer were included. Contrast enhancement patterns and quantitative parameters were compared in different groups. The receiver operating characteristic (ROC) curve was used to analyze the efficacy of CEUS in the preoperative prediction of pathological characteristics, including histologic grade and molecular subtypes. Results Heterogeneous enhancement, perfusion defects, and peripheral radial vessels were mostly observed in higher histologic grade (grade III) breast cancer. Heterogeneous enhancement and perfusion defect were the most effective indicators for grade III breast cancer, with the areas under the ROC curve of 0.768 and 0.756, respectively. There were significant differences in the enhancement intensity, post-enhanced margin, perfusion defects, and peripheral radial vessel among the different molecular subtypes of breast cancer (all P < 0.01). Perfusion defects and clear edge after enhancement were the best qualitative criteria for the diagnosis of HER-2 overexpressed and triple-negative breast cancers, and the corresponding areas under the ROC curves were 0.804 and 0.905, respectively. There were significant differences in PE, WiR, WiPI, and WiWoAUC between grade III vs grade I and II breast cancer (P < 0.05). PE, WiR, WiPI, and WiWoAUC had good efficiency in the diagnosis of high-histologic-grade breast cancer. PE had the highest diagnostic efficiency in Luminal A, while WiPI had the highest diagnostic efficiency in Luminal B subtype breast cancer, and the areas under the ROC curve were 0.825 and 0.838, respectively. WiWoAUC and WiR were the most accurate parameters for assessing triple-negative subtype breast cancers, and the areas under the curve were 0.932 and 0.922, respectively. Conclusion Qualitative and quantitative perfusion analysis of contrast-enhanced ultrasound may be useful in the non-invasive prediction of the histological grade and molecular subtypes of breast cancers.
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Affiliation(s)
- Ling-Ling Li
- Departments of Ultrasound, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Quan-Li Su
- Departments of Ultrasound, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Yun-Xia Deng
- Departments of Ultrasound, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Wen-Wen Guo
- Departments of Pathology, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Hai-Mei Lun
- Departments of Ultrasound, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Qiao Hu
- Departments of Ultrasound, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
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Grewal D, Bhanu KU, Sahni H, Maheshwari S, Kakria N, Mishra P, Anand V. Role of qualitative contrast-enhanced ultrasound in the diagnosis of malignant breast lesions. Med J Armed Forces India 2023; 79:414-420. [PMID: 37441290 PMCID: PMC10334224 DOI: 10.1016/j.mjafi.2022.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 01/27/2022] [Indexed: 12/24/2022] Open
Abstract
Background Carcinoma breast is the commonest cancer among women. Various authors have studied breast cancer with Contrast-Enhanced Ultrasound (CEUS) with promising results. Despite promising results, the additional cost of post-processing software limits its availability. In this study, we evaluated the utility of CEUS in differentiating malignant from benign breast lesions on regular ultrasound equipment without the use of dedicated software. Methods We performed CEUS in 121 women with 121 breast lesions. CEUS was done by creating a custom preset on existing ultrasound equipment with the help of an application specialist authorized by the vendor. Lesions were evaluated qualitatively without the use of any commercial software. The pattern of enhancement i.e. homogenous, heterogeneous, peripheral, or no enhancement, and the number of penetrating vessels i.e., few or multiple were recorded. Results were compared with histopathological diagnosis. Results There were a total of 121 breast lesions. The study showed sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 86.67 %, 54.10 %, 65 %, and 80.49% respectively for differentiating benign vs malignant lesions on the basis of the pattern of contrast enhancement. Using penetrating vessels for differentiating malignant lesions from benign lesions, the sensitivity, specificity, PPV, and NPV were found to be 64%, 67.86%, 78.05%, and 51.35% respectively. Conclusion CEUS is useful in differentiating malignant from benign breast lesions. It can be easily performed by creating a custom preset on standard ultrasound equipment without the use of expensive software.
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Affiliation(s)
- D.S. Grewal
- Associate Professor, Department of Radiodiagnosis & Imaging, Armed Forces Medical College, Pune, India
| | - K. Uday Bhanu
- Professor, Department of Radiodiagnosis & Imaging, Armed Forces Medical College, Pune, India
| | - Hirdesh Sahni
- Professor & Head, Department of Radiodiagnosis & Imaging, Armed Forces Medical College, Pune, India
| | - Saurabh Maheshwari
- Assistant Professor, Department of Radiodiagnosis & Imaging, Armed Forces Medical College, Pune, India
| | - Neha Kakria
- Classified Specialist (Radiology), Command Hospital (Northern Command), Udhampur, India
| | - P.S. Mishra
- Classified Specialist, Department of Pathology, Army Hospital (R & R), New Delhi, India
| | - Varun Anand
- Clinical Tutor, Department of Radiodiagnosis & Imaging, Armed Forces Medical College, Pune, India
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Shao S, Yao M, Li C, Li X, Wang J, Chen J, Zheng Y, Wu R. Ultrasound features for prediction of long-term outcomes of women with primary breast cancer <20 mm. Front Oncol 2023; 13:1103397. [PMID: 37007100 PMCID: PMC10061109 DOI: 10.3389/fonc.2023.1103397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 02/27/2023] [Indexed: 03/18/2023] Open
Abstract
BackgroundSome women die despite the favorable prognosis of small breast cancers. Breast ultrasound features may reflect pathological and biological characteristics of a breast tumor. This study aimed to explore whether ultrasound features could identify small breast cancers with poor outcomes.MethodsThis retrospective study examined confirmed breast cancers with a size of <20 mm diagnosed in our hospital between 02/2008 and 08/2019. Clinicopathological and ultrasound features were compared between alive and deceased breast cancer patients. Survival was analyzed using the Kaplan-Meier curves. Multivariable Cox proportional hazards models were used to examine the factors associated with breast cancer-specific survival (BCSS) and disease-free survival (DFS).ResultsAmong the 790 patients, the median follow-up was 3.5 years. The deceased group showed higher frequencies of spiculated (36.7% vs. 11.2%, P<0.001), anti-parallel orientation (43.3% vs. 15.4%, P<0.001), and spiculated morphology combined with anti-parallel orientation (30.0% vs. 2.4%, P<0.001). Among 27 patients with spiculated morphology and anti-parallel orientation, nine cancer-specific deaths and 11 recurrences occurred, for a 5-year BCSS of 77.8% and DFS of 66.7%, while 21 breast-cancer deaths and 41 recurrences occurred among the remaining patients with higher 5-year BCSS (97.8%, P<0.001) and DFS (95.4%, P<0.001). Spiculated and anti-parallel orientation (HR=7.45, 95%CI: 3.26-17.00; HR=6.42, 95%CI: 3.19-12.93), age ≥55 years (HR=5.94, 95%CI: 2.24-15.72; HR=1.98, 95%CI: 1.11-3.54), and lymph nodes metastasis (HR=3.99, 95%CI: 1.89-8.43; HR=2.99, 95%CI: 1.71-5.23) were independently associated with poor BCSS and DFS.ConclusionsSpiculated and anti-parallel orientation at ultrasound are associated with poor BCSS and DFS in patients with primary breast cancer <20 mm.
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Affiliation(s)
- Sihui Shao
- Department of Ultrasound, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Minghua Yao
- Department of Ultrasound, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chunxiao Li
- Department of Ultrasound, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xin Li
- Department of Ultrasound, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jianfeng Wang
- Department of General Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jing Chen
- Department of Ultrasound, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yi Zheng
- Department of Ultrasound, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Rong Wu
- Department of Ultrasound, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- *Correspondence: Rong Wu,
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Guo Q, Dong Z, Jiang L, Zhang L, Li Z, Wang D. Establishment and validation of an ultrasound-based nomogram with risk stratification for short disease-free survival in breast cancer. JOURNAL OF CLINICAL ULTRASOUND : JCU 2023; 51:134-147. [PMID: 36054346 DOI: 10.1002/jcu.23296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 06/07/2022] [Accepted: 07/07/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE This retrospective study aimed to develop and validate an Ultrasound (US)-based nomogram to predict short disease-free survival (short-DFS, less than 120 months DFS) in breast cancer (BC). METHODS Nomogram was established based on a training data of 311 BC patients by multivariable logistic regression, and were assessed by discrimination, calibration, and clinical usefulness. Risk stratification was performed by X-tile. An independent testing data of 200 patients with BC was used for external validation. RESULTS Nine predictors including three US features and six clinical parameters were screened into the nomogram by Lasso (log λ = -3.594) in training data. Better performance was obtained in the training data (C-index: 0.942) and testing data (C-index: 0.914). Calibration analysis indicated optimal agreement between nomogram predictions and actual observations (p = 0.67). Decision curve analysis showed a great clinical benefit (Youden index: 0.634). Three risk levels are low-risk (<184.0), moderate-risk (184.0-345.3) and high-risk (>345.3). Our nomograms had larger area under the receiver operating characteristic (ROC) curves compared with Magee Equation and Nottingham Prognostic models (0.942 vs. 0.824, 0.790). CONCLUSION The US-based nomogram and the practical score system facilitate individualized prediction of short-DFS to optimize clinical decisions and improve prognosis in patients with BC.
