Parameters for Contrast-Enhanced Ultrasound (CEUS) of Enlarged Superficial Lymph Nodes for the Evaluation of Therapeutic Response in Lymphoma: A Preliminary Study

Multimodality high-frequency ultrasound in the evaluation of cervical malignant lymphoma before biopsy

OBJECTIVE

To investigate the application value of multimodality ultrasound in the evaluation of lymphoma.

METHODS

The regression models were performed to determine whether there were differences in differentiating lymphoma from benign lymph nodes. Receiver operator curves were drawn to evaluate the diagnostic performance of three ultrasound modalities.

RESULTS

Multivariate analysis showed statistically significant differences in the long to short axes ratio, visibility of the hilum, Adler grade of blood flow, cortical echo, maximum elasticity, elastic color pattern, enhancement distribution, and Area. The combination of three modalities achieved a sensitivity of 95.6%, specificity of 87.5%, accuracy of 93.5%, positive predicted value of 97.0%, and negative predicted value of 82.4%.

CONCLUSION

Multimodal ultrasound can provide valuable differential diagnosis and improve the diagnostic performance.

Tumor Microenvironment Reprogramming Improves Nanomedicine-Based Chemo-Immunotherapy in Sarcomas

Sarcomas are a heterogeneous group of rare cancers that originate in soft tissues or bones. Their complexity and tendency for metastases make treatment challenging, highlighting the need for new therapeutic approaches to improve patient survival. The difficulties in treating these cancers primarily stem from abnormalities within the tumor microenvironment (TME), which leads to reduced blood flow and oxygen levels in tumors. Consequently, this hampers the effective delivery of drugs to tumors and diminishes treatment efficacy despite higher toxic doses of chemotherapy. In this study, we tested the mechanotherapeutic ketotifen combined with either pegylated liposomal doxorubicin (PLD) or pegylated liposomal coencapsulated alendronate-doxorubicin (PLAD) plus anti-programmed cell death protein 1 antibody in mouse models of fibrosarcoma and osteosarcoma. We found that ketotifen successfully reprogrammed the TME by reducing tumor stiffness and increasing perfusion, proven by changes measured by shear-wave elastography and contrast-enhanced ultrasound, respectively, and enhanced the therapeutic efficacy of our nanomedicine-based chemo-immunotherapy protocols. Furthermore, we observed a trend toward improved antitumor responses when nano-chemotherapy is given alongside anti-programmed cell death protein 1 and when the immunomodulator alendronate was present in the treatment. We next investigated the mechanisms of action of this combination. Ketotifen combined with nanomedicine-based chemo-immunotherapy increased T-cell infiltration, specifically cytotoxic CD8+ T cells and CD4+ T helper cells, and decreased the number of regulatory T cells. In addition, the combination also altered the polarization of tumor-associated macrophages, favoring the M1 immune-supportive phenotype over the M2 immunosuppressive phenotype. Collectively, our findings provide evidence that ketotifen-induced TME reprogramming can improve the efficacy of nanomedicine-based chemo-immunotherapy in sarcomas.

Quantitative and qualitative analysis of contrast-enhanced ultrasound for differentiating benign and malignant superficial enlarged lymph nodes

Background

In many clinical situations, it is critical to exclude or identify abnormally lymph nodes (LNs). The nature of superficial abnormally LNs is closely related to the stage, treatment, and prognosis of the disease. Ultrasound (US) is an important method for examining superficial LNs due to its cheap and safe characteristics. However, it is still difficult to determine the nature of some LNs with overlapping benign and malignant features in images. Contrast-enhanced ultrasound (CEUS) can be used to evaluate the microperfusion status of tissues in real time, and it can improve diagnostic accuracy to a certain extent. Therefore, in this study, we will analyze the correlation between CEUS quantitative parameters and benign and malignant superficial abnormally LNs, to evaluate the efficacy and value of CEUS in distinguishing benign and malignant superficial LNs.

