A new Doppler signal enhancing agent for flow assessment in breast lesions

Best Practice Guideline - DEGUM Recommendations on Breast Ultrasound

Alongside mammography, breast ultrasound is an important and well-established method in assessment of breast lesions. With the "Best Practice Guideline", the DEGUM Breast Ultrasound (in German, "Mammasonografie") working group, intends to describe the additional and optional application modalities for the diagnostic confirmation of breast findings and to express DEGUM recommendations in this Part II, in addition to the current dignity criteria and assessment categories published in Part I, in order to facilitate the differential diagnosis of ambiguous lesions.The present "Best Practice Guideline" has set itself the goal of meeting the requirements for quality assurance and ensuring quality-controlled performance of breast ultrasound. The most important aspects of quality assurance are explained in this Part II of the Best Practice Guideline.

Clinical value and application of contrast-enhanced ultrasound in the differential diagnosis of malignant and benign breast lesions

The aim of the present study was to assess the performance of contrast-enhanced ultrasound in distinguishing between malignant and benign breast lesions and the diagnostic value of its clinical application. A total of 52 cases with malignant breast tumors and 73 cases with benign breast lesions were included in the study. Time-intensity curves (TICs) for contrast-enhanced ultrasound were recorded, and the perfusion parameters were obtained and analyzed. Typical features of malignant breast tumors included irregular shape and vascular morphology, uneven contrast agent distribution, filling defects and contrast agent retention, ‘fast-out’ wash-out mode, unclear boundaries and uneven internal echo. Benign lesions were characterized by ‘slow-out’ or synchronous wash-out mode. Regarding perfusion, the starting time of the perfusion of the Sone-Vue microbubble contrast (always 20-30 sec) and time to peak (TTP) were significantly earlier for the malignant lesions, while the wash-out time was later. A significantly greater peak intensity, rising slope and area under the TIC were observed for the malignant breast lesions. All of the malignant breast lesions exhibited an enlarged focus scope on ultrasound, while no obvious focus scope enhancement was observed for benign breast lesions. Furthermore, the TICs of 88.4% of malignant breast lesions were of the fast-rising and slow-declining type, while the TICs of 75.3 and 17.8% of the benign breast lesions were of the slow-rising and fast-declining, and fast-rising and fast-declining type, respectively. Receiver operating characteristics analysis indicated that the TTP, wash-out time and rising slope might contribute to the differential diagnosis between malignant and benign breast lesions. In conclusion, TIC parameters of contrast-enhanced ultrasound have promising clinical value in differentiating between malignant and benign breast lesions. The TTP, wash-out time and rising slope may contribute to the diagnosis of patients with breast lesions to facilitate timely treatment and prognostication of breast cancer patients.

Characterizing Breast Lesions Using Quantitative Parametric 3D Subharmonic Imaging: A Multicenter Study

RATIONALE AND OBJECTIVES

Breast cancer is the leading type of cancer among women. Visualization and characterization of breast lesions based on vascularity kinetics was evaluated using three-dimensional (3D) contrast-enhanced ultrasound imaging in a clinical study.

MATERIALS AND METHODS

Breast lesions (n = 219) were imaged using power Doppler imaging (PDI), 3D contrast-enhanced harmonic imaging (HI), and 3D contrast-enhanced subharmonic imaging (SHI) with a modified Logiq 9 ultrasound scanner using a 4D10L transducer. Quantitative metrics of vascularity derived from 3D parametric volumes (based on contrast perfusion; PER and area under the curve; AUC) were generated by off-line processing of contrast wash-in and wash-out. Diagnostic accuracy of these quantitative vascular parameters was assessed with biopsy results as the reference standard.

RESULTS

Vascularity was observed with PDI in 93 lesions (69 benign and 24 malignant), 3D HI in 8 lesions (5 benign and 3 malignant), and 3D SHI in 83 lesions (58 benign and 25 malignant). Diagnostic accuracy for vascular heterogeneity, PER, and AUC ranged from 0.52 to 0.75, while the best logistical regression model (vascular heterogeneity ratio, central PER, and central AUC) reached 0.90.

