Relationship between ultrasound elastography and myofibroblast distribution in breast cancer and its clinical significance

Clinical Significance of Ultrasound Elastography and Fibrotic Focus and Their Association in Breast Cancer

(1) Background: Ultrasound (US) elastography is an imaging technology that reveals tissue stiffness. This study aimed to investigate whether fibrotic focus (FF) affects elastographic findings in breast cancer, and to evaluate the clinical significance of US elastography and FF in breast cancer. (2) Methods: In this study, 151 patients with breast cancer who underwent surgery were included. Strain elastography was performed and an elasticity scoring system was used to assess the findings. The elasticity scores were classified as negative, equivocal, or positive. FF was evaluated in the surgical specimens. Medical records were reviewed for all patients. (3) Results: Elastographic findings were equivocal in 30 patients (19.9%) and positive in 121 patients (80.1%). FF was present in 68 patients (46.9%). There was no correlation between elastographic findings and FF. Older age, larger tumor size, lymph node metastasis, and higher tumor stage were associated with positive elastographic results. FF showed a positive correlation with age, postmenopausal status, tumor size, lymphovascular invasion, lymph node metastasis, tumor stage, and intratumoral and peritumoral inflammation. (4) Conclusions: Our study showed that positive elastographic results and FF were associated with poor prognostic factors for breast cancer. FF did not affect the elastographic findings of this study.

IETA Ultrasonic Features Combined with GI-RADS Classification System and Tumor Biomarkers for Surveillance of Endometrial Carcinoma: An Innovative Study

Objectives: We were the first to combine IETA ultrasonic features with GI-RADS and tumor biomarkers for the surveillance of endometrial carcinoma. The aim was to evaluate the efficacy of single IETA ultrasonography GI-RADS classification and combined tumor biomarkers in differentiating benign and malignant lesions in the uterine cavity and endometrium. Methods: A total of 497 patients with intrauterine and endometrial lesions who had been treated surgically between January 2017 and December 2021 were enrolled; all of them had undergone ultrasound examinations before surgery. We analyzed the correlation between the terms of ultrasonic signs of the uterine cavity and endometrial lesions defined by the expert consensus of IETA and the benign and malignant lesions and then classified these ultrasonic signs by GI-RADS. In addition, the tumor biomarkers CA125, CA15-3, CA19-9 and HE4 were combined by adjusting the classification. The results of the comprehensive analysis were compared with pathological results to analyze their diagnostic efficacy. Results: (1) The statistic analysis confirmed that there were seven independent predictors of malignant lesions, including thickened endometrium (premenopause ≥ 18.5 mm, postmenopause ≥ 15.5 mm), non-uniform endometrial echogenicity (heterogeneous with irregular cysts), endometrial midline appearance (not defined), the endometrial-myometrial junction (interrupted or not defined), intracavitary fluid (ground glass or "mixed" echogenicity), color score (3~4 points) and vascular pattern (focal origin multiple vessels or multifocal origin multiple vessels). (2) In traditional ultrasound GI-RADS (U-T-GI-RADS), if category 4a was taken as the cut-off value of benign and malignant, the diagnostic sensitivity, specificity, PPV, NPV and diagnostic accuracy were 97.2%, 65.2%, 44.0%, 98.8% and 72.2%, respectively, and the area under the ROC curve (AUC) was 0.812. If 4b was taken as the cut-off value, the diagnostic sensitivity, specificity, PPV, NPV diagnostic accuracy and AUC were 88.1%, 92.0%, 75.6%, 96.5% and 91.2%, 0.900, respectively. The diagnostic sensitivity, specificity, PPV, NPV diagnostic accuracy and AUC were 75.2%, 98.5%, 93.2%, 93.4%, 93.4% and 0.868, respectively, when taking category 5 as the cutoff point. In modified ultrasound GI-RADS (U-M-GI-RADS), if 4a was taken as the cut-off value, The diagnostic efficacy was the same as U-T-GI-RADS. If 4b was taken as the cut-off value, the diagnostic sensitivity, specificity, PPV, NPV, diagnostic accuracy and AUC were 88.1%, 92.3%, 76.2%, 96.5%, 91.3% and 0.902, respectively. If 4c was taken as the cutoff point, the diagnostic sensitivity, specificity, PPV, NPV diagnostic accuracy and AUC were 75.2%, 98.7%, 94.3%, 93.4%, 93.6% and 0.870, respectively. The diagnostic sensitivity, specificity, PPV, NPV diagnostic accuracy and AUC were 66.1%, 99.7%, 98.6%, 91.3%, 92.4% and 0.829, respectively, if taking category 5 as the cutoff point. (3) In the comprehensive diagnostic method of U-T-GI-RADS combined tumor biomarkers results, the AUC of class 4a, 4b and 5 as the cutoff value was 0.877, 0.888 and 0.738, respectively. The AUC of class 4a, 4b, 4c and 5 as the cutoff value in the comprehensive diagnostic method of U-M-GI-RADS combined tumor biomarkers results was 0.877, 0.888, 0.851 and 0.725, respectively. There was no significant difference in diagnostic efficiency between the two comprehensive diagnostic methods. Conclusions: In this study, no matter which diagnostic method was used, the best cutoff value for predicting malignant EC was ≥GI-RADS 4b. The GI-RADS classification had good performance in discriminating EC. The tumor biomarkers, CA125, CA19-9, CA15-3 and HE4, could improve the diagnostic efficacy for preoperative endometrial carcinoma assessment.