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Affiliation(s)
- Qiang Guo
- Department of Ultrasound Medicine, Jinshan Branch of Shanghai Sixth People's Hospital Affiliated to Shanghai Jiaotong University, Shanghai, China
| | - Zhiwu Dong
- Department of Laboratory Medicine, Jinshan Branch of Shanghai Sixth People's Hospital Affiliated to Shanghai Jiaotong University, Shanghai, China
| | - Lixin Jiang
- Department of Ultrasound in Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Institute of Ultrasound in Medicine, Shanghai, China
| | - Lei Zhang
- Department of Ultrasound Medicine, Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Ziyao Li
- Department of Ultrasound Medicine, Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Dongmo Wang
- Department of Ultrasound Medicine, Second Affiliated Hospital of Harbin Medical University, Harbin, China
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Chen J, Ma J, Li C, Shao S, Su Y, Wu R, Yao M. Multi-parameter ultrasonography-based predictive model for breast cancer diagnosis. Front Oncol 2022; 12:1027784. [PMID: 36465370 PMCID: PMC9714455 DOI: 10.3389/fonc.2022.1027784] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 11/01/2022] [Indexed: 12/31/2023] Open
Abstract
OBJECTIVES To develop, validate, and evaluate a predictive model for breast cancer diagnosis using conventional ultrasonography (US), shear wave elastography (SWE), and contrast-enhanced US (CEUS). MATERIALS AND METHODS This retrospective study included 674 patients with 674 breast lesions. The data, a main and an independent datasets, were divided into three cohorts. Cohort 1 (80% of the main dataset; n = 448) was analyzed by logistic regression analysis to identify risk factors and establish the predictive model. The area under the receiver operating characteristic curve (AUC) was analyzed in Cohort 2 (20% of the main dataset; n = 119) to validate and in Cohort 3 (the independent dataset; n = 107) to evaluate the predictive model. RESULTS Multivariable regression analysis revealed nine independent breast cancer risk factors, including age > 40 years; ill-defined margin, heterogeneity, rich blood flow, and abnormal axillary lymph nodes on US; enhanced area enlargement, contrast agent retention, and irregular shape on CEUS; mean SWE higher than the cutoff value (P < 0.05 for all). The diagnostic performance of the model was good, with AUC values of 0.847, 0.857, and 0.774 for Cohorts 1, 2, and 3, respectively. The model increased the diagnostic specificity (from 31% to 81.3% and 7.3% to 73.1% in cohorts 2 and 3, respectively) without a significant loss in sensitivity (from 100.0% to 90.1% and 100.0% to 81.8% in cohorts 2 and 3, respectively). CONCLUSION The multi-parameter US-based model showed good performance in breast cancer diagnosis, improving specificity without a significant loss in sensitivity. Using the model could reduce unnecessary biopsies and guide clinical diagnosis and treatment.
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Affiliation(s)
| | | | | | | | | | - Rong Wu
- Department of Ultrasound, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Minghua Yao
- Department of Ultrasound, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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B-Mode and Contrast-Enhanced Ultrasonography Aspects of Benign and Malignant Superficial Neoplasms in Dogs: A Preliminary Study. Animals (Basel) 2022; 12:ani12202765. [PMID: 36290151 PMCID: PMC9597709 DOI: 10.3390/ani12202765] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 09/28/2022] [Accepted: 10/12/2022] [Indexed: 11/05/2022] Open
Abstract
Simple Summary In dogs, superficial neoplasms are common, and it is crucial to determine their malignancy, as this will have an impact on treatment and prognosis. So far, the diagnostic value of ultrasound modalities, such as B-mode and contrast enhanced ultrasound, for superficial neoplasms in dogs is still unclear, despite promising studies in humans. B-mode ultrasound enables assessment of the size, shape and arrangement of the neoplastic tissue, whereas contrast enhanced ultrasound enables the assessment of blood flow intensity and pattern. The aim of this study was to identify B-mode and contrast enhanced ultrasound characteristics that may be used to distinguish benign and malignant superficial neoplasms in dogs. Ultrasonographic characteristics, for which a significant difference was observed between benign and malignant neoplasms, were border definition, echogenicity, echotexture, blood flow pattern at wash-in and blood flow intensity during wash-out at the center of the neoplasm. Despite these significant differences, there was a considerable overlap in ultrasonographic characteristics between benign and malignant neoplasms. In conclusion, B-mode and contrast enhanced ultrasound might contribute to malignancy prediction; however, based on individual ultrasonographic characteristics, they seem unable to replace cytology or histopathology. Abstract Contrast-enhanced ultrasonography (CEUS) is considered a promising technique for differentiation of benign and malignant tumors in humans. However, few studies have assessed superficial neoplasms in dogs by means of CEUS. The aim of this study was to identify ultrasonographic criteria evaluated by B-mode ultrasound (US) and CEUS that may be used to distinguish benign and malignant superficial neoplasms in dogs. A total of 63 superficial neoplasms from 59 dogs were evaluated using B-mode US and CEUS prior to histopathologic examination. Qualitative and quantitative parameters were compared between benign and malignant neoplasms by Fischer’s exact test or fixed effects model. With B-mode US, a significant difference was found for border definition, echogenicity and echotexture. With CEUS, a significant difference was found for the enhancement pattern at wash-in and the wash-out area under the curve at the center of the neoplasm. Malignant neoplasms had on average a lower regional blood volume during the wash-out phase compared to benign neoplasms. Despite these significant differences, there was a considerable overlap in B-mode and CEUS parameters between benign and malignant neoplasms. In conclusion, B-mode US and CEUS might contribute to malignancy prediction; however, based on individual ultrasonographic parameters, they seem unable to replace cytology or histopathology.
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Radiomic Signatures Derived from Hybrid Contrast-Enhanced Ultrasound Images (CEUS) for the Assessment of Histological Characteristics of Breast Cancer: A Pilot Study. Cancers (Basel) 2022; 14:cancers14163905. [PMID: 36010897 PMCID: PMC9405598 DOI: 10.3390/cancers14163905] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/09/2022] [Accepted: 08/11/2022] [Indexed: 12/30/2022] Open
Abstract
The purpose of this study was to evaluate the diagnostic performance of radiomic features extracted from standardized hybrid contrast-enhanced ultrasound (CEUS) data for the assessment of hormone receptor status, human epidermal growth factor receptor 2 (HER2) status, tumor grade and Ki-67 in patients with primary breast cancer. METHODS This prospective study included 72 patients with biopsy-proven breast cancer who underwent CEUS examinations between October 2020 and September 2021. RESULTS A radiomic analysis found the WavEnHH_s_4 parameter as an independent predictor associated with the HER2+ status with 76.92% sensitivity, and 64.41% specificity and a prediction model that could differentiate between the HER2 entities with 76.92% sensitivity and 84.75% specificity. The RWavEnLH_s-4 parameter was an independent predictor for estrogen receptor (ER) status with 55.93% sensitivity and 84.62% specificity, while a prediction model (RPerc01, RPerc10 and RWavEnLH_s_4) could differentiate between the progesterone receptor (PR) status with 44.74% sensitivity and 88.24% specificity. No texture parameter showed statistically significant results at the univariate analysis when comparing the Nottingham grade and the Ki-67 status. CONCLUSION Our preliminary data indicate a potential that hybrid CEUS radiomic features allow the discrimination between breast cancers of different receptor and HER2 statuses with high specificity. Hybrid CEUS radiomic features might have the potential to provide a noninvasive, easily accessible and contrast-agent-safe method to assess tumor biology before and during treatment.
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Comparison of Linear and Convex-Array Transducers in Assessing the Enhancement Characteristics of Suspicious Breast Lesions at Contrast-Enhanced Ultrasound (CEUS). Diagnostics (Basel) 2022; 12:diagnostics12040798. [PMID: 35453846 PMCID: PMC9025659 DOI: 10.3390/diagnostics12040798] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/21/2022] [Accepted: 03/23/2022] [Indexed: 12/14/2022] Open
Abstract
The purpose of this study was to determine the observer agreement in assessing the enhancement pattern of suspicious breast lesions with contrast-enhanced ultrasound (CEUS) using high and low frequency transducers. Methods: This prospective study included 70 patients with suspicious breast lesions detected at mammography and/or ultrasound and classified according to the American College of Radiology (ACR) Breast Imaging-Reporting and Data System (BI-RADS) in 4A, 4B, 4C, or 5, who underwent CEUS examinations between October 2020 and August 2021. Results: Participants’ ages ranged from 28 to 83 years (48.5 + 6.36, mean age + SD). We obtained a substantial agreement for the first reader (kappa = 0.614, p < 0.001) and a perfect agreement for the second and third reader (kappa = 1, p < 0.001) between the two transducers for the uptake pattern. A moderate agreement for the second and third reader (kappa = 0.517 and 0.538, respectively, p < 0.001) and only a fair agreement (kappa = 0.320, p < 0.001) in the case of the first reader for the perilesional enhancement was observed. We obtained an excellent inter-observer agreement (Cronbach’s Alpha coefficient = 0.960, p < 0.001) for the degree of enhancement, a good inter-observer agreement for the uptake pattern and perilesional enhancement (Cronbach’s Alpha coefficient = 0.831 and 0.853, respectively, p < 0.001), and a good and acceptable inter-observer agreement for internal homogeneity, perfusion defects and margins of the lesions (Cronbach’s Alpha coefficient = 0.703, 0.703 and 0.792, respectively, p < 0.001) concerning the evaluation of breast lesions with the linear-array transducer. Conclusions: The evaluation of suspicious breast lesions by three experts with high-frequency linear-array transducer and low-frequency convex-array transducer was comparable in terms of uptake pattern and perilesional enhancement. The agreement regarding the evaluation of the degree of enhancement, the internal homogeneity, and the perfusion defects varied between fair and substantial. For all CEUS characteristics, the inter-observer agreement was superior for linear-array transducer, which leads to more a homogeneous and reproducible interpretation.