CONCLUSION

3D SHI successfully detects contrast agent flow in breast lesions and characterization of these lesions based on quantitative measures of vascular heterogeneity and 3D parametric volumes is promising.

Breast Ultrasound Technology and Performance Evaluation of Ultrasound Equipment: B-Mode

Ultrasound (US) has become increasingly important in imaging and image-guided interventional procedures. In order to ensure that the imaging equipment performs to the highest level achievable and thus provides reliable clinical results, a number of quality control (QC) methods have been developed. Such QC is increasingly required by accrediting agencies and professional organizations; however, these requirements typically do not include detailed procedures for how the tests should be performed. In this paper, a detailed overview of QC methods for general and breast US imaging using computer-based objective methods is described. The application of QC is then discussed within the context of a common clinical application (US-guided needle biopsy) as well as for research applications, where QC may not be mandated, and thus is rarely discussed. The implementation of these methods will help in finding early stage equipment faults and in optimizing image quality, which could lead to better detection and classification of suspicious findings in clinical applications, as well as improving the robustness of research studies.

Recent technological advancements in breast ultrasound

Ultrasound is becoming increasingly common as an imaging tool for the detection and characterization of breast tumors. This paper provides an overview of recent technological advancements, especially those that may have an impact in clinical applications in the field of breast ultrasound in the near future. These advancements include close to 100% fractional bandwidth high frequency (5-18MHz) 2D and 3D arrays, automated breast imaging systems to minimize the operator dependence and advanced processing techniques, such as those used for detection of microcalcifications. In addition, elastography and contrast-enhanced ultrasound examinations that are expected to further enhance the clinical importance of ultrasound based breast tumor screening are briefly reviewed. These techniques have shown initial promise in clinical trials and may translate to more comprehensive clinical adoption in the future.

Quantitative Nonlinear Contrast-Enhanced Ultrasound of the Breast

OBJECTIVE

Breast cancer is the most frequent type of cancer among women (25% of all cancers). The angiogenic process that fuels the growth of tumors is a potential early indicator for differentiating between malignant and benign tumors. Recently, the use of microbubble-based contrast agents combined with ultrasound has allowed the development of contrast agent-specific imaging modes that provide visualization of tumor neovascularity.

CONCLUSION

Contrast-enhanced Doppler, harmonic, and subharmonic imaging are some of the imaging modes that have been investigated for visualizing and quantifying the vascularity in breast tumors.

Computer aided diagnosis system for breast cancer based on color Doppler flow imaging

Color Doppler flow imaging takes a great value in diagnosing and classifying benign and malignant breast lesions. However, scanning of color Doppler sonography is operator-dependent and ineffective. In this paper, a novel breast classification system based on B-Mode ultrasound and color Doppler flow imaging is proposed. First, different feature extraction methods were used to obtain the texture and geometric features from B-Mode ultrasound images. In color Doppler feature extraction stage, several spectrum features are extracted by applying blood flow velocity analysis to Doppler signals. Moreover, a velocity coherent vector method is proposed based on color coherence vector, which is helpful for designing to the optimize detection of flow indices from different blood flow velocity fields automatically. Finally, a support vector machine classifier with selected feature vectors is used to classify breast tumors into benign and malignant. The experimental results demonstrate that the proposed computer-aided diagnosis system is useful for reducing the unnecessary biopsy and death rate.

Differentiation between benign and malignant breast tumors using kinetic features of real-time harmonic contrast-enhanced ultrasound

BACKGROUND

Contrast-enhanced ultrasound (CEUS) has gained interest because of its ability to gather vascular information in diverse organs. There is still a subject of debate concerning its value in breast lesions, especially as a differential diagnostic tool.

PURPOSE

To investigate whether kinetic parameters of CEUS can differentiate between malignant and benign breast lesions.