Combination IETA Ultrasonographic Characteristics Simple Scoring Method With Tumor Biomarkers Effectively Improves the Differentiation Ability of Benign and Malignant Lesions in Endometrium and Uterine Cavity

Objectives

To evaluate International Endometrial Tumor Analysis (IETA) ultrasonographic characteristics simple scoring method and tumor biomarkers for the diagnosis of uterine cavity and endometrial lesions.

Methods

We classified and scored the normalized description of IETA ultrasonic characteristics, according to IETA expert consensus literature, previous IETA-related research articles, and the previous research experience of this project group. We conducted a retrospective analysis of the ultrasound images of 594 patients enrolled from January 2017 to June 2020, scored them item by item, and finally calculated the total score of each case. Meanwhile, we combined the results of seven tumor biomarkers. The objective was to evaluate the sensitivity, specificity, coincidence rate, and the area under receiver operating characteristic (ROC) curve of IETA ultrasonographic characteristics simple scoring method and tumor biomarkers for benign and malignant uterine cavity or endometrial lesions. The diagnostic efficiency between the combined method and the single method was compared.

Results

A total of 594 cases were confirmed by postoperative pathology or surgery records, including 475 benign lesions and 119 malignant lesions. In the simple ultrasound scoring method, the average score of benign lesions was 3.879 ± 1.279 and that of malignant lesions was 9.676 ± 4.491. If ≥6.5 points was taken as the cutoff value for the judgment of malignant lesions, the sensitivity, specificity, coincidence rate, and the area under receiver operating characteristic (ROC) curve (AUC) were 76.5%, 96.0%, 92.1%, and 0.935, respectively. The difference in tumor antigen 19-9 (CA19-9) and human epididymal protein 4 (HE4) between benign and malignant lesions was statistically significant (all p ≤ 0.01). The other five tumor biomarkers (CA125, CA15-3, SCC-Ag, AFP, and CEA) showed no statistically significant difference in benign and malignant lesions. If the value of CA19-9 ≥13.96 U/ml was taken as cutoff value, the sensitivity, specificity, and coincidence rate of the diagnosis of endometrial benign and malignant lesions were 54.8%, 74.7%, and 70.7%, respectively, and the AUC was 0.620. If the value of HE4 ≥ 39.075 pmol/L was taken as cutoff point, the sensitivity, specificity, coincidence rate, and AUC were 77.4%, 67.9%, 69.8%, and 0.796, respectively. The sensitivity was increased to 97.6% and the AUC was 0.939 when IETA ultrasound characteristics simple scoring method combined CA19-9 and HE4 in parallel test.

Conclusions

In IETA ultrasound characteristics simple scoring method, with ≥6.5 points as the cutoff value, it could quickly and accurately assess the benign and malignant in uterine cavity and endometrial lesions, with high diagnostic value. The diagnostic efficacy of seven tumor biomarkers was all mediocre. Combining with these two methods, the comprehensive diagnosis could improve sensitivity and accuracy and reduce the risk of missed diagnosis.

Tumor elastography and its association with cell-free tumor DNA in the plasma of breast tumor patients: a pilot study

Background

Breast tumor stiffness, which can be objectively and noninvasively evaluated by ultrasound elastography (UE), has been useful for the differentiation of benign and malignant breast lesions and the prediction of clinical outcomes. Liquid biopsy analyses, including cell-free tumor DNA (ctDNA), exhibit great potential for personalized treatment. This study aimed to investigate the correlations between the UE and ctDNA for early breast cancer diagnosis.