Methods

This study retrospectively analyzed 120 patients of abnormal LNs who underwent US and CEUS at the China-Japan Union Hospital of Jilin University from December 2020 to August 2023. All 120 cases of abnormal LNs underwent US-guided coarse needle biopsy, and accurate pathological results were obtained, along with complete US and CEUS images. According to the pathological results, LNs were divided into benign and malignant groups, and the qualitative and quantitative parameters of US and CEUS between the two groups were analyzed. The cutoff value is determined by the receiver operating characteristic (ROC) curve of the subjects, and sensitivity, specificity, and accuracy are applied to evaluate the ability of the cutoff value to distinguish between the two groups.

Results

There were a total of 120 LNs, including 36 in the benign group and 84 in the malignant group. The results showed that malignant LNs were usually characterized by the disappearance of lymphatic hilum, round ness index (L/T) <2, irregular morphology, and the manifestation of uneven perfusion (P<0.05). The differences in the quantitative parameters peak enhancement (PE), rise time (RT), time to peak (TTP), wash-in rate (WIR), and wash-out rate (WOR) were statistically significant (P<0.05). The result showed that RT and TTP in the malignant LNs were higher than those in the benign LNs, while the PE, WIR, and WOR were lower. A comparison of the ∆ values showed that the differences in ∆PE, ∆WIR, and ∆fall time (FT) were statistically significant (P<0.05), Among them, the ∆PE and ∆WIR of malignant LNs were higher than those of benign LNs, while the ∆FT was lower than that of benign LNs.

Conclusions

Quantitative analysis of CEUS features is valuable in the diagnosis of benign and malignant LNs, and US combined with CEUS helps to improve the accuracy of identifying the nature of LNs.

Analysis of early response to chemotherapy for non-Hodgkin's lymphoma by quantitative contrast-enhanced ultrasound: A prospective case-control crossectional study

OBJECTIVE

To investigate the value of quantitative contrast-enhanced ultrasonography (CEUS) in assessing and predicting early therapy response of non-Hodgkin's lymphoma (NHL).

METHODS

Fifty-six cases of NHL were studied using CEUS before and after three cycles of R-CHOP / CHOP. Quantitative parameters such as arrival time (ATM), time to peak (TTP), △T = TTP-ATM, area under the gamma curve (Area), curve gradient (Grad), wash-out time (WT), base intensity (BI), peak intensity (PI) and ΔI = PI-BI were compared between the lymphoma and normal lymph nodes before and at mid-treatment, respectively. Changes in quantitative CEUS parameters were also compared between complete response (CR) and incomplete response(non-CR) groups. Besides, the correlation analysis was performed between pretreatment PI and changes in quantitative parameters.

RESULTS

After three cycles of R-CHOP/CHOP, S/L (P < 0.001), PI (P = 0.002), ΔI (P < 0.001), Grad (P < 0.001), and Area (P < 0.001) of NHL were significantly decreased. The CR group and non-CR group only differed in ATM before treatment. In contrast, there was no statistical difference in any of the parameters between the two groups at mid-treatment. Finally, a significant correlation was observed between pre-treatment PI and PI△% (r = 0.736, P < 0.001).

CONCLUSIONS

CEUS is promising for the assessment of response of NHL to R-CHOP/CHOP. Intra-lesion perfusion changes take precedence over morphological changes suggesting treatment efficacy. Pre-treatment ATM values may help to suggest efficacy outcomes and pre-treatment PI values may be a valid predictor of lymphoma perfusion response.

The Use of Contrast-Enhanced Sonography for Therapy Monitoring of Metastatic Lymph Nodes: A Systematic Review

Metastatic cervical lymph nodes are a frequent finding in head and neck squamous cell carcinoma (HNSCC). If a non-surgical approach is primarily chosen, a therapy response evaluation of the primary tumor and the affected lymph nodes is necessary in the follow-up. Supplementary contrast-enhanced ultrasound (CEUS) can be used to precisely visualize the microcirculation of the target lesion in the neck, whereby malignant and benign findings differ in their uptake behavior. The same applies to many other solid tumors. For various tumor entities, it has already been shown that therapy monitoring is possible through regular contrast-enhanced sonography of the primary tumor or the affected lymph nodes. Thus, in some cases, maybe in the future, a change in therapy strategy can be achieved at an early stage in the case of non-response or, in the case of therapy success, a de-escalation of subsequent (surgical) measures can be achieved. In this paper, a systematic review of the available studies and a discussion of the potential of therapy monitoring by means of CEUS in HNSCC are presented.

