Advancing Breast Cancer Diagnosis: The Impact of Elastography Integration Into Breast Imaging Reporting and Data System (BIRADS) Categorization

OBJECTIVE

This study evaluates the impact of integrating elastography into the Breast Imaging Reporting and Data System (BIRADS) categorization on breast cancer diagnostics in an African population. It explores the association and agreement between traditional BIRADS and those modified by elastography, as well as between quantitative and qualitative elastography methods.

METHODS

A total of 200 participants who underwent breast imaging as part of their diagnostic evaluation for breast lesions were included in the study. Participant characteristics, including age distribution and indicators for breast cancer diagnoses, were analyzed. Brightness mode (B-mode) findings without elastography were assessed using the BIRADS classification. Elastography was integrated into the BIRADS categorization to evaluate its impact on breast cancer diagnostics. The association and agreement between BIRADS with and without elastography were analyzed.

RESULTS

Participants predominantly aged 40-49 showed significant staging differences with the integration of elastography. Traditional B-mode staging identified 29 (49%) of participants in BIRADS stage IV and 14 (23%) in stage V, whereas elastography adjusted these figures significantly, enhancing diagnostic refinement. There was a fair agreement between BIRADS with and without elastography (kappa = 0.322), while a substantial agreement was found between quantitative and qualitative elastography (kappa = 0.674).

CONCLUSION

The results of the study provide evidence that the integration of elastography into BIRADS categorization can significantly improve the accuracy of breast cancer diagnosis in African women. Elastography enhanced lesion characterization, supporting more personalized and precise clinical management. Continued research is needed to fully integrate elastography into routine diagnostic workflows and understand its broader clinical implications in Africa.

Development of a Multi-Parametric ultrasonography nomogram for prediction of invasiveness in ductal carcinoma in situ

OBJECTIVE

To investigate the independent risk variables associated with the potential invasiveness of ductal carcinoma in situ (DCIS) on multi-parametric ultrasonography, and further construct a nomogram for risk assessment.

METHODS

Consecutive patients from January 2017 to December 2022 who were suspected of having ductal carcinoma in situ (DCIS) based on magnetic resonance imaging or mammography were prospectively enrolled. Histopathological findings after surgical resection served as the gold standard. Grayscale ultrasound, Doppler ultrasound, shear wave elastography (SWE), and contrast-enhanced ultrasound (CEUS) examinations were preoperative performed. Binary logistic regression was used for multifactorial analysis to identify independent risk factors from multi-parametric ultrasonography. The correlation between independent risk factors and pathological prognostic markers was analyzed. The predictive efficacy of DCIS associated with invasiveness was assessed by logistic analysis, and a nomogram was established.

RESULTS

A total of 250 DCIS lesions were enrolled from 249 patients, comprising 85 pure DCIS and 165 DCIS with invasion (DCIS-IDC), of which 41 exhibited micro-invasion. The multivariate analysis identified independent risk factors for DCIS with invasion on multi-parametric ultrasonography, including image size (>2cm), Doppler ultrasound RI (≥0.72), SWE's Emax (≥66.4 kPa), hyper-enhancement, centripetal enhancement, increased surrounding vessel, and no contrast agent retention on CEUS. These factors correlated with histological grade, Ki-67, and human epidermal growth factor receptor 2 (HER2) (P < 0.1). The multi-parametric ultrasound approach demonstrated good predictive performance (sensitivity 89.7 %, specificity 73.8 %, AUC 0.903), surpassing single US modality or combinations with SWE or CEUS modalities. Utilizing these factors, a predictive nomogram achieved a respectable performance (AUC of 0.889) for predicting DCIS with invasion. Additionally, a separate nomogram for predicting DCIS with micro-invasion, incorporating independent risk factors such as RI (≥0.72), SWE's Emax (≥65.2 kPa), and centripetal enhancement, demonstrated an AUC of 0.867.