Methods

Breast tumor stiffness in 10 patients were assessed by shear wave elastography (SWE), and the ctDNA of eight collected plasma specimens with different tumor stiffness were analyzed by whole-genome sequencing (WGS). Subsequently, the distribution of carcinoma-associated fibroblasts (CAFs) was investigated by detecting the expression levels of alpha-smooth muscle actin (α-SMA) in tissues of breast lesions. We validated the function of discoidin domain receptor 2 (DDR2) in breast tumor CAFs by knockout of fibroblast activation protein (FAP) with different tumor stiffness during cancer progression in vitro and vivo.

Results

The UE estimates of tumor stiffness positively correlated with CAF-rich (α-SMA⁺) tumors (P<0.05). Copy number profiles and percent genome alterations were remarkably different between benign and malignant breast lesions. Somatic genomic alterations or structural variants of DDR2, ANTXRL, TPSG1, and TPSB2 genes were identified in ctDNA of plasma from breast lesions with high SWE values and an increase in the CAF content obtained from clinical samples. Deletion of FAP in breast tumor CAFs by CRISPR/Cas9-mediated gene knockout and decreased tumor stiffness resulted in downregulated expression of DDR2 (P<0.05), which in turn led to decreasing the tumor stiffness and carcinogenesis process in vitro and in vivo.

Conclusions

These results have established proof of principle that WGS analysis of ctDNA could complement current UE approaches to assess tumor stiffness changes for the early diagnosis and prognostic assessment of breast cancer.

Imaging methods to evaluate tumor microenvironment factors affecting nanoparticle drug delivery and antitumor response

Standard small molecule and nanoparticulate chemotherapies are used for cancer treatment; however, their effectiveness remains highly variable. One reason for this variable response is hypothesized to be due to nonspecific drug distribution and heterogeneity of the tumor microenvironment, which affect tumor delivery of the agents. Nanoparticle drugs have many theoretical advantages, but due to variability in tumor microenvironment (TME) factors, the overall drug delivery to tumors and associated antitumor response are low. The nanotechnology field would greatly benefit from a thorough analysis of the TME factors that create these physiological barriers to tumor delivery and treatment in preclinical models and in patients. Thus, there is a need to develop methods that can be used to reveal the content of the TME, determine how these TME factors affect drug delivery, and modulate TME factors to increase the tumor delivery and efficacy of nanoparticles. In this review, we will discuss TME factors involved in drug delivery, and how biomedical imaging tools can be used to evaluate tumor barriers and predict drug delivery to tumors and antitumor response.

Combination diagnosis with elastography strain ratio and molecular markers effectively improves the diagnosis rate of small breast cancer and lymph node metastasis

Background

To evaluate the strain ratio (SR) combined with molecular pathological and serum markers for the diagnosis of breast masses.

Methods

SR and 7-point scale elasticity scores were used with real-time tissue elastography and 2-dimensional color-Doppler ultrasound (US) to diagnose breast lesions in 311 hospitalized patients. Immunohistochemical staining and enzyme-linked immunosorbent assays (ELISAs) were used to examine pathological and serum tumor markers and their correlations with SR findings.

Results

SR had a higher diagnostic value compared to the 7-point scale elasticity score, displaying an obvious low-to-high distribution from benign to malignant lesions with an optimal cutoff point at 3.88, which yielded an area under the curve (AUC) of 0.896 with 89.1% sensitivity, 85.6% specificity, and positive and negative predictive values of 91.0% and 82.8%, respectively. The differences of SR values between small (≤1.5 cm), large (>3 cm) (P=0.010), and moderate (>1.5 cm and ≤3 cm) sizes (P=0.038) in distinguishing benign from malignant breast masses were statistically significant, with SR being most specific and sensitive for diagnosing small lesions. Expression of 3 molecular pathological indicators (p75NTR, p63, and CK5/6), and 5 serum mastocarcinoma markers (uPA, PAI-I, CA27-29, CEA, and CA15-3) showed statistical significance (P<0.05) in distinguishing between benign and malignant breast lesions. Furthermore, SR combined with CA15-3 and CK5/6 positivity showed 94.2% sensitivity and 89.2% specificity as combined markers for triple-negative (TN) breast cancer, whereas SR combined with D2-40 and CK19 were good diagnostic markers for breast cancer lymph node metastasis.

Conclusions

SR, together with a molecular and serological marker, may serve as an additional tool for the diagnosis of small breast cancer tumors.

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.