MATERIAL AND METHODS

We evaluated 75 malignant and 21 benign lesions in the breast or axilla. Contrast harmonic imaging (CHI) US was performed after the injection of a bolus dose of 2.4 mL of Sono Vue® (Bracco, Milano, Italy). The following parameters were calculated for kinetic analysis: initial slope, time to peak enhancement, wash-out ratios W(21) and W(50) (relative decrease in signal intensity from the peak enhancement to 21 s and 50 s, respectively).

RESULTS

A significant difference was found between the benign and malignant lesions in time-to-peak (P value <0.05) and wash-out ratios W(21) (P value <0.001) and W(50) (P value <0.001). The mean time-to-peak was 9.3 s for malignant and 14.6 s for benign lesions. The mean signal drop from peak to signal intensity measured at 50 s was 85% for malignant and 66% for benign lesions. There was no difference in absolute values of peak signal intensity and initial slope. The most significant difference between standardized benign and malignant wash-out curves was found at 21 s but statistical significance was reached in the range of 14-50 s.

CONCLUSION

Real-time CEUS can evolve into a new non-invasive option for differentiate malignant from benign breast lesions.

Blood perfusion of the contralateral testis evaluated with contrast-enhanced ultrasound in rabbits with unilateral testicular torsion

The changes of blood perfusion of contralateral testis after unilateral testicular torsion remain controversial. In this study, 28 New Zealand white male rabbits were randomly divided into five groups. Group A (n = 8), the control group, underwent a sham operation on the unilateral testis without inducing testicular torsion. In groups B, C, and D (n = 5 each), unilateral testicular torsion was induced, and, after 3, 6 or 24 h, respectively, detorsion was performed. In group E (n = 5), permanent unilateral testicular torsion was applied. Contrast-enhanced ultrasound was used to observe the blood perfusion of the contralateral testis at the following stages: pre-torsion (preopration), immediately post-torsion (postopration), pre-detorsion, immediately post-detorsion, and late-stage post-detorsion (6-12 h post-detorsion in groups B-D) or at a similar time point (15-21 h post-torsion in group E). Time-intensity curves were generated, and the following parameters were derived and analyzed: arrival time, time to peak intensity, peak intensity, and half-time of the descending peak intensity. The analysis revealed that blood perfusion of the contralateral testis increased immediately after testicular torsion on the opposite side (P < 0.05), which increased with prolonged testicular torsion of the other testis. This research demonstrated that contrast-enhanced ultrasound was valuable in evaluating blood perfusion of the contralateral testis after unilateral testicular torsion.

New potential and applications of contrast-enhanced ultrasound of the breast: Own investigations and review of the literature

Imaging of angiogenesis is a challenge for modern imaging. Velocimetry in malignant breast lesions and density of malignant vessels are very low. In breast imaging, first results of contrast-enhanced ultrasound (CEUS) were disappointing. Microbubbles are fragile when examined with high frequency US, commonly used in breast imaging. Second-generation contrast agents increase intensively the signal level of breast lesions and new sequences like CPS (Coherence Pulse Sequencing) might be accurate to detect malignant vessels in breast lesions for characterization, to assess the extent of infiltrative breast carcinoma or to evaluate the tumor response after chemotherapy. Another interesting clinical application is the differentiation between post-operative changes and recurrences. In this review, we detail the main results obtained with contrast ultrasonography in a characterization study. In malignant lesions, enhancement was fast, starting with less than 20s. Compared to MR, enhancement appeared faster. Malignant vessels were predominant in the external ring of the nodule, conversely vessels were seen in the center of the lesion in benign nodules. Malignant vessels were also seen outside the lesion. This knowledge could lead the surgeon to perform a larger lumpectomy in these cases, to obtain sane margins and to reduce recurrences.