CONCLUSION

Multi-parametric ultrasonography demonstrates good discriminatory ability in predicting both DCIS with invasion and micro-invasion through the analysis of lesion morphology, stiffness, neovascular architecture, and perfusion. The use of a nomogram based on ultrasonographic images offers an intuitive and effective method for assessing the risk of invasion in DCIS. Although the nomogram is not currently considered a clinically applicable diagnostic tool due to its AUC being below the threshold of 0.9, further research and development are anticipated to yield positive outcomes and enhance its viability for clinical utilization.

Embedded Bioprinting of Breast Tumor Cells and Organoids Using Low-Concentration Collagen-Based Bioinks

Bioinks for 3D bioprinting of tumor models should not only meet printability requirements but also accurately maintain and support phenotypes of tumor surrounding cells to recapitulate key tumor hallmarks. Collagen is a major extracellular matrix protein for solid tumors, but low viscosity of collagen solution has made 3D bioprinted cancer models challenging. This work produces embedded, bioprinted breast cancer cells and tumor organoid models using low-concentration collagen I based bioinks. The biocompatible and physically crosslinked silk fibroin hydrogel is used to generate the support bath for the embedded 3D printing. The composition of the collagen I based bioink is optimized with a thermoresponsive hyaluronic acid-based polymer to maintain the phenotypes of both the noninvasive epithelial and invasive breast cancer cells, as well as cancer-associated fibroblasts. Mouse breast tumor organoids are bioprinted using optimized collagen bioink to mimic in vivo tumor morphology. A vascularized tumor model is also created using a similar strategy, with significantly enhanced vasculature formation under hypoxia. This study shows the great potential of embedded bioprinted breast tumor models utilizing a low-concentration collagen-based bioink for advancing the understanding of tumor cell biology and facilitating drug discovery research.

Adenoid Cystic Carcinoma of the Breast: Radiologic-Pathologic Correlation

Adenoid cystic carcinoma (ACC) is an uncommon malignancy occurring most frequently in the salivary glands. Breast ACC is rare. Pain is common at the site of ACC; otherwise, presentation is similar to other primary breast cancers. Adenoid cystic carcinomas classically lack calcifications; the imaging manifestations of ACC are otherwise highly variable, likely related to multiple pathologic growth patterns. While ACC in other regions of the body tends to be more aggressive, ACC involving the breast typically has less aggressive biologic characteristics. Classic-type breast ACC has a lower tendency to recur locally with radiation, metastasize to regional lymph nodes, and spread to other parts of the body. Perineural spread of disease can be seen but is not common. The rarer solid basaloid-type has a higher tendency for local or distant spread and recurrence. Although ACC is usually triple receptor-negative (estrogen receptor, progesterone receptor, human epidermal growth factor-2 receptor), the indolent nature of this tumor dictates its management. With classic-type ACC, the inclusion of axillary surgery has no consensus and the use of chemotherapy or hormonal therapy is rare. Axillary nodal surgery and chemotherapy are often included in management of the more aggressive solid basaloid-type. An understanding of the breast imaging, histopathology, and clinical course is key for appropriate treatment and follow-up of ACC.

Qualitative and quantitative strain and shear wave elastography paradigm in differentiation of breast lesions

Background

Breast cancer is the most common life-threatening cancer in women worldwide. A high number of women are going through biopsy procedures for characterization of breast masses every day and yet 75% of the pathological results prove these masses to be benign. Ultrasound (US) elastography is a non-invasive technique that measures tissue stiffness. It is convenient for differentiating benign from malignant breast tumors. Our study aims to evaluate the role of qualitative ultrasound elastography scoring (ES), quantitative mass strain ratio (SR), and shear wave elasticity ratio (SWER) in differentiation between benign and malignant breast lesions.