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Lin J, Lin W, Xu L, Lin T. Diagnostic value of various vascular features of breast cancer by age. Clin Hemorheol Microcirc 2022; 80:317-325. [PMID: 34719486 DOI: 10.3233/ch-211258] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Tumor angiogenesis plays a critical role in the growth and metastasis of breast cancer. Evaluating the added value of vascular features to Breast Imaging Reporting and Data System (BI-RADS) in differentiating malignant masses from benign ones is essential. Micro-flow Imaging (MFI) is a promising noninvasive diagnostic method for the microvessels in breast tumors, but its precise value is still uncertain. OBJECTIVES Understanding whether malignant tumor vascular characteristics by MFI are associated with breast cancer and whether the diagnostic efficiency varies by age. MATERIALS AND METHODS B-mode ultrasound and MFI were performed for 153 solid breast lesions. The vessels images by MFI were reviewed and assessed by two investigators, respectively. Then the diagnostic efficacy of different vascular features combined with BI-RADS was evaluated in different age groups. RESULTS The mean size of lesions is 19.4 (range 18-78) mm. There were 94 breast masses in benign, while 59 breast masses in malignant by pathology. III Adler classification, penetrating vessels, and complex flow pattern showed a positive association with a high risk of malignant breast lesions (p < 0.05). BI-RADS combined with vessel characteristics show better improvement of diagnostic performance of breast lesions in the elderly group than in the young group. CONCLUSIONS Vascular features by MFI contribute to malignant breast masses' diagnosis, and the association might be modified by age.
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Affiliation(s)
- Jia Lin
- Department of Ultrasound, First Affiliated Hospital, Shantou Unviersity Medical College, Shantou, Guangdong, China
| | - Wenqiang Lin
- Department of Ultrasound, First Affiliated Hospital, Shantou Unviersity Medical College, Shantou, Guangdong, China
| | - Liang Xu
- Shantou University Medical College, Shantou, Guangdong, China
| | - Teng Lin
- Department of Ultrasound, First Affiliated Hospital, Shantou Unviersity Medical College, Shantou, Guangdong, China
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Sharma A, Grover SB, Mani C, Ahluwalia C. Contrast enhanced ultrasound quantitative parameters for assessing neoadjuvant chemotherapy response in patients with locally advanced breast cancer. Br J Radiol 2021; 94:20201160. [PMID: 33860674 DOI: 10.1259/bjr.20201160] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES To evaluate the role of contrast-enhanced ultrasound (CEUS) quantitative parameters in predicting neoadjuvant chemotherapy (NACT) response in patients with locally advanced breast cancer (LABC). METHODS 30 patients with histologically proven LABC scheduled for NACT were recruited. CEUS was performed using a contrast bolus of 4.8 ml and time intensity curves (TICs) were obtained by contrast dynamics software. CEUS quantitative parameters assessed were peak enhancement (PE), time-to-peak (TTP), area under the curve (AUC) and mean transit time (MTT). The parameters were documented on four consecutive instances: before NACT and 3 weeks after each of the three cycles. The gold-standard was pathological response using Miller Payne Score obtained pre NACT and post-surgery. RESULTS A decrease in mean values of PE and an increase in mean values of TTP and MTT was observed with each cycle of NACT among responders. Post each cycle of NACT (compared with baseline pre-NACT), there was a statistically significant difference in % change of mean values of PE, TTP and MTT between good responders and poor responders (p-value < 0.05). The diagnostic accuracy of TTP post-third cycle was 87.2% (p = 0.03), and MTT post--second and third cycle was 76.7% (p = 0.004) and 86.7% (p = 0.006) respectively. CONCLUSION In responders, a decrease in the tumor vascularity was reflected in the CEUS quantitative parameters as a reduction in PE, and a prolongation in TTP, MTT. ADVANCES IN KNOWLEDGE Prediction of NACT response by CEUS has the potential to serve as a diagnostic modality for modification of chemotherapy regimens during ongoing NACT among patients with LABC, thus affecting patient prognosis.
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Affiliation(s)
- Anant Sharma
- Department of Radiology and Imaging, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Shabnam Bhandari Grover
- Department of Radiology and Imaging, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India.,Currently at Department of Radiology, School of Medical Sciences and Research, Sharda University, Greater Noida, Uttar Pradesh, India
| | - Chinta Mani
- Department of Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Charanjeet Ahluwalia
- Department of Pathology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
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Boca (Bene) I, Dudea SM, Ciurea AI. Contrast-Enhanced Ultrasonography in the Diagnosis and Treatment Modulation of Breast Cancer. J Pers Med 2021; 11:jpm11020081. [PMID: 33573122 PMCID: PMC7912589 DOI: 10.3390/jpm11020081] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 01/23/2021] [Accepted: 01/28/2021] [Indexed: 12/22/2022] Open
Abstract
The aim of this paper is to highlight the role of contrast-enhanced ultrasound in breast cancer in terms of diagnosis, staging and follow-up of the post-treatment response. Contrast-enhanced ultrasound (CEUS) is successfully used to diagnose multiple pathologies and has also clinical relevance in breast cancer. CEUS has high accuracy in differentiating benign from malignant lesions by analyzing the enhancement characteristics and calculating the time-intensity curve’s quantitative parameters. It also has a significant role in axillary staging, especially when the lymph nodes are not suspicious on clinical examination and have a normal appearance on gray-scale ultrasound. The most significant clinical impact consists of predicting the response to neoadjuvant chemotherapy, which offers the possibility of adjusting the therapy by dynamically evaluating the patient. CEUS is a high-performance, feasible, non-irradiating, accessible, easy-to-implement imaging method and has proven to be a valuable addition to breast ultrasound.
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Hu W, Dong Y, Zhang X, Zhang H, Li F, Bai M. The clinical value of Arrival-time Parametric Imaging using contrast-enhanced ultrasonography in differentiating benign and malignant breast lesions. Clin Hemorheol Microcirc 2020; 75:369-382. [PMID: 32280085 DOI: 10.3233/ch-200826] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To evaluate the clinical value of Arrival-time Parametric Imaging (At-PI) in the differentiation of benign and malignant breast lesions. METHODS For this ethics committee-approved retrospective study, a total of 184 breast lesions in 176 women were included and gray-scale ultrasound, contrast-enhanced ultrasound (CEUS) and At-PI were performed. In CEUS and At-PI, perfusion patterns, perfusion uniformity and color spatial distribution for lesions were analyzed qualitatively and the maximal diameter ratio of the lesion in accumulated parametric images and that in gray-scale images (MDRAI/GI) and area ratio of the lesion in accumuated parametric images and that in gray-scale images (ARAI/GI) were calculated quantitatively. Kappa and Intraclass Correlation Coefficient were used to evaluate the interobserver reproducibility for CEUS and At-PI and the intraobserver reproducibility for At-PI, respectively. The area under receiver operating characteristic (AUC), sensitivity, specificity, accuracy and positive and negative likelihood ratios (PPV, NPV) were calculated for MDRAI/GI and ARAI/GI. RESULTS Good interobserver and intraobserver reproducibility for At-PI were identified. In At-PI, there were statistically significant differences in perfusion patterns, color spatial distribution, MDRAI/GI and ARAI/GI between benign and malignant breast lesions (P < 0.05). The AUCs of MDRAI/GI and ARAI/GI were 0.895 and 0.954, respectively, with no significant difference between them (Z = 1.84, P > 0.05). By using the thresholds of 1.125 for MDRAI/GI and 1.21 for ARAI/GI, the sensitivity, specificity, accuracy, PPV and NPV of At-PI were 84.48%, 88.24%, 85.57%, 92.45% and 76.92%, respectively, for MDRAI/GI and 93.10%, 91.18%, 92.39%, 94.74% and 88.57%, respectively, for ARAI/GI. CONCLUSIONS At-PI is helpful to distinguish benign from malignant breast lesions. And MDRAI/GI and ARAI/GI are useful and efficient features for differential diagnosis.
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Affiliation(s)
- Wenjie Hu
- Department of Ultrasound, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yi Dong
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xuemei Zhang
- Department of Pathology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Huiping Zhang
- Department of Ultrasound, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fan Li
- Department of Ultrasound, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Min Bai
- Department of Ultrasound, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Vairavan R, Abdullah O, Retnasamy PB, Sauli Z, Shahimin MM, Retnasamy V. A Brief Review on Breast Carcinoma and Deliberation on Current Non Invasive Imaging Techniques for Detection. Curr Med Imaging 2020; 15:85-121. [PMID: 31975658 DOI: 10.2174/1573405613666170912115617] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 08/27/2017] [Accepted: 08/29/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND Breast carcinoma is a life threatening disease that accounts for 25.1% of all carcinoma among women worldwide. Early detection of the disease enhances the chance for survival. DISCUSSION This paper presents comprehensive report on breast carcinoma disease and its modalities available for detection and diagnosis, as it delves into the screening and detection modalities with special focus placed on the non-invasive techniques and its recent advancement work done, as well as a proposal on a novel method for the application of early breast carcinoma detection. CONCLUSION This paper aims to serve as a foundation guidance for the reader to attain bird's eye understanding on breast carcinoma disease and its current non-invasive modalities.