Comparing contrast-enhanced color flow imaging and pathological measures of breast lesion vascularity

This study was conducted to compare quantifiable measures of vascularity obtained from contrast-enhanced color flow images of breast lesions to pathologic vascularity measurements. Nineteen patients with solid breast masses received Levovist Injection (10 mL at 300 mg/mL; Berlex Laboratories, Montville, NJ, USA). Color flow images of the mass pre and post contrast were obtained using an HDI 3000 scanner (Philips Medical Systems, Bothell, WA, USA) optimized for clinical scanning on an individual basis. After surgical removal, specimens were sectioned in the same planes as the ultrasound images and stained with an endothelial cell marker (CD31). Microvessel area (MVA) and intratumoral microvessel density (MVD) were determined for vessels 10-19 microm, 20-29 microm, 30-39 microm, 40-49 microm and > or =50 microm in diameter using a microscope and image processing software. From the ultrasound images, the number of color pixels before and after contrast administration relative to the total area of the breast mass was calculated as a first-order measure of fractional tumor vascularity. Vascularity measures were compared using reverse stepwise multiple linear regression analysis. In total, 58 pathology slides (with 8,106 frames) and 185 ultrasound images were analyzed. There was a significant increase in flow visualization pre to post Levovist injection (p = 0.001), but no differences were found between the 11 benign and the eight malignant lesions (p > 0.35). Ultrasound vascularity measurements post contrast correlated significantly with pathology (0.15 < or = r2 < or = 0.46; p < 0.03). The 30-39 microm vessel range contributed most significantly to the MVD relationship (p < 0.001), whereas the MVA was mainly influenced by vessels 20-29 microm (p < 0.004). Precontrast ultrasound only correlated with pathology for relative MVA (r2 = 0.16; p = 0.01). In conclusion, contrast-enhanced color flow imaging provides a noninvasive measure of breast tumor neovascularity, corresponding mainly to vessels 20-39 microm in diameter, when used in a typical clinical setting.

Breast lesions: imaging with contrast-enhanced subharmonic US--initial experience

PURPOSE

To prospectively compare accuracy of gray-scale subharmonic imaging (SHI) with that of standard gray-scale ultrasonography (US), power Doppler US (with and without contrast material), and mammography for the diagnosis of breast cancer, with histopathologic or clinical follow-up results as the reference standard.

MATERIALS AND METHODS

This HIPAA-compliant pilot study had institutional review board approval; all subjects gave written informed consent. Fourteen women (age range, 37-66 years) had 16 biopsy-proved breast lesions. In SHI, pulses are transmitted at one frequency, but only echoes at half that frequency (the subharmonic) are received. A US scanner was modified to perform gray-scale SHI (transmitting at 4.4 and receiving at 2.2 MHz). Precontrast imaging (gray-scale US and power Doppler) was followed by contrast material-enhanced power Doppler and gray-scale SHI. A reader blinded to mammographic and pathologic findings assessed diagnosis on a six-point scale. Sensitivity, specificity, accuracy, and receiver operating characteristic (ROC) curves were computed for mammography, gray-scale and power Doppler imaging (pre- and postcontrast), and SHI.

RESULTS

Of the 16 lesions, four (25%) were malignant. Mammography had 100% sensitivity and 20% specificity. Sensitivity and specificity, respectively, were 50% and 92% for precontrast imaging and 75% and 75% for contrast-enhanced power Doppler. SHI had 75% sensitivity and 83% specificity. Specificity was higher for all US modes than for mammography (P<.04). There were no significant differences in specificity among US modes or in sensitivity (P>or=.50). Area under the ROC curve for the diagnosis of breast cancer was 0.64 for standard gray-scale US and power Doppler US, 0.67 for contrast-enhanced power Doppler US, 0.76 for mammography, and 0.78 for SHI (P>.20). Contrast enhancement was better with SHI than with power Doppler (100% vs 44% of lesions with good or excellent enhancement; P=.004).

CONCLUSION

SHI appears to improve the diagnosis of breast cancer relative to conventional US and mammography, albeit on the basis of results in a very limited number of subjects.