Ultrasound stiffness and perfusion markers correlate with tumor volume responses to immunotherapy

Immunotherapy has revolutionized the treatment of dozens of cancers and became a standard of care for some tumor types. However, the majority of patients do not benefit from current immunotherapeutics and many develop severe toxicities. Therefore, the identification of biomarkers to classify patients as likely responders or non-responders to immunotherapy is a timely task. Here, we test ultrasound imaging markers of tumor stiffness and perfusion. Ultrasound imaging is non-invasive and clinically available and can be used both for stiffness and perfusion evaluation. In this study, we employed syngeneic orthotopic models of two breast cancers, a fibrosarcoma and melanoma, to demonstrate that ultrasound-derived measures of tumor stiffness and perfusion (i.e., blood volume) correlate with the efficacy of immune checkpoint inhibition (ICI) in terms of changes in primary tumor volume. To modulate tumor stiffness and perfusion and thus, get a range of therapeutic outcomes, we employed the mechanotherapeutic tranilast. Mechanotherapeutics combined with ICI are advancing through clinical trials, but biomarkers of response have not been tested until now. We found the existence of linear correlations between tumor stiffness and perfusion imaging biomarkers as well as strong linear correlations between the stiffness and perfusion markers with ICI efficacy on primary tumor growth rates. Our findings set the basis for ultrasound imaging biomarkers predictive of ICI therapy in combination with mechanotherapeutics. STATEMENT OF SIGNIFICANCE: Hypothesis: Monitoring Tumor Microenvironment (TME) mechanical abnormalities can predict the efficacy of immune checkpoint inhibition (ICI) and provide biomarkers predictive of response. Tumor stiffening and solid stress elevation are hallmarks of tumor patho-physiology in desmoplastic tumors. They induce hypo-perfusion and hypoxia by compressing tumor vessels, posing major barriers to immunotherapy. Mechanotherapeutics is a new class of drugs that target the TME to reduce stiffness and improve perfusion and oxygenation. In this study, we show that measures of stiffness and perfusion derived from ultrasound shear wave elastography and contrast enhanced ultrasound can provide biomarkers of tumor response.

[Use of Contrast enhanced Ultrasound (CEUS) in the Head and Neck Area: Update]

With the help of contrast enhanced ultrasound, the diagnostic accuracy of conventional sonography can be increased in many areas of otorhinolaryngology. Vascularisation and tissue perfusion can be objectified through the examination. This offers promising approaches for example to monitor the therapy of metastatic cervical lymph nodes or in the treatment of vascular malformations. Contrast Enhanced Ultrasound (CEUS) also offers great potential for differential diagnosis, for example of thyroid nodules. Valid threshold values for the quantitative time intensity curve (TIC) analysis of cervical pathologies are currently still not available. Further studies are necessary. As there is currently no license for the use of contrast enhanced ultrasound in otorhinolaryngology patients must be informed about its off-label use before the examination. This article is intended to provide an overview of the current possibilities and to serve as an introduction to the topic.

The findings on the CEUS of diffuse large B cell lymphoma in abdomen: A case report and literature review

Background

PET-CT is the first choice for the imaging diagnosis of intraperitoneal lymphomas. Contrast-enhanced ultrasound (CEUS) is rare in the diagnosis of intraperitoneal nodal lymphoma.

Case summary

A 62-year-old man was admitted for examination with "right upper abdominal pain". Ultrasound was used to refer to the masses in the hilar region, spleen, and anterior sacral region respectively. The masses were all hypoechoic, and blood flow signals could be detected by CDFI. Laboratory tests of CA125 were within normal limits. CEUS examination was performed on the three masses respectively. The three masses showed different perfusion patterns. Thickened vessels appeared around the mass in the hilar region, a peripheral centrally directed perfusion pattern was observed in the splenic mass, and blood supply vessels appeared in the center of the presacral mass with a significant filling defect. They all showed a contrast pattern with rapid clearance and hypoenhancement compared with the surrounding areas. Ultrasound guided needle biopsy revealed non-Hodgkin's lymphoma, diffuse large B-cell lymphoma, non-germinal center origin. After biopsy, the patient was treated with R-CHOP regimen for chemotherapy, and the tumor disappeared by routine ultrasound review after 5 cycles of chemotherapy.