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Affiliation(s)
- Rajendaran Vairavan
- School of Microelectronic Engineering, Universiti Malaysia Perlis, Pauh Putra Campus, 02600 Arau, Perlis, Malaysia
| | - Othman Abdullah
- Hospital Sultan Abdul Halim, 08000 Sg. Petani, Kedah, Malaysia
| | | | - Zaliman Sauli
- School of Microelectronic Engineering, Universiti Malaysia Perlis, Pauh Putra Campus, 02600 Arau, Perlis, Malaysia
| | - Mukhzeer Mohamad Shahimin
- Department of Electrical and Electronic Engineering, Faculty of Engineering, National Defence University of Malaysia (UPNM), Kem Sungai Besi, 57000 Kuala Lumpur, Malaysia
| | - Vithyacharan Retnasamy
- School of Microelectronic Engineering, Universiti Malaysia Perlis, Pauh Putra Campus, 02600 Arau, Perlis, Malaysia
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Multimodal Ultrasound Imaging in Breast Imaging-Reporting and Data System 4 Breast Lesions: A Prediction Model for Malignancy. ULTRASOUND IN MEDICINE & BIOLOGY 2020; 46:3188-3199. [PMID: 32896449 DOI: 10.1016/j.ultrasmedbio.2020.08.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 08/04/2020] [Accepted: 08/04/2020] [Indexed: 12/21/2022]
Abstract
The purpose of this study was to develop, validate and test a prediction model for discriminating malignant from benign breast lesions using conventional ultrasound (US), US elastography of strain elastography and contrast-enhanced ultrasound (CEUS). The study included 454 patients with breast imaging-reporting and data system (BI-RADS) category 4 breast lesions identified on histologic examinations. Firstly, 228 breast lesions (cohort 1) were analyzed by logistic regression analysis to identify the risk factors, and a breast malignancy prediction model was created. Secondly, the prediction model was validated in cohort 2 (84 patients) and tested in cohort 3 (142 patients) by using analysis of the area under the receiver operating characteristic curve (AUC). Univariate regression indicated that age ≥40 y, taller than wide shape on US, early hyperenhancement on CEUS and enlargement of enhancement area on CEUS were independent risk factors for breast malignancy (all p < 0.05). The logistic regression equation was established as follows: p = 1/1+Exp∑[-5.066 + 3.125 x (if age ≥40 y) + 1.943 x (if taller than wide shape) + 1.479 x (if early hyperenhancement) + 4.167 x (if enlargement of enhancement area). The prediction model showed good discrimination performance with an AUC of 0.967 in cohort 1, 0.948 in cohort 2 and 0.920 in cohort 3. By using the prediction model to selectively downgrade category 4a lesions, the re-rated BI-RADS yield an AUC of 0.880 (95% confidence interval [CI], 0.794-0.965) in cohort 2 and 0.870 (95% CI, 0.801-0.939) in cohort 3. The specificity increased from 0.0% (0/35) to 80.0% (28/35) without loss of sensitivity (from 100.0% to 95.9%, p = 0.153) in cohort 2. Similarly, the specificity increased from 0.0% (0/58) to 77.6% (45/58) without loss of sensitivity (from 100.0% to 96.4%, p = 0.081) in cohort 3. Multimodal US showed good diagnostic performance in predicting breast malignancy of BI-RADS category 4 lesions. Although the loss of sensitivity was existing, the addition of multimodal US to US BI-RADS could improve the specificity in BI-RADS category 4 lesions, which reduced unnecessary biopsies.
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Janu E, Krikavova L, Little J, Dvorak K, Brancikova D, Jandakova E, Pavlik T, Kovalcikova P, Kazda T, Valek V. Prospective evaluation of contrast-enhanced ultrasound of breast BI-RADS 3-5 lesions. BMC Med Imaging 2020; 20:66. [PMID: 32552678 PMCID: PMC7302394 DOI: 10.1186/s12880-020-00467-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 06/10/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To determine the benefit of contrast-enhanced ultrasound (CEUS) in the assessment of breast lesions. METHODS A standardized contrast-enhanced ultrasound was performed in 230 breast lesions classified as BI-RADS category 3 to 5. All lesions were subjected to qualitative and quantitative analysis. MVI (MicroVascular Imaging) technique was used to derive qualitative analysis parameters; blood perfusion of the lesions was assessed (perfusion homogeneity, type of vascularization, enhancement degree). Quantitative analysis was conducted to estimate perfusion changes in the lesions within drawn regions of interest (ROI); parameters TTP (time to peak), PI (peak intensity), WIS (wash in slope), AUC (area under curve) were obtained from time intensity (TI) curves. Acquired data were statistically analyzed to assess the ability of each parameter to differentiate between malignant and benign lesions. The combination of parameters was also evaluated for the possibility of increasing the overall diagnostic accuracy. Biological nature of the lesions was verified by a pathologist. Benign lesions without histopathological verification (BI-RADS 3) were followed up for at least 24 months. RESULTS Out of 230 lesions, 146 (64%) were benign, 67 (29%) were malignant, 17 (7%) lesions were eliminated. Malignant tumors showed statistically significantly lower TTP parameters (sensitivity 77.6%, specificity 52.7%) and higher WIS values (sensitivity 74.6%, specificity 66.4%) than benign tumors. Enhancement degree also proved to be statistically well discriminating as 55.2% of malignant lesions had a rich vascularity (sensitivity 89.6% and specificity 48.6%). The combination of quantitative analysis parameters (TTP, WIS) with enhancement degree did not result in higher accuracy in distinguishing between malignant and benign breast lesions. CONCLUSIONS We have demonstrated that contrast-enhanced breast ultrasound has the potential to distinguish between malignant and benign lesions. In particular, this method could help to differentiate lesions BI-RADS category 3 and 4 and thus reduce the number of core-cut biopsies performed in benign lesions. Qualitative analysis, despite its subjective element, appeared to be more beneficial. A combination of quantitative and qualitative analysis did not increase the predictive capability of CEUS.
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Affiliation(s)
- Eva Janu
- The Clinic of Radiology and Nuclear Medicine, The University Hospital Brno, Brno, Czech Republic.,The Clinic of Radiology and Nuclear Medicine, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Lucie Krikavova
- The Clinic of Radiology and Nuclear Medicine, The University Hospital Brno, Brno, Czech Republic
| | - Jirina Little
- The Clinic of Radiology and Nuclear Medicine, The University Hospital Brno, Brno, Czech Republic
| | - Karel Dvorak
- The Clinic of Radiology and Nuclear Medicine, The University Hospital Brno, Brno, Czech Republic
| | - Dagmar Brancikova
- The Clinic of Internal Medicine - Haematology and Oncology, The University Hospital Brno, Brno, Czech Republic
| | - Eva Jandakova
- The Institute of Pathology, The University Hospital Brno, Brno, Czech Republic
| | - Tomas Pavlik
- The Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University Brno, Brno, Czech Republic
| | - Petra Kovalcikova
- The Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University Brno, Brno, Czech Republic
| | - Tomas Kazda
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Zluty kopec 7, 65653, Brno, Czech Republic. .,Department of Radiation Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic.
| | - Vlastimil Valek
- The Clinic of Radiology and Nuclear Medicine, The University Hospital Brno, Brno, Czech Republic
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Li C, Yao M, Shao S, Li X, Li G, Wu R. Diagnostic efficacy of contrast-enhanced ultrasound for breast lesions of different sizes: a comparative study with magnetic resonance imaging. Br J Radiol 2020; 93:20190932. [PMID: 32216631 PMCID: PMC10993209 DOI: 10.1259/bjr.20190932] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 03/06/2020] [Accepted: 03/20/2020] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE This study aimed to compare the diagnostic performance of contrast-enhanced ultrasound (CEUS), MRI, and the combined use of the two modalities for differentiating breast lesions of different sizes. METHODS A total of 406 patients with 406 solid breast masses detected by conventional ultrasound underwent both CEUS and MRI scans. Histological results were used as reference standards. The lesions were categorized into three groups according to size (Group 1, ≤ 20 mm; Group 2, > 20 mm, Group 3: total lesions). Sensitivity, specificity, accuracy, and receiver operating characteristic (ROC) curve analysis were used to assess the diagnostic performance of these imaging methods for breast lesions. RESULTS There were 194 benign and 212 malignant breast lesions according to the histological diagnosis. Compared with MRI, CEUS demonstrated similar sensitivity in detecting breast cancer (p = 1.0000 for all) in all the three groups. With regard to specificity, accuracy, and the area under the ROC curve (Az) values, MRI showed a better performance than that shown by CEUS (p <0.05 for all), and the combination of the two modalities improved the diagnostic performance of CEUS alone significantly (p <0.05 for all) in all the three groups. However, the diagnostic specificity and accuracy of the combined method was not superior to that of MRI alone except for Group 2. CONCLUSION CEUS demonstrated good sensitivity in detecting breast cancer, and the combined use with MRI can optimize the diagnostic specificity and accuracy in breast cancer prediction. ADVANCES IN KNOWLEDGE Few studies have compared the diagnostic efficacy of CEUS and MRI, and this study is the first attempt to seek out the diagnostic values for breast lesions of variable sizes (lesions with ≤20 mm and >20 mm).