Ultrasonographic portography with low mechanical index gray-scale imaging in hepatic VX2 tumor

To evaluate the characteristics of portal blood supply of hepatic tumors by ultrasonographic portography (USP), an in vivo model was studied using SonoVue, a second-generation ultrasound contrast agent (UCA) and low mechanical index (MI), gray-scale harmonic imaging. SonoVue (0.05 mL) was administrated through catheter placed into the main trunk of portal vein at laparotomy, followed by a 0.5 mL saline flush, in 12 rabbits with hepatic VX2 tumor, implanted by VX2 tumor tissue cubes of approximately 1 mm3 from carrier rabbit. Results showed that low MI gray-scale imaging delineated clearly the dynamic enhancement of tumors and liver parenchyma. Among 22 tumors, seven tumors were diffusely increased, with the intensity of enhancement weaker than that of the surrounding liver parenchyma. The UCA was washed out earlier from tumors than from surrounding liver parenchyma. Three tumors showed the branches of portal vein. Five tumors showed peripheral contrast enhancement and a central coarse unenhanced hypoechoic area. Seven tumors displayed no actual enhancement. All lesions (100% [22 of 22]) were depicted clearly in the whole duration of enhancement, especially in the early and late phase, regardless of enhancement pattern, and portal blood flow was manifested in 15 of 22 (68%) tumors, by USP. The enhancement pattern of the tumors corresponded to the pathologic findings. The results indicated that ultrasonographic portography, combined with low MI levels and second-generation UCA, is a sensitive and safe method to study portal blood supply for liver cancer. It may contribute to improvement of the detectability and diagnostic ability and assist the choice of a therapeutic strategy for treatment of liver cancer. However, applicability of the method to human may be problematic because of high invasiveness and great difficulty in administering contrast medium.

Diagnostic efficiency of sestamibi gammagraphy and Doppler sonography in the preoperative assessment of breast lesions

INTRODUCTION

It would be desirable to have preoperative methods that allow an adequate selection of patients with breast lesions to rule out breast cancer. The aim of the present study is to evaluate the efficiency of preoperative Sestamibi gammagraphy and Doppler sonography regarding the differential diagnosis of malignancy in breast lesions.

MATERIAL AND METHODS

A prospective observational study was conducted on 88 consecutive patients with breast lesions. All the patients underwent preoperative Doppler sonography with an echo-enhancing agent and Sestamibi gammagraphy. All the patients had histopathological study of the surgical specimen to compare with the result of the preoperative techniques. These comparisons were done both for the overall series and separately for palpable and non-palpable lesions.

RESULTS

In the overall series results, both tests separately and the two combined, are related significantly to the malignant histological diagnosis (p < 0.001). In palpable lesions, there is a considerable increase in sensitivity, and especially in specificity, attaining 100%, with the combination of both tests. In non-palpable lesions, a relationship was only found between the results of the Sestamibi gammagraphy and the malignant histological diagnosis (93.3%; p < 0.05).

CONCLUSIONS

Sestamibi gammagraphy and Doppler sonography are two efficient exploratory techniques in the preoperative assessment of malignancy in breast lesions, especially for palpable lesions, and this efficiency is greater when they are combined.

Characterization of benign hepatic tumors arising in fatty liver with SonoVue and pulse inversion US

BACKGROUND

We describe the spectrum of contrast-enhancement patterns of benign hepatic tumors arising in fatty liver on contrast-enhanced ultrasound (US).

METHODS

Sixteen patients (12 women and four men) with 27 benign hepatic tumors (17 hemangiomas, eight focal nodular hyperplasias, and two hepatocellular adenomas) arising in fatty liver underwent baseline and pulse inversion US after administration of SonoVue. Two experienced radiologists evaluated baseline echogenicity and dynamic enhancement pattern of each lesion in comparison with adjacent liver parenchyma.

RESULTS

After administration of SonoVue, in the arterial phase 13 of 17 hemangiomas showed peripheral globular enhancement and one showed a rim of peripheral enhancement, followed by progressive centripetal fill-in, which was complete in 10 of 14 cases and incomplete in four. Three of 18 hemangiomas showed rapid and complete fill-in in the arterial phase. Eight of eight focal nodular hyperplasias became hyperechoic in comparison with adjacent liver parenchyma in the arterial phase and slightly hyperechoic or isoechoic in the portal venous and delayed phases. Both adenomas showed strong arterial contrast enhancement that became less intense in the portal venous and delayed phases.