Conclusion

To the best of our knowledge, this report is the first to describe the findings of CEUS in intraperitoneal nodal lymphoma. CEUS has various manifestations in intraperitoneal nodal lymphoma. Future studies are still needed to explore the diagnostic features of CEUS in intraperitoneal nodal lymphoma.

Assessment of Early Therapy Response of Non-Hodgkin's and Hodgkin's Lymphoma Using B-Mode Ultrasound and Dynamic Contrast-Enhanced Ultrasound

OBJECTIVES

Here we asked, whether contrast enhanced ultrasound (CEUS) enables to judge early treatment response in malignant lymphoma as a potential guidance for further treatment.

METHODS

From May 2017 to May 2018, 21 patients with histologically confirmed diagnosis of lymphoma were examined by B-mode ultrasound (B-US) and CEUS at fixed early time points after commencing therapy (days [d] 0, 15 and 30 after therapy start) and contrast enhancement patterns in target lymphoma lesions were quantified using Bracco-VUE Box® (DCE-US). To estimate the potential value of CEUS-enhancement patterns for early response prediction, patients were grouped according to their best achieved actual response into complete remission (CR) patients, partial remission (PR) patients or progressive disease (PD) patients.

RESULTS

Between d0, d15 and d30, CR-patients showed a median lymphoma shrinking by 34% in B-US. PD-patients experienced a median lymphoma size reduction by 44% on day 15, but lymphoma mass again increased by 20% between d15 and d30. In contrast, the median CEUS enhancement intensity, as assessed by the area under the curve (AUC) was increasing at d15 in CR and PD patients (CR to 152%, PD: to 126%), but decreased at d30 to 14% in CR patients and 22% in PD patients.

CONCLUSIONS

While early response assessment using B-US might be useful to predict treatment response in lymphoma, CEUS and DCE-US-although often feasible-do not provide additional value in this regard.

Performance Evaluation of Multiple Ultrasonographical Methods for the Detection of Primary Sjögren's Syndrome

Major salivary gland ultrasonography (SGUS) is increasingly being recognized as having critical roles in differentiating primary Sjögren’s syndrome (pSS) from other connective tissue disorders. Contrast-enhanced ultrasonography (CEUS) has been reported to evaluate microvascularity of lesions in different tissues with objective angiographic index, eliminating the observer-dependent defect of ultrasonography. However, there are few relevant studies concentrating on the application of CEUS in the diagnosis and assessment for pSS, and their clinical utility prospect remains uncertain. In this study, a total of 227 eligible patients were enrolled, including 161 pSS and 66 non-pSS patients with comprehensive ultrasonographic evaluation of the parotid and submandibular glands, including grayscale ultrasonography, color Doppler sonography (CDS), and CEUS. Compared with non-pSS, pSS patients had significantly higher grayscale ultrasound (US) scores and CDS blood grades in the parotid gland and significantly higher grayscale US and CEUS scores in the submandibular glands. Diagnostic model combining ultrasonographic signatures, anti-SSA/Ro60, and keratoconjunctivitis sicca (KCS) tests showed a remarkable discrimination [mean area under the curve (AUC)0.963 in submandibular glands and 0.934 in parotid glands] for pSS, and the nomogram provided excellent prediction accuracy and good calibration in individualized prediction of pSS. A combination of multiple ultrasonographical examinations of the major salivary glands (SGs) is a promising technique that may be used as a practical alternative to minor SG biopsy in the detection of pSS.

Lymph Node Ultrasound in Lymphoproliferative Disorders: Where Are We Now?