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Affiliation(s)
- Chunxiao Li
- Department of Ultrasound, Shanghai General Hospital, Shanghai
Jiao Tong University School of Medicine,
Shanghai 200080, China
| | - Minghua Yao
- Department of Ultrasound, Shanghai General Hospital, Shanghai
Jiao Tong University School of Medicine,
Shanghai 200080, China
| | - Sihui Shao
- Department of Ultrasound, Shanghai General Hospital, Shanghai
Jiao Tong University School of Medicine,
Shanghai 200080, China
| | - Xin Li
- Department of Ultrasound, Shanghai General Hospital, Shanghai
Jiao Tong University School of Medicine,
Shanghai 200080, China
| | - Gang Li
- Department of Ultrasound, Shanghai General Hospital, Shanghai
Jiao Tong University School of Medicine,
Shanghai 200080, China
| | - Rong Wu
- Department of Ultrasound, Shanghai General Hospital, Shanghai
Jiao Tong University School of Medicine,
Shanghai 200080, China
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Zhu AQ, Li XL, An LW, Guo LH, Fu HJ, Sun LP, Xu HX. Predicting Axillary Lymph Node Metastasis in Patients With Breast Invasive Ductal Carcinoma With Negative Axillary Ultrasound Results Using Conventional Ultrasound and Contrast-Enhanced Ultrasound. JOURNAL OF ULTRASOUND IN MEDICINE 2020; 39:2059-2070. [PMID: 32367518 DOI: 10.1002/jum.15314] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 03/18/2020] [Accepted: 04/06/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The purpose of this study was to establish a scoring system for predicting axillary lymph node metastasis (ALNM) in patients with breast invasive ductal carcinoma with negative axillary ultrasound (US) results. METHODS In this retrospective study, 156 breast invasive ductal carcinoma lesions from 156 women were retrospectively enrolled. The features of conventional US and contrast-enhanced ultrasound (CEUS) qualitative enhancement patterns and quantitative enhancement parameters were analyzed. Subsequently, a scoring system was created by a multivariate logistic regression analysis. RESULTS The results found that 60 patients (38%) showed ALNM. A scoring system was defined as risk score = 1.75 × (if lesion size ≥20 mm) + 1.93 × (if uncircumscribed margin shown on conventional US) + 1.77 × (if coarse or twisting penetrating vessels shown on CEUS). When the risk scores were less than 1.75, 1.75 to 1.93, 1.94 to 3.70, and 3.70 or higher, the risk rates of ALNM were 0% (0 of 9), 10.7% (5 of 46), 29.2% (14 of 48) and 77.4% (41 of 53), respectively. In comparison with conventional US alone, the scoring system using the combination of conventional US and CEUS showed better discrimination ability in terms of the area under the curve (0.830 versus 0.777; P = .037). CONCLUSIONS A scoring system based on conventional US and CEUS may improve the prediction of ALNM.
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Affiliation(s)
- An-Qi Zhu
- Department of Medical Ultrasound, Shanghai Tenth People's Hospital, Ultrasound Research and Education Institute, Tongji University Cancer Center, Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Tongji University School of Medicine, Shanghai, China
- Thyroid Institute Tongji University School of Medicine, Shanghai, China
- Shanghai Center for Thyroid Diseases, Shanghai, China
| | - Xiao-Long Li
- Department of Medical Ultrasound, Shanghai Tenth People's Hospital, Ultrasound Research and Education Institute, Tongji University Cancer Center, Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Tongji University School of Medicine, Shanghai, China
- Thyroid Institute Tongji University School of Medicine, Shanghai, China
- Shanghai Center for Thyroid Diseases, Shanghai, China
| | - Li-Wei An
- Department of Medical Ultrasound, Shanghai Tenth People's Hospital, Ultrasound Research and Education Institute, Tongji University Cancer Center, Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Tongji University School of Medicine, Shanghai, China
- Thyroid Institute Tongji University School of Medicine, Shanghai, China
- Shanghai Center for Thyroid Diseases, Shanghai, China
| | - Le-Hang Guo
- Department of Medical Ultrasound, Shanghai Tenth People's Hospital, Ultrasound Research and Education Institute, Tongji University Cancer Center, Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Tongji University School of Medicine, Shanghai, China
- Thyroid Institute Tongji University School of Medicine, Shanghai, China
- Shanghai Center for Thyroid Diseases, Shanghai, China
| | - Hui-Jun Fu
- Thyroid Institute Tongji University School of Medicine, Shanghai, China
- Department of Pathology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
- Shanghai Center for Thyroid Diseases, Shanghai, China
| | - Li-Ping Sun
- Department of Medical Ultrasound, Shanghai Tenth People's Hospital, Ultrasound Research and Education Institute, Tongji University Cancer Center, Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Tongji University School of Medicine, Shanghai, China
- Thyroid Institute Tongji University School of Medicine, Shanghai, China
- Shanghai Center for Thyroid Diseases, Shanghai, China
| | - Hui-Xiong Xu
- Department of Medical Ultrasound, Shanghai Tenth People's Hospital, Ultrasound Research and Education Institute, Tongji University Cancer Center, Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Tongji University School of Medicine, Shanghai, China
- Thyroid Institute Tongji University School of Medicine, Shanghai, China
- Shanghai Center for Thyroid Diseases, Shanghai, China
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Liu G, Wang ZL, Zhang MK, He Y, Liu Y. Breast hamartoma: Ultrasound, elastosonographic, and contrast-enhanced ultrasound features. J Cancer Res Ther 2020; 15:864-870. [PMID: 31436244 DOI: 10.4103/jcrt.jcrt_711_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Aims To present the ultrasound (US), shear-wave elastography (SWE), and contrast-enhanced ultrasonography (CEUS) features of breast hamartomas. Subjects and Methods In this retrospective analysis, we included 36 breast hamartomas of 36 female patients who had been scheduled for US-guided vacuum-assisted biopsy (VAB) or surgical excision between May 2013 and October 2016. In the 36 patients, US, CEUS, and SWE were performed, and the pathology results from surgical or VAB were obtained. The US, SWE, and CEUS features of the lesions were analyzed. Results All breast hamartomas had an oval-shaped and a circumscribed margin. Of the 36 hamartomas, 30 (83.3%) had heterogeneous echogenicity and 28 (77.8%) displayed no changes in posterior echogenicity. There were no significant differences in the maximum, mean, and minimum elasticity between the hamartomas and peripheral parenchyma (P = 0.885, 0.683, and 0.451, respectively). All hamartomas appeared with a clear edge on CEUS, and none showed lesion diameter expansion after the injection of contrast. Compared with the peripheral parenchyma, 10 hamartomas (27.8%) showed rapid perfusion mode, 23 (63.9%) showed equal perfusion mode, 24 (66.7%) showed equal enhancement, and 9 (25.0%) showed hyperenhancement. The mean peak intensity and area under the curve of hamartomas were significantly higher than those of peripheral parenchyma (P = 0.013 and P = 0.011, respectively). The peak time and increasing-start time were not significantly different between hamartomas and peripheral parenchyma (P = 0.321 and P = 0.215, respectively). Conclusions Hamartomas have typical features on US, SWE, and CEUS. Applying multiple ultrasound techniques would be helpful for their diagnosis.
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Affiliation(s)
- Gang Liu
- Department of Radiology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Zhi Li Wang
- Department of Ultrasound, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Meng Ke Zhang
- Department of Ultrasound, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Yan He
- Department of Ultrasound, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Yuan Liu
- Department of Ultrasound, Chinese People's Liberation Army General Hospital, Beijing, China
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Vraka I, Panourgias E, Sifakis E, Koureas A, Galanis P, Dellaportas D, Gouliamos A, Antoniou A. Correlation Between Contrast-enhanced Ultrasound Characteristics (Qualitative and Quantitative) and Pathological Prognostic Factors in Breast Cancer. In Vivo 2018; 32:945-954. [PMID: 29936484 DOI: 10.21873/invivo.11333] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 04/21/2018] [Accepted: 04/23/2018] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Irene Vraka
- Department of Radiology, Aretaieion Hospital, Department of Medicine, National & Kapodistrian University of Athens, Athens, Greece
| | - Evangelia Panourgias
- Department of Radiology, Aretaieion Hospital, Department of Medicine, National & Kapodistrian University of Athens, Athens, Greece
| | - Emmanouil Sifakis
- Department of Oncology-Pathology, Jonas Bergh Research Group, Karolinska Institute, Stockholm, Sweden
| | - Andreas Koureas
- Department of Radiology, Aretaieion Hospital, Department of Medicine, National & Kapodistrian University of Athens, Athens, Greece
| | - Petros Galanis
- Center for Health Services Management and Evaluation, Department of Nursing, National & Kapodistrian University of Athens, Athens, Greece
| | - Dionysios Dellaportas
- 2nd Department of Surgery, Aretaieion Hospital, Department of Medicine, National & Kapodistrian University of Athens, Athens, Greece
| | - Athanasios Gouliamos
- Department of Radiology, Aretaieion Hospital, Department of Medicine, National & Kapodistrian University of Athens, Athens, Greece
| | - Aristides Antoniou
- Department of Radiology, Aretaieion Hospital, Department of Medicine, National & Kapodistrian University of Athens, Athens, Greece
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Significance of microvascular evaluation of ductal lesions on breast ultrasonography: Influence on diagnostic performance. Clin Imaging 2018; 51:252-259. [PMID: 29902659 DOI: 10.1016/j.clinimag.2018.05.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 05/10/2018] [Accepted: 05/31/2018] [Indexed: 11/21/2022]
Abstract
We aim to investigate the significance of microvascular ultrasonography in breast ductal lesions for distinguishing benign from malignant lesions. Sixty-two ductal lesions were evaluated with gray-scale and three Doppler techniques before biopsy, Superb Microvascular Imaging (SMI), color Doppler (CDI), and power Doppler imaging (PDI). We evaluated number, distribution, and morphology of vessels. The area under the ROC curve of combined use of Doppler imaging was greater than that of gray-scale only and SMI had higher value than CDI and PDI (p < 0.05). Microvascular ultrasonography improves diagnostic performance that distinguishes benign from malignant breast ductal lesions, and SMI is superior to CDI and PDI.
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Du R, Zhang H, Shu W, Chen B, Li Y, Zhang X, Wu X, Wang Z. Correlation between Ki-67 Expression and Hemodynamics of Contrast-Enhanced Ultrasound in Patients with Breast Infiltrative Ductal Carcinoma. Am Surg 2018. [DOI: 10.1177/000313481808400632] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Breast cancer causes great threats to public health worldwide. The aim of this study was to investigate the correlation between Ki-67 expression and the hemodynamics of contrast-enhanced ultrasound (CEUS) in patients with infiltrative ductal carcinoma (IDC). CEUS was performed on 109 masses in 85 IDC cases before resection. Based on the immunohistochemical staining on the antigen Ki-67, the masses were divided into negative group, weakly positive group, positive group, and strong-positive group. Significant statistical differences were noticed in time to peak, arrive intensity, and peak intensity in the positive groups compared with the negative group. Compared with the positive groups, the negative group showed significant statistical differences in arrive intensity and peak intensity. The antigen Ki-67 was positively correlated with arrived intensity, intensity changes, and rising curve's slope. In contrast, it was negatively correlated with arrived time, time to peak, and continuous time. The hemodynamic parameters of CEUS were correlated with the expression of antigen Ki-67. On this basis, Ki-67 is an effective supplement to the diagnosis of IDC.