CONCLUSION

Contrast-enhanced US after administration of SonoVue enables depiction of typical contrast-enhancement patterns in most benign hepatic tumors arising in fatty liver, thus providing useful clues for characterization.

Contrast enhanced ultrasound of breast cancer

The importance of ultrasound examination in the diagnosis of breast cancer has been widely demonstrated. During the last few years, the introduction of ultrasound contrast media has been considered a promising tool for studying the vascular pattern of focal lesions within the breast. Our purpose was to assess whether contrast-enhanced (CE) ultrasound examination, performed using specific contrast imaging modes, can be helpful for detection and characterization of breast lesions, and for prediction of the response of breast cancer to therapy.

Gray scale contrast enhancement and quantification in different positions of rabbit liver

OBJECTIVE

The purpose of this study was to evaluate the difference between central and ventral peripheral positions and the difference between left and right lobes in rabbit liver with gray scale contrast enhancement.

METHODS

An in vivo model of perfusion was studied with a sulfur hexafluoride contrast agent and low-mechanical-index, real-time, gray scale harmonic imaging. The contrast agent (0.1 mL/kg body weight) was applied respectively in 10 rabbits by intravenous bolus injection. The time-intensity curve was used to obtain flow-related parameters such as time to enhancement (ET), time to peak intensity (PIT), peak signal intensity (PSI), enhancement duration (ED), and area under the curve (AUC).

RESULTS

There was a significant difference in parameters of the time-intensity curve between central and peripheral ventral positions of liver parenchyma (P < .05), except for the ED in the left liver. The ET and PIT were earlier, the PSI higher, the ED longer, and the AUC larger in the central position of parenchyma than in the peripheral position. In addition, the ET and PIT were earlier, the PSI higher, the ED longer, and the AUC larger in the right lobe of liver parenchyma than in the left lobe. There was a significant difference in parameters of the time-intensity curve between the left and right lobes of liver parenchyma (P < .05), except for the ET of the peripheral position.

CONCLUSIONS

Flow parameters are different between central and ventral peripheral positions and between left and right lobes of hepatic parenchyma.

The use of contrasted transvaginal sonography in the diagnosis of gynecologic diseases: a preliminary study

OBJECTIVE

The purpose of this study was to evaluate the efficacy of a new contrast-dedicated ultrasound technology, contrast-tuned imaging (CnTI), implemented on an endovaginal probe and using the second-generation contrast agent SonoVue (Bracco International BV, Amsterdam, the Netherlands), compared with the standard ultrasound examination in different gynecologic diseases.

METHODS

Eighty-nine patients were enrolled in the study in 4 different clinical centers. The study included 40 patients with uncertain pelvic adnexal masses, 10 patients with pelvic masses indicative of recurrences of gynecologic tumors, 26 patients with uterine pathologic features, and 13 patients with cervical lesions.

RESULTS

Application of CnTI technology after the SonoVue injection gave a picture of the intralesional microvascularization dramatically different from that obtained during color Doppler examination. Of the 40 pelvic masses, 15 (37.5%) were considered benign and 25 (62.5%) were considered malignant at B-mode and color Doppler examinations. Contrast-enhanced sonography showed no intralesional contrast perfusion in 11 (73%) of 15 cases, and all these were benign at final diagnosis. Of the 4 (27%) cases that had perfusion, 2 were malignant. Conversely, of the 25 cases with positive findings at color Doppler examination and therefore expected to show the appearance of contrast tissue-filling morphologic characteristics, 13 (52%) were malignant at final diagnosis. For evaluation of uterine pathologic features, the CnTI-SonoVue technology did not appear to be superior to the B-mode and color Doppler examinations; however, for the evaluation of cervical cancer, CnTI-SonoVue technology revealed a better definition of the margins of the neoplastic lesions in 4 (40%) of 10 cases.