Results

Among 51 female patients with 77 histopathologically proved breast lesions, 57 breast masses were malignant and 20 were benign. All patients were examined by B-mode ultrasound then strain and shear wave elastographic examinations using ultrasound machine (Logiq E9, GE Medical Systems) with 8.5–12 MHz high-frequency probes. Our study showed that ES best cut-off point > 3 with sensitivity, specificity, PPV, NPP, accuracy was 94.7%, 85%, 94.7%, 85%, 90.9%, respectively, and AUC = 0.926 at P < 0.001, mass SR the best cut-off point > 4.6 with sensitivity, specificity, PPV, NPP, accuracy was 96.5%, 80%, 93.2%, 88.9%, 92.2%, respectively, and AUC = 0.860 at P < 0.001, SWER the best cut-off value > 4.9 with sensitivity, specificity, PPV, NPP and accuracy was 91.2%, 80%, 92.9%, 76.2%, 93.5%, respectively, and AUC = 0.890 at P < 0.001. The mean mass strain ratio for malignant lesions is 10.1 ± 3.7 SD and for solid benign lesions 4.7 ± 4.3 SD (p value 0.001). The mean shear wave elasticity ratio for malignant lesions is 10.6 ± 5.4 SD and for benign (solid and cystic) lesions 3.6 ± 4.2 SD. Using ROC curve and Youden index, the difference in diagnostic performance between ES, SR and SWER was not significant in differentiation between benign and malignant breast lesions and also was non-significant difference when comparing them with conventional US alone.

Conclusion

ES, SR, and SWER have a high diagnostic performance in differentiating malignant from benign breast lesions with no statistically significant difference between them.

Prospective analysis of breast masses using the combined score for quantitative ultrasonography parameters

To investigate the diagnostic value of combined SWE, SMI, and B-mode US scores for distinguishing between benign and malignant masses. A total of 450 breast masses that underwent US-guided core needle biopsies were prospectively enrolled. The breast masses were assessed based on the BI-RADS and quantitative SWE and SMI parameters. The SWEmax, SWEratio, and SMI_VI cutoff value were determined using Youden’s index by comparison to the pathological results. The BI-RADS categories were scored on a scale from 1 to 5, and SWEmax, SWEratio, and SMI_VI were dichotomized based on each cutoff values (0 or 1). The combined scores (1 to 8) were calculated as the sum of the BI-RADS score and the quantitative scores and compared to the pathologic results using AUROC analysis. The cutoff values were 52.25 kPa for SWEmax, 5.03 for SWEratio, and 2.15% for SMI_VI. In AUROC, the combined scores showed significantly better diagnostic performance compared to BI-RADS alone (p < 0.001). The combined score showed significantly increased than BI-RADS alone in specificity (p < 0.001) and accuracy (p < 0.001), but a sensitivity decreased without significance (p = 0.082). When a combined score cutoff value of 4 was used, the false negative rate was 2.7%. Using the combined score, 76.4% of the C4a lesions were considered benign also pathologically diagnosed as benign. The combined scores showed improved diagnostic performance in differentiating between benign and malignant breast masses, which could be helpful for determining a breast biopsy eligibility.

Analysis of influencing factors of shear wave elastography of the superficial tissue: A phantom study

Shear wave elastography (SWE) is widely used in clinical work. But there is no standard protocol and operation specification for SWE acquisition methods, which impacts the diagnosis and clinical staging. This study aimed to investigate the influence factors of diameter, depth, and stiffness on SWE using different probes at superficial depths and discuss SWE differences with two machines at superficial depths. We performed SWE on two elastic phantoms that each phantom contained six subjects with two stiffness (41.06 ± 4.62 kpa and 57.30 ± 4.31 kpa), three diameters (10, 15, and 18 mm), and two depths (15 and 25 mm). A total of 240 measurements were obtained by using two ultrasound machines (SuperSonic Imagine Aixplorer and Mindray Resona 7) and 4 probes (SL15-4 and SL10-2, L11-3, and L14-5). The measurements were compared among 4 probes, 3 diameters, and 2 depths. There was no significant difference in SWE measurements among the probes from the same machine. The SWE measurements were affected by diameter, and the degree of influence was related to the stiffness. The SWE measurements were unaffected at a 15–25 mm depth range.