Lymphoproliferative disorders are one of the most frequent hematological malignancies affecting the blood and lymphatic system. To better stratify patients, an accurate imaging evaluation is needed. Although computed tomography and positron emission tomography are considered the standard methods, these procedures have several clinical drawbacks, such as biological risk and high costs. Ultrasound (US) is a rapid and user-friendly method to evaluate lymph node (LN) and organ enlargements. US imaging provides more sensitive information about LN structure, vascularization, and metabolism and new techniques have increased its specificity, especially in malignant setting. However, validated and standardized criteria for its use are missing, with only several single-center experiences reported. Therefore, the aim of this paper is to review and briefly illustrate the status of the US knowledge and applications in lymphoproliferative workup, particularly concerning malignant LN pathology.

Correlation between alterations in blood flow of malignant lymphomas after induction chemotherapies and clinical outcomes: a pilot study utilising contrast-enhanced ultrasonography for early interim evaluation of lymphoma treatment

AIM

To clarify the utility of contrast-enhanced ultrasonography (CEUS) for interim evaluation of response to chemotherapy in lymphoma treatment.

MATERIALS AND METHODS

CEUS was performed both before (day 0) and after the treatment (7 and/or 14 days), and a time-intensity curve was obtained. The patients were divided into two groups (complete remission [CR] group and non-CR group) according to the results of conventional response evaluation, and peak enhancement (PE), time to peak enhancement, perfusion index (PI), the total area under the curve during wash-in (AUC-in), and the total AUC were compared between the groups.

RESULTS

Among 27 patients with various types of lymphoma, the median change ratio of PE and PI at day 7 evaluation were significantly different between the CR group and the non-CR group (0.81 versus 1.39, p=0.017 for PE and 0.92 versus 2.09, p=0.010 for PI). The change ratio of PE < 1.09 (specificity: 86%; sensitivity, 88%) and PI < 1.65 (specificity: 86%; sensitivity: 94%) distinguished CR from non-CR. Patients who achieved a PE change ratio <1.09 or a PI change ratio <1.65 had significantly better estimated progression-free survival (p<0.001).

CONCLUSION

The present study demonstrated that changes in tumour perfusion parameters evaluated with CEUS at 1 week after the treatment initiation were significantly different between lymphoma patients in CR group and non-CR group. Alterations in perfusion parameters evaluated via CEUS could impact the prognosis of lymphoma patients.

Clinical Utility of Contrast-enhanced Ultrasound for the Diagnosis of Lymphadenopathy

This meta-analysis aimed to evaluate the diagnostic accuracy of contrast-enhanced ultrasonography (CEUS) in identifying lymphazdenopathy. PubMed, Web of Science, Embase and the Cochrane Library were searched for relevant articles through September 2020. A total of 16 articles, which included 1787 participants, were analyzed. The summary sensitivity, specificity, positive likelihood ratio (LR), negative LR and diagnostic odds ratio of CEUS for diagnosing lymphadenopathy were 0.88 (0.86-0.90), 0.90 (0.88-0.92), 6.04 (3.67-9.95), 0.15 (0.10-0.21) and 47.38 (23.45-95.66), respectively. The summary receiver operating characteristic (SROC) area under the curve (AUC) was 0.9405. After omitting outliers identified in a bivariate box plot and forest plot, heterogeneity was decreased, and the pooled sensitivity and specificity were 0.87 (0.84-0.90) and 0.87 (0.84-0.90), respectively. Furthermore, the SROC AUC was 0.9327. In conclusion, CEUS has the potential to be a valuable tool for characterizing lymphadenopathy and could provide clinical decision support.

Ultrasonographic Algorithm for the Assessment of Sentinel Lymph Nodes That Drain the Mammary Carcinomas in Female Dogs