CONCLUSIONS

In the evaluation of uncertain pelvic masses, the CnTI technology led to an improvement in the ability of the practitioner to differentiate benign from malignant adnexal lesions.

Grey-scale contrast enhancement in rabbit liver with SonoVue at different doses

To evaluate the dose of ultrasound (US) contrast agent (UCA) in relation to the contrast-enhancement effect, an in vivo model of perfusion was studied using SonoVue, a second-generation UCA, and low mechanical index (MI) grey-scale harmonic imaging. SonoVue, at eight different doses (0.02, 0.04, 0.06, 0.08, 0.10, 0.12, 0.14 and 0.16 mL/kg BW), was applied in five normal rabbits. Flow-related parameters obtained from time-intensity curves were calculated and plotted over the contrast agent doses, and nonlinear curve fitting was performed. Results showed that, along with an increase of the administrated contrast agent dose, the enhancement duration (ED) and the area under the curve (AUC) increased logarithmically, and the time to enhancement (ET) decreased logarithmically. There was a progressive increase of the peak signal intensity (PSI) following an increase of SonoVue dose only in the dose range of 0.02 up to 0.10 mL/kg body weight (BW) in the portal vein and in the dose range of 0.02 up to 0.12 mL/kg BW in the liver parenchyma. Moreover, a good correlation was observed between the parameters obtained from liver parenchyma and those obtained from the portal vein. The results indicated that SonoVue in conjunction with continuous harmonic low-MI grey-scale imaging has the capability of flow quantification on both vessels and parenchyma. The parameters of time-intensity curve were influenced intensely by different contrast agent doses.

Liver haemangiomas undetermined at grey-scale ultrasound: contrast-enhancement patterns with SonoVue and pulse-inversion US

The objective of this study was to describe the spectrum of contrast-enhancement patterns of hepatic haemangiomas undetermined at grey-scale ultrasound (US) on SonoVue-enhanced pulse-inversion (PI) US. Twenty patients (11 women, nine men) with 35 haemangiomas (size range: 1-7 cm; mean: 3.1 cm) undetermined at baseline US underwent PI at low M.I. (0.05-0.08) after i.v. injection of SonoVue. All haemangiomas were confirmed by typical helical computed tomography (CT) and/or magnetic resonance imaging (MRI) findings. US examinations were videotaped and then reviewed by two experienced radiologists blinded to the final diagnosis. Readers evaluated by consensus the baseline echogenicity and the dynamic enhancement pattern of each lesion, in comparison with adjacent liver parenchyma. After administration of SonoVue, 31/35 (88%) haemangiomas showed peripheral hyperechoic nodules in the arterial phase, followed by progressive centripetal fill-in, which was complete in 25/35 cases and incomplete in 6/35 cases. Three out of 35 (9%) haemangiomas showed rapid and complete fill-in in the arterial phase, which persisted in the portal and delayed phases. Finally, 1/35 haemangiomas (3%) showed a rim of arterial contrast enhancement with progressive and complete centripetal fill-in in portal-venous and delayed phases. In conclusion, PI after the administration of SonoVue enabled the depiction of typical contrast-enhancement patterns in haemangiomas undetermined at baseline US.

Diagnosing breast lesions with contrast-enhanced 3-dimensional power Doppler imaging

OBJECTIVE

To compare mammography with contrast-enhanced 2- and 3-dimensional power Doppler imaging for the diagnosis of breast cancer.

METHODS

Fifty-five patients, who underwent breast biopsies with histopathologic assessment, participated in a study of mammography and contrast-enhanced sonography. Levovist (Berlex Laboratories, Montville, NJ) and Optison (Mallinckrodt, St Louis, MO) were administrated to 22 and 33 patients, respectively. Precontrast and postcontrast 2-dimensional power Doppler data of the lesion were obtained with an HDI 3000 system (Philips Medical Systems, Bothell, WA), and 3-dimensional data were acquired with an LIS 6000A system (Life Imaging Systems Inc, London, Ontario, Canada). Two independent and blinded readers assessed diagnosis. Receiver operating characteristic curves were computed individually and in combination for mammography and 2- and 3-dimensional sonography (before and after contrast). Histopathologic and imaging parameters were compared by Mann-Whitney statistics.