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Affiliation(s)
| | | | - Weiwei Shu
- Emergency, The Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | | | - Yuefeng Li
- Department of Anesthesia, The No.1 People's Hospital of Zhenjiang, Zhenjiang, China; Departments of
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Guo Q, Dong Z, Zhang L, Ning C, Li Z, Wang D, Liu C, Zhao M, Tian J. Ultrasound Features of Breast Cancer for Predicting Axillary Lymph Node Metastasis. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:1354-1353. [PMID: 29119589 DOI: 10.1002/jum.14469] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 08/19/2017] [Accepted: 08/22/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES The purpose of this study was to assess the clinical value of ultrasound (US) features of breast lesions for predicting the risk of axillary lymph node metastasis in patients with breast cancer. METHODS In this retrospective study, 425 patients with breast cancer were recruited, and their preoperative US features and postoperative pathologic results were collected. The association of these US features of breast cancer with axillary lymph node metastasis was determined by univariate and multivariate analyses. RESULTS Among the 425 patients, 200 (47.1%) had axillary lymph node metastasis, and 225 (52.9%) did not. The parameters of tumor shape, color Doppler flow imaging grades, histologic grade, and E-cadherin level were significantly and independently associated with axillary lymph node metastasis (P < .05 for all). CONCLUSIONS Axillary lymph node metastasis was prone to happen in patients with US features of an irregular tumor shape and higher color Doppler flow imaging grades. Ultrasound imaging provides a promising tool for predicting axillary lymph node metastasis in patients with breast cancer.
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Affiliation(s)
- Qiang Guo
- Department of Ultrasound Medicine, Second Affiliated Hospital of Harbin Medical University, Harbin, China
- Departments of Ultrasound Medicine, Jinshan Branch of Shanghai Sixth People's Hospital affiliated with Shanghai Jiaotong University, Shanghai, China
| | - Zhiwu Dong
- Departments of Laboratory Medicine, Jinshan Branch of Shanghai Sixth People's Hospital affiliated with Shanghai Jiaotong University, Shanghai, China
| | - Lei Zhang
- Department of Ultrasound Medicine, Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Chunping Ning
- Department of Ultrasound, Affiliated Hospital of Qingdao University, Medical College, Qingdao, China
| | - Ziyao Li
- Department of Ultrasound Medicine, Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Dongmo Wang
- Department of Ultrasound Medicine, Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Chong Liu
- Department of Ultrasound Medicine, Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Ming Zhao
- Department of Ultrasound Medicine, Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Jiawei Tian
- Department of Ultrasound Medicine, Second Affiliated Hospital of Harbin Medical University, Harbin, China
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Liu GF, Wang ZQ, Zhang SH, Li XF, Liu L, Miao YY, Yu SN. Diagnostic and prognostic values of contrast‑enhanced ultrasound combined with diffusion‑weighted magnetic resonance imaging in different subtypes of breast cancer. Int J Mol Med 2018; 42:105-114. [PMID: 29620140 PMCID: PMC5979941 DOI: 10.3892/ijmm.2018.3591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 03/20/2018] [Indexed: 12/17/2022] Open
Abstract
The present study aimed to investigate the diagnostic and prognostic values of contrast-enhanced ultrasound (CEUS) combined with diffusion-weighted magnetic resonance imaging (DW-MRI) in different subtypes of breast cancer (BC). CEUS and DW-MRI were conducted in 232 patients with BC prior to surgical treatment. Patients were categorized as having the luminal A subtype, the luminal B subtype, triple-negative subtype or the human epidermal growth factor receptor 2 (Her-2)-positive subtype according to their expression of the estrogen receptor (ER), progesterone receptor (PR) and Her-2, as detected by immunohistochemistry. The CEUS and DW-MRI parameters of patients with different subtypes of BC were obtained and analyzed. The risk factors for the prognosis of patients with different subtypes of BC were analyzed using Kaplan-Meier and COX regression analyses. The diagnostic accuracy rate of CEUS combined with DW-MRI (93.10%) was higher than that of CEUS (88.79%) or DW-MRI (82.33%) alone. The local recurrence rate and distant metastasis rate of the Her-2-positive subtype were the highest among all the subtypes. Furthermore, patients with Her-2-positive BC exhibited a higher proportion of lesions with indistinct margins and histological grade III. Lymph node metastasis and BC subtype were independent risk factors for the prognosis of BC. The overall survival and disease-free survival of patients with the luminal A subtype were higher than those of patients with the Her-2-positive subtype. The results of the current study therefore indicate that CEUS combined with DW-MRI is more effective at diagnosing the different subtypes of BC than either CEUS or DW-MRI alone.
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Affiliation(s)
- Gui-Feng Liu
- Department of Radiology, China‑Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
| | - Zong-Qiang Wang
- Medical Department, China‑Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
| | - Shu-Hua Zhang
- Operation Room, China‑Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
| | - Xue-Feng Li
- Department of Anesthesiology, China‑Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
| | - Lin Liu
- Department of Radiology, China‑Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
| | - Ying-Ying Miao
- Department of Radiology, China‑Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
| | - Shao-Nan Yu
- Department of Radiology, China‑Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
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Guo Q, Zhang L, Di Z, Ning C, Dong Z, Li Z, Wang D, Liu C, Zhao M, Tian J. Assessing Risk Category of Breast Cancer by Ultrasound Imaging Characteristics. ULTRASOUND IN MEDICINE & BIOLOGY 2018; 44:815-824. [PMID: 29331358 DOI: 10.1016/j.ultrasmedbio.2017.12.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 11/03/2017] [Accepted: 12/03/2017] [Indexed: 06/07/2023]
Abstract
The purpose of our study was to assess the potential clinical value of ultrasound imaging in predicting risk category in patients with breast cancer. Three hundred thirty-six patients were enrolled and divided into a high-risk group (99, 29.5%) and mid- to low-risk group (237, 70.5%) according to the St. Gallen risk criteria. All data were retrospectively collected to analyze correlations between ultrasound features and risk category. The results revealed that the ultrasound features of irregular shape (p= 0.002), vertical growth orientation (p= 0.002), angular contour (p= 0.022) and high color Doppler flow imaging grade (p= 0.001) tended to be present in images of the high-risk group. Therefore, tumor ultrasound features should be recognized as an ideal option for determination of risk category in patients with breast cancer.
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Affiliation(s)
- Qiang Guo
- Department of Ultrasound Medicine, Jinshan Branch of Shanghai Sixth People's Hospital, Shanghai Jiaotong University, Shanghai, China; Department of Ultrasound Medicine, Hospital of Harbin Medical University, Heilongjiang, China
| | - Lei Zhang
- Department of Ultrasound Medicine, Hospital of Harbin Medical University, Heilongjiang, China
| | - Zhixin Di
- Department of Ultrasound Medicine, Hospital of Harbin Medical University, Heilongjiang, China
| | - Chunping Ning
- Department of Ultrasound, Hospital of Qingdao University, Medical College, Qingdao, China
| | - Zhiwu Dong
- Department of Laboratory Medicine, Jinshan Branch of Shanghai Sixth People's Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Ziyao Li
- Department of Ultrasound Medicine, Hospital of Harbin Medical University, Heilongjiang, China
| | - Dongmo Wang
- Department of Ultrasound Medicine, Hospital of Harbin Medical University, Heilongjiang, China
| | - Chong Liu
- Department of Ultrasound Medicine, Hospital of Harbin Medical University, Heilongjiang, China
| | - Ming Zhao
- Department of Ultrasound Medicine, Hospital of Harbin Medical University, Heilongjiang, China
| | - Jiawei Tian
- Department of Ultrasound Medicine, Hospital of Harbin Medical University, Heilongjiang, China.
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Feliciano MAR, Ramirez RAU, Maronezi MC, Maciel GS, Avante ML, Senhorello ILS, Mucédola T, Gasser B, Carvalho CF, Vicente WRR. Accuracy of four ultrasonography techniques in predicting histopathological classification of canine mammary carcinomas. Vet Radiol Ultrasound 2018; 59:444-452. [PMID: 29430763 DOI: 10.1111/vru.12606] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 12/11/2017] [Accepted: 01/06/2018] [Indexed: 11/29/2022] Open
Abstract
Due to the importance of presurgical, noninvasive, and accurate diagnostic tools in mammary carcinoma characterization, this prospective secondary observational cohort study was designed to evaluate and compare the diagnostic accuracy of B-mode, Doppler, contrast enhancement ultrasonography, or acoustic radiation force impulse-elastography in identifying mammary carcinomas types with high degree of malignancy. A total of 246 mammary carcinomas from 141 female dogs were analyzed using B-mode, Doppler, contrast enhancement ultrasonography, and acoustic radiation force impulse ultrasonography prior to their histopathological classification according to types (simple, complex, or special) and grade (I, II, or III). Qualitative and quantitative variables were compared between carcinoma types and grades by Fisher's or analysis of variance. Diagnostic performance was estimated by receiver-operating characteristic analysis, using histopathological classification as a reference. Deformability (acoustic radiation force impulse) had a diagnostic specificity of 100% and sensitivity of 12% in identifying special carcinomas. A width:length ratio greater than 0.53 can be suggestive of special carcinoma, with 80% sensitivity and 76% specificity. Contrast wash-in and peak enhancement times lower than 7.5 and 13.5 s, respectively, were indicative of complex carcinoma at 62% sensitivity and 60% specificity. Contrast wash-in, peak enhancement, and wash-out times greater than 6.5, 12.5, and 64.5 s, respectively; were indicative of grade II and III carcinoma at 68% sensitivity and 62% specificity. In conclusion, B-mode ultrasonography, contrast enhancement ultrasonography, and acoustic radiation force impulse-elastography enabled the identification of some of the characteristics of high-grade mammary carcinoma types and grades in female dogs with limited accuracy. The findings from this study may contribute to oncology research and clinical management canine patients.