The status of sentinel lymph nodes (SLNs) is decisive in staging, prognosis, and therapeutic approach. Using an ultrasonographic examination algorithm composed of B-mode, Doppler technique, contrast-enhanced ultrasound (CEUS) and elastography, this study aimed to determine the diagnostic performance of the four techniques compared to histopathological examination. 96 SLNs belonging to 71 female dogs with mammary gland carcinomas were examined. After examinations, mastectomy and lymphadenectomy were performed. Histopathological examination confirmed the presence of metastases in 54 SLNs. The elasticity score had the highest accuracy-89.71%, identifying metastases in SLNs with 88.9.9% sensitivity (SE) and 90.5% specificity (SP), ROC analysis providing excellent results. The S/L (short axis/long axis) ratio showed 83.3% SE and 78.6% SP as a predictor of the presence of metastases in SLN having a good accuracy of 81.2%. On Doppler examination, the resistivity index(RI) showed good accuracy of 80% in characterizing lymph nodes with metastases versus unaffected ones; the same results being obtained by CEUS examination. By assigning to each ultrasonographic parameter a score (0 or 1) and summing up the scores of the four techniques, we obtained the best diagnostic performance in identifying lymph node metastases with 92.2% accuracy. In conclusion, the use of the presented algorithm provides the best identification of metastases in SLNs, helping in mammary carcinoma staging and appropriate therapeutic management.

The Value of CEUS in Distinguishing Cancerous Lymph Nodes From the Primary Lymphoma of the Head and Neck

Aim: The purpose of this study was to assess the ability of contrast-enhanced ultrasonography (CEUS) in the differential diagnosis of cancerous lymph nodes.

Methods: Contrast-enhanced ultrasonography was performed in the cervical nodules of included patients, and the diagnoses were confirmed by pathological examination. Contrast-enhanced ultrasonography images and parameters of head and neck lymphomas were compared with those of cancerous lymph nodes. Besides, receiver operating characteristic curve was operated to access the diagnostic value of CEUS.

Results: Finally, a total of 63 head and neck lymphomas and 80 cervical cancerous lymph nodes were enrolled in this study. Results showed that the CEUS images of lymphoma were mainly characterized by homogeneous enhancement (71.43%), and approximately half of them were centripetal perfusion (58.73%), whereas most CEUS images of cancerous lymph nodes were inhomogeneous enhancement (82.50%) and centripetal perfusion (92.50%). Quantitative analysis of CEUS parameters indicated that PI (derived peak intensity) and AUC (area under the curve) of lymphomas were both lower than those of cancerous lymph nodes (PI: 8.78 vs. 10.51, AUC: 652.62 vs. 784.09, respectively) (P < 0.05). Receiver operating characteristic analysis showed that the sensitivity of CEUS parameters in the differential diagnosis was significant (80.00%), although the specificity was not high (47.62%). When parameters were combined with the image features, the accuracy of diagnosis was greatly improved (from 0.655 to 0.899).

Conclusion: Contrast-enhanced ultrasonography could be a promising tool for the differential diagnosis of head and neck lymphomas and cancerous lymph nodes.

[Contrast-enhanced ultrasound in the diagnostic workup of lymph nodes]

CLINICAL/METHODICAL ISSUE

Daily tasks in sonographic diagnostics include detection and characterization of peripheral and abdominal lymph nodes.

STANDARD RADIOLOGICAL METHODS

In addition to the B‑mode methods, color-coded Doppler sonography (CCDS) plays an important role in the evaluation of lymph nodes.

METHODICAL INNOVATIONS

Contrast-enhanced ultrasound (CEUS) has become a standard procedure in vascular and organ diagnostics. Tissue perfusion can be recorded visually and retrospectively in real time using time-dependent intensity analysis. The contrast agent dosage depends primarily on the location of the lymph nodes and the type and frequency of the transducer. Vascular and tumor cell density, intranodal pressure due to increased vascular permeability and preservation or destruction of the capsule must be taken into account when interpreting the findings.

PERFORMANCE

The indication for CEUS results from the B‑mode and CCDS findings and plays an important role especially in the verification of vitality before and after therapy. Uneven or apparently non-perfused areas allow a targeted puncture of vital tumor tissue.

ACHIEVEMENTS

Especially in abdominal lymph nodes, CEUS has a high diagnostic reliability. It is not always possible to differentiate between inflamed lymph nodes and lymph nodes altered by lymphoma filtration.

PRACTICAL RECOMMENDATIONS

CEUS helps to better assess the dignity of lymph nodes by visualizing their micro- and macrovascularization. After frustrated puncture, vital areas can be specifically biopsied. CEUS is particularly valuable in assessing the success of therapy.