RESULTS

Mammographic findings were available for 50 patients, biopsy for 54, and 2- and 3-dimensional sonographic images for 53 and 52, respectively. Of the 50 patients who had all 4 measures, 15 (30%) had malignancies. The areas under the receiver operating characteristic curve for the diagnosis of breast cancer were 0.51 for 2-dimensional contrast-enhanced imaging, 0.60 for 3-dimensional power Doppler imaging, and 0.76 for 3-dimensional contrast-enhanced imaging (P < .01). Mammography produced an area of 0.86, which increased when combined with 3-dimensional contrast-enhanced imaging to 0.90 and with all sonographic modalities to 0.96 (P < .001). The histopathologic diagnosis of benign or malignant correlated with the presence or absence of anastomoses and with the degree of vascularity assessed with contrast-enhanced 3-dimensional power Doppler imaging (P = .007 and .02).

CONCLUSIONS

Contrast-enhanced 3-dimensional power Doppler imaging increases the ability to diagnose breast cancer relative to conventional 2- and 3-dimensional sonographic imaging.

Palpable breast lesions: utility of Doppler sonography for diagnosis of malignancy

This study was designed to find whether there are any differences between benign and malignant palpable breast lesions as they are seen on grey-scale and colour-Doppler and on power-Doppler sonography; to determine which variables for each technique are most helpful in distinguishing any such differences; and to see whether the use of an echo-enhancing agent gives better results in the differential diagnosis. Forty-five palpable breast lesions (16 benign and 29 malignant) were evaluated in a preoperative study using grey-scale sonography, colour-Doppler sonography and power-Doppler sonography before and after administration of an echo-enhancing agent (Levovist). We reached the following conclusions: (1) In the grey-scale ultrasound study of palpable breast lesions the presence of microcalcifications, acoustic shadowing and non-well-defined margins are related to malignancy. (2) Colour- and power-Doppler sonography may help in the differential diagnosis. (3) The use of an echo enhancer (Levovist) accentuates these differences and enables them to be noted in other variables, such as pulsatility index, nodule-to-vascularity ratio and number of poles.

Complex pelvic mass as a target of evaluation of vessel distribution by color Doppler sonography for the diagnosis of adnexal malignancies: results of a multicenter European study

OBJECTIVE

To compare the diagnostic accuracy of gray scale sonography and color Doppler imaging in the differential diagnosis of adnexal malignancies from benign complex pelvic masses in a multicenter prospective study.

METHODS

The study was performed as a collaborative work at 3 European university departments of obstetrics and gynecology. A total of 826 complex pelvic masses on which transvaginal sonography and evaluation of cancer antigen 125 plasma concentrations were performed before surgical exploration were included in the study. The scanning procedure was the same in the 3 institutions. An adnexal mass was first studied in gray scale sonography, and a probable histologic type was predicted. Second, solid excrescences or solid portions of the tumor were evaluated for vascular flow with color Doppler sonography (conventional or power). A mass was graded malignant if flow was shown within the excrescences or solid areas and benign if there was no flow. The overall agreement between the test result and the actual outcome was calculated by kappa statistics.

RESULTS

Color Doppler evaluation was more accurate in the diagnosis of adnexal malignancies in comparison with gray scale sonography (kappa = 0.82 and 0.65, respectively) because of significantly higher specificity (0.94 versus 0.84; P < .001). The evaluation of the cancer antigen 125 plasma concentration did not seem to increase the accuracy of either method.

CONCLUSIONS

The evaluation of vessel distribution by color Doppler sonography in complex adnexal cysts seems to increase the diagnostic accuracy of gray scale sonography in the detection of adnexal malignancies in a large study population.