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Affiliation(s)
- Marcus Antonio Rossi Feliciano
- UNESP-Universidade Estadual Paulista Julio de Mesquita Filho Faculdade de Ciencias Agrarias e Veterinarias, Campus Jaboticabal, Jaboticabal, Brazil.,UFRB-Universidade Federal do Recôncavo da Bahia, Cruz das Almas, Brazil
| | - Ricardo Andrés Uscategui Ramirez
- UNESP-Universidade Estadual Paulista Julio de Mesquita Filho Faculdade de Ciencias Agrarias e Veterinarias, Campus Jaboticabal, Jaboticabal, Brazil
| | - Marjury Cristina Maronezi
- UNESP-Universidade Estadual Paulista Julio de Mesquita Filho Faculdade de Ciencias Agrarias e Veterinarias, Campus Jaboticabal, Jaboticabal, Brazil
| | - Giovanna Serpa Maciel
- UNESP-Universidade Estadual Paulista Julio de Mesquita Filho Faculdade de Ciencias Agrarias e Veterinarias, Campus Jaboticabal, Jaboticabal, Brazil
| | - Michelle Lopes Avante
- UNESP-Universidade Estadual Paulista Julio de Mesquita Filho Faculdade de Ciencias Agrarias e Veterinarias, Campus Jaboticabal, Jaboticabal, Brazil
| | - Igor Luiz Salardani Senhorello
- UNESP-Universidade Estadual Paulista Julio de Mesquita Filho Faculdade de Ciencias Agrarias e Veterinarias, Campus Jaboticabal, Jaboticabal, Brazil
| | - Talita Mucédola
- UNESP-Universidade Estadual Paulista Julio de Mesquita Filho Faculdade de Ciencias Agrarias e Veterinarias, Campus Jaboticabal, Jaboticabal, Brazil
| | - Beatriz Gasser
- UNESP-Universidade Estadual Paulista Julio de Mesquita Filho Faculdade de Ciencias Agrarias e Veterinarias, Campus Jaboticabal, Jaboticabal, Brazil
| | | | - Wilter Ricardo Russiano Vicente
- UNESP-Universidade Estadual Paulista Julio de Mesquita Filho Faculdade de Ciencias Agrarias e Veterinarias, Campus Jaboticabal, Jaboticabal, Brazil
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Park AY, Seo BK. Up-to-date Doppler techniques for breast tumor vascularity: superb microvascular imaging and contrast-enhanced ultrasound. Ultrasonography 2017; 37:98-106. [PMID: 29025210 PMCID: PMC5885476 DOI: 10.14366/usg.17043] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 08/09/2017] [Accepted: 08/19/2017] [Indexed: 12/21/2022] Open
Abstract
Ultrasonographic Doppler techniques have improved greatly over the years, allowing more sophisticated evaluation of breast tumor vascularity. Superb microvascular imaging (SMI) and contrast-enhanced ultrasound (CEUS) with second-generation contrast agents are two representative up-to-date techniques. SMI is a sensitive Doppler technique that adopts an intelligent filter system to separate low-flow signals from artifacts. With the development of second-generation contrast agents, CEUS has also emerged as a useful Doppler technique for evaluating tumor microcirculation. Both techniques can improve the diagnostic performance of gray-scale ultrasonography by providing vascular information useful not only for the morphologic assessment of microvessels, but also for the quantitative analysis of perfusion. In this review, we explain the imaging principles and previous research underlying these two vascular techniques, and describe our clinical experiences.
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Affiliation(s)
- Ah Young Park
- Department of Radiology, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea.,Department of Radiology, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Bo Kyoung Seo
- Department of Radiology, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
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Zhao YX, Liu S, Hu YB, Ge YY, Lv DM. Diagnostic and prognostic values of contrast-enhanced ultrasound in breast cancer: a retrospective study. Onco Targets Ther 2017; 10:1123-1129. [PMID: 28260926 PMCID: PMC5328613 DOI: 10.2147/ott.s124134] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
This study aimed to explore the diagnostic and prognostic values of contrast-enhanced ultrasound (CEUS) in breast cancer. Between September 2009 and October 2011, a total of 143 breast cancer patients and 161 healthy people were selected as case group and control group, respectively. After the identification of lesions by conventional ultrasound, all patients underwent CEUS. The CEUS images were analyzed, and time-intensity curves (TICs) were obtained. Hematoxylin-eosin and immunohistochemistry staining was performed on tissue specimens, according to which the expressions of estrogen receptor (ER), c-erb-B2, p53, and Ki-67 were measured. Multivariate logistic regression analysis was used to compare CEUS and TIC parameters between the two groups. Compared with the control group, cancer patients showed high enhancement, heterogeneous enhancement or defects in the central region, expansion of lesion diameter after enhancement and crab-like blur lesion edges. The peak intensity (PI), relative start time of enhancement, relative PI, and relative area under the curve in the case group were significantly higher than those in the control group. Logistic analysis showed that the uniformity of enhancement, expansion of lesion diameter, and relative PI were significant diagnostic parameters of breast cancer, with area under the curve being 0.798, 0.776, and 0.919, respectively. There were strong associations between CEUS characteristics and expressions of prognostic factors in breast cancer: the heterogeneous enhancement was common in c-erb-B2-positive tumors; the centripetal enhancement occurred more in ER-negative tumors; perforator vessels were often seen in tumors at high histological grade; perfusion defects were common in ER-negative, c-erb-B2-positive, and Ki-67-positive tumors. CEUS is a useful tool for the early diagnosis and prognosis of breast cancer.
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Affiliation(s)
- Yi-Xuan Zhao
- Department of Ultrasound, Second Hospital, Jilin University, Changchun, People’s Republic of China
| | - Shuang Liu
- Department of Ultrasound, Second Hospital, Jilin University, Changchun, People’s Republic of China
| | - Yan-Bing Hu
- Department of Ultrasound, Second Hospital, Jilin University, Changchun, People’s Republic of China
| | - Yan-Yan Ge
- Department of Ultrasound, Second Hospital, Jilin University, Changchun, People’s Republic of China
| | - Dong-Mei Lv
- Department of Ultrasound, Second Hospital, Jilin University, Changchun, People’s Republic of China
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Song JL, Chen C, Yuan JP, Sun SR. Progress in the clinical detection of heterogeneity in breast cancer. Cancer Med 2016; 5:3475-3488. [PMID: 27774765 PMCID: PMC5224851 DOI: 10.1002/cam4.943] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 09/22/2016] [Accepted: 09/23/2016] [Indexed: 12/18/2022] Open
Abstract
Breast cancer is currently the most common form of cancer and the second‐leading cause of death from cancer in women. Though considerable progress has been made in the treatment of breast cancer, the heterogeneity of tumors (both inter‐ and intratumor) remains a considerable diagnostic and prognostic challenge. From clinical observation to genetic mutations, the history of understanding the heterogeneity of breast cancer is lengthy and detailed. Effectively detecting heterogeneity in breast cancer is important during treatment. Various methods of depicting this heterogeneity are now available and include genetic, pathologic, and imaging analysis. These methods allow characterization of the heterogeneity of breast cancer on a genetic level, providing greater insight during the process of establishing an effective therapeutic plan. This study reviews how the understanding of tumor heterogeneity in breast cancer evolved, and further summarizes recent advances in the detection and monitoring of this heterogeneity in patients with breast cancer.
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Affiliation(s)
- Jun-Long Song
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, 430060, China
| | - Chuang Chen
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, 430060, China
| | - Jing-Ping Yuan
- Department of Pathology, Renmin Hospital of Wuhan University, Wuhan, Hubei, 430060, China
| | - Sheng-Rong Sun
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, 430060, China
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Pedro MT, Antoniadis G, Scheuerle A, Pham M, Wirtz CR, Koenig RW. Intraoperative high-resolution ultrasound and contrast-enhanced ultrasound of peripheral nerve tumors and tumorlike lesions. Neurosurg Focus 2016; 39:E5. [PMID: 26323823 DOI: 10.3171/2015.6.focus15218] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
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.
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Affiliation(s)
| | | | | | - Mirko Pham
- Department of Neuroradiology, University of Heidelberg, Germany
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Wang YM, Fan W, Zhang K, Zhang L, Tan Z, Ma R. Comparison of transducers with different frequencies in breast contrast-enhanced ultrasound (CEUS) using SonoVue as contrast agent. Br J Radiol 2016; 89:20151050. [PMID: 27143439 DOI: 10.1259/bjr.20151050] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To explore the effectiveness of different transducers in breast contrast-enhanced ultrasound (CEUS) using SonoVue(®) (Bracco, Plan-Les-Ouates, Switzerland) as the contrast agent. METHODS Breast CEUS was performed in 51 patients with 51 breast lesions using a low-frequency transducer (probe C5-1) and a high-frequency transducer (probe L12-5) separately. All image processes were reviewed for the presence of local blood perfusion defects and surrounding vessels. McNemar's test was conducted to compare the detection effectiveness between these two transducers. RESULTS Pathological results revealed 38 malignant and 13 benign lesions. The two transducers showed no difference in detecting benign lesions. Among malignant lesions, CEUS conducted by probe C5-1 (frequency range from 1 to 5 MHz) presented 23 (60.5%) lesions with local blood perfusion defects and 26 (68.4%) lesions with surrounding vessels. Meanwhile, probe L12-5 (frequency range from 5 to 12 MHz) showed only 12 (31.6%) lesions with local blood perfusion defects and 12 (31.6%) lesions with surrounding vessel. Probe C5-1 was more sensitive than probe L12-5 in detecting malignant CEUS characteristics (p-value < 0.05). CONCLUSION The low-frequency transducer was more sensitive than the high-frequency transducer in breast CEUS using SonoVue as the contrast agent. A new contrast agent with a higher resonance frequency, specially designed for high-frequency transducers, may be helpful in improving the clinical value of breast CEUS. ADVANCES IN KNOWLEDGE The first study comparing different frequency transducers in breast CEUS of the same patient lesions. We brought out the requirement for CEUS contrast agents which are more suitable for high-frequency examinations.
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Affiliation(s)
- Yong-Mei Wang
- 1 Department of Breast Surgery, Qilu Hospital of Shandong University, Jinan, China
| | - Wei Fan
- 2 Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
| | - Kai Zhang
- 1 Department of Breast Surgery, Qilu Hospital of Shandong University, Jinan, China
| | - Li Zhang
- 3 Department of Health Care Ultrasound, Qilu Hospital of Shandong University, Jinan, China
| | - Zhen Tan
- 4 Department of Health Science Technology and Management, Stony Brook University, Stony Brook, NY, USA
| | - Rong Ma
- 1 Department of Breast Surgery, Qilu Hospital of Shandong University, Jinan, China
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Zhan J, Diao XH, Jin JM, Chen L, Chen Y. Superb Microvascular Imaging-A new vascular detecting ultrasonographic technique for avascular breast masses: A preliminary study. Eur J Radiol 2016; 85:915-21. [PMID: 27130051 DOI: 10.1016/j.ejrad.2015.12.011] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 11/15/2015] [Accepted: 12/14/2015] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Superb Microvascular Imaging (SMI) is a new vascular imaging technique detecting a slower velocity that color Doppler flow image (CDFI) cannot. The aim of this study is to evaluate the clinical value of SMI for detecting penetrating vessels (PVs) in avascular breast lesions. METHODS Seventy-nine patients with 82 breast lesions were examined by conventional ultrasound and diagnosed as Breast Imaging Reporting and Data System (BI-RADS) level 3 or 4. CDFI detected no PVs; subsequently, Power Doppler (PD), Advanced Dynamic Flow (ADF), and SMI were performed to detect any PVs in the breast lesions. RESULTS Compared with PD or ADF, SMI revealed significantly (P<0.01) higher median numbers of PVs in breast lesions. The area under the receiver operating characteristic curve was 0.914 before the corrected classification versus 0.947 after the corrected classification (P<0.05). CONCLUSIONS SMI was helpful in the differential diagnosis of benign versus malignant in avascular breast lesions, especially those in BI-RADS category 4.
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Affiliation(s)
- Jia Zhan
- Department of Ultrasound Huadong Hospital, Fudan University, Shanghai, PR China.
| | - Xue-Hong Diao
- Department of Ultrasound Huadong Hospital, Fudan University, Shanghai, PR China.
| | - Jia-Mei Jin
- Department of Ultrasound Huadong Hospital, Fudan University, Shanghai, PR China.
| | - Lin Chen
- Department of Ultrasound Huadong Hospital, Fudan University, Shanghai, PR China.
| | - Yue Chen
- Department of Ultrasound Huadong Hospital, Fudan University, Shanghai, PR China.
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Zhao LX, Liu H, Wei Q, Xu G, Wu J, Xu HX, Wu R, Pu H. Contrast-Enhanced Ultrasonography Features of Breast Malignancies with Different Sizes: Correlation with Prognostic Factors. BIOMED RESEARCH INTERNATIONAL 2015; 2015:613831. [PMID: 26881202 PMCID: PMC4735976 DOI: 10.1155/2015/613831] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 12/01/2015] [Accepted: 12/14/2015] [Indexed: 12/18/2022]
Abstract
This study was to investigate the correlation between contrast-enhanced ultrasonography (CEUS) characteristics with prognostic factors in breast cancers with different sizes. A retrospective analysis of CEUS characteristics of 104 pathologically proven malignant lesions from 104 women was conducted. Lesions were divided into two groups according to their size measured by US (Group 1: maximum diameter ≤20 mm; Group 2: maximum diameter >20 mm). Features including enhancement degree, order and pattern, enlargement of the enhancement area, and penetrating vessels on CEUS were evaluated. Pathologic prognostic factors, including estrogen and progesterone receptor status, and the expression of c-erb-B2, p53, Ki-67, and VEGF were assessed. Comparison of enhancement pattern parameters between Group 1 and Group 2 showed statistically significant differences (P < 0.0001). A significant correlation was found between enlargement of the enhancement area and ER positivity in Group 1 (P = 0.032). In Group 2 the absence of penetrating vessels was significantly associated with VEGF negativity (P = 0.022) and ER negativity (P = 0.022). Centripetal enhancement reflected VEGF negativity (P = 0.033) in lesions with diameter >20 mm. Thus, breast cancers with different sizes show different CEUS features; small breast cancers show homogeneous enhancement pattern while cancers with diameter >20 mm show homogeneous enhancement pattern. Some CEUS characteristics of differently sized breast cancers could be correlated with prognostic factors, which may be useful in prognosis assessment.
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Affiliation(s)
- Li-Xia Zhao
- Department of Medical Ultrasound, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai 200072, China
- Ultrasound Research and Education Institute, Tongji University School of Medicine, Shanghai 200072, China
| | - Hui Liu
- Department of Medical Ultrasound, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai 200072, China
- Ultrasound Research and Education Institute, Tongji University School of Medicine, Shanghai 200072, China
| | - Qing Wei
- Department of Pathology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai 200072, China
| | - Guang Xu
- Department of Medical Ultrasound, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai 200072, China
- Ultrasound Research and Education Institute, Tongji University School of Medicine, Shanghai 200072, China
| | - Jian Wu
- Department of Medical Ultrasound, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai 200072, China
- Ultrasound Research and Education Institute, Tongji University School of Medicine, Shanghai 200072, China
| | - Hui-Xiong Xu
- Department of Medical Ultrasound, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai 200072, China
- Ultrasound Research and Education Institute, Tongji University School of Medicine, Shanghai 200072, China
| | - Rong Wu
- Department of Medical Ultrasound, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai 200072, China
- Ultrasound Research and Education Institute, Tongji University School of Medicine, Shanghai 200072, China
| | - Huan Pu
- Department of Medical Ultrasound, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai 200072, China
- Ultrasound Research and Education Institute, Tongji University School of Medicine, Shanghai 200072, China
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Wang Y, Fan W, Zhao S, Zhang K, Zhang L, Zhang P, Ma R. Qualitative, quantitative and combination score systems in differential diagnosis of breast lesions by contrast-enhanced ultrasound. Eur J Radiol 2015; 85:48-54. [PMID: 26724648 DOI: 10.1016/j.ejrad.2015.10.017] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Revised: 10/14/2015] [Accepted: 10/27/2015] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To assess the feasibility of score systems in differential diagnosis of breast lesions by contrast-enhanced ultrasound (CEUS). METHODS CEUS was performed in 121 patients with 127 breast lesions by Philips iU22 with Sonovue as contrast agent. Pearson Chi-square χ(2) test, binary logistic regression analysis and Student's t-test are used to identify significant CEUS parameters in differential diagnosis. Based on these significant CEUS parameters, qualitative, quantitative and combination score systems were built by scoring 1 for benign characteristic and scoring 2 for malignant characteristic. Receiver operating characteristic (ROC) curve was applied to evaluate the diagnostic efficacy of different analytical methods. RESULTS Pathological results showed 41 benign and 86 malignant lesions. Qualitative analysis and logistic regression analysis showed that there are significant differences in enhancement degree, enhancement order, internal homogeneity, enhancement margin, surrounding vessels and enlargement of diameters (P<0.05) between benign and malignant lesions. Quantitative analysis indicated that malignant lesions tended to show higher peak intensity (PI), larger area under the curve (AUC) and shorter time to peak (TTP) than benign ones (P<0.05). Qualitative score systems showed higher diagnostic efficacy than single quantitative CEUS parameters. The corresponding area under the ROC curve for qualitative, quantitative and combination score systems were 0.897, 0.716 and 0.903 respectively. Z test showed that area under the ROC curve of quantitative score system was statistically smaller than that of other score systems. CONCLUSIONS Quantitative score system helps little in improving the diagnostic efficacy of CEUS. While qualitative score system improves the performance of CEUS greatly in discrimination of benign and malignant breast lesions. The application of qualitative could develop the diagnostic performance of CEUS which is clinically promising.
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Affiliation(s)
- YongMei Wang
- Department of Breast Surgery, Qilu Hospital of Shandong University, Jinan, China.
| | - Wei Fan
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, China.
| | - Song Zhao
- Department of Breast Surgery, Qilu Hospital of Shandong University, Jinan, China.
| | - Kai Zhang
- Department of Breast Surgery, Qilu Hospital of Shandong University, Jinan, China.
| | - Li Zhang
- Department of Health Care Ultrasound, Qilu Hospital of Shandong University, Jinan, China.
| | - Ping Zhang
- Department of Health Care Ultrasound, Qilu Hospital of Shandong University, Jinan, China.
| | - Rong Ma
- Department of Breast Surgery, Qilu Hospital of Shandong University, Jinan, China.
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