Role of Shear-Wave Elastography in Achilles Tendon in Psoriatic Arthritis and Its Correlation with Disease Severity Score, Psoriasis Area and Severity Index

Purpose  The aim of this study was to compare accuracy of shear-wave elastography (SWE) with gray scale (GS) ultrasound and power Doppler (pD) for diagnosing Achilles tendinopathy in psoriatic patients with and without arthritis and correlation with achillodynia and disease severity score, psoriasis area and severity index (PASI).

Methods  A total of 100 Achilles tendons were evaluated where 56% were cases of psoriatic arthritis with achillodynia; 44% were controls of psoriasis without arthritis in this prospective study. Evaluation was done with GS, pD, SWE at proximal, mid, and distal third of the tendon. Qualitative (color maps) and quantitative data, elastic modulus, kilopascal (kPa), were generated. Pearson's correlation was done to see association between kPa, PASI and clinical symptoms, achillodynia, scored using visual analog scale (VAS).

Results  Significant negative correlation was seen between duration of arthritis, VAS and PASI with SWE values with r  = −0.34, −0.47, and −0.41, respectively. SWE could identify abnormal tendons in 71/100 (71%) in the overall study, 53/56 (94.6%) in cases, and 18/44 (40.9%) in control. The statistical significance was set at p  ≤ 0.05. In comparison, conventional ultrasound, GS, and pD together could identify 13/56 (23.21%) in cases and no abnormal tendon was identified in the control group.

Conclusion  SWE is a reliable, noninvasive, and valuable tool to detect early tendinopathy and monitor progression of disease.

Differential diagnosis of B-mode ultrasound Breast Imaging Reporting and Data System category 3-4a lesions in conjunction with shear-wave elastography using conservative and aggressive approaches

BACKGROUND

The high false-positive rates of US Breast Imaging Reporting and Data System (BI-RADS) category 3-4a breast lesions leads to excessive biopsies of many benign lesions, and our aim was to investigate the diagnostic performance achieved by adding a maximum elasticity (Emax) of shear-wave elastography (SWE) to ultrasound (US) to evaluate US BI-RADS category 3-4a breast lesions using conservative and aggressive approaches. We explored the capacity of using this method to avoid unnecessary biopsies without increasing the probability of missing breast cancers.

METHODS

A total of 123 breast lesions of 120 patients classified as BI-RADS category 3 or 4a were enrolled from January 2019 to December 2019. The US features were evaluated according to the US BI-RADS lexicon. The maximum diameter measured on the US was defined as the size of the lesion. The Emax was assessed by SWE, and the average Emax of breast lesions on two images were calculated and recorded as the final maximum Young's modulus. The diagnostic performance of the combined B-mode US and SWE approach for BI-RADS category 3-4a breast lesions was tested using a conservative approach and an aggressive approach. In the conservative approach, the lesions were downgraded with Emax of 30 kPa or less and upgraded with Emax of 160 kPa or more. In the aggressive approach, the lesions were downgraded with Emax of 80 kPa or less and upgraded with Emax of 160 kPa or more. Pathologic results were defined as the reference standard.

RESULTS

Among all 123 breast lesions, there were 60 lesions classified as BI-RADS category 3 and 63 lesions classified as BI-RADS category 4a. Compared to the B-mode US, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, and area under the receiver operating characteristic (ROC) curve (AUC) of the combined B-mode US and SWE with a conservative approach changed from 88.9% to 94.4%, 55.2% to 60.0%, 25.4% to 28.8%, 96.7% to 98.4%, 60.2% to 65.0%, and 0.721 to 0.772, respectively. The specificity, PPV, and accuracy of combined B-mode US and SWE with an aggressive approach increased from 55.2% to 72.4%, 25.4% to 29.3%, and 60.2% to 71.5%, respectively, but this was accompanied with decreases in the sensitivity from 88.9% to 66.7%, the NPV from 96.7% to 92.7%, and the AUC from 0.721 to 0.695.

CONCLUSIONS

The addition of SWE improves the diagnostic performance of breast US. Adding the diagnostic criteria of SWE to the BI-RADS assessment of B-mode US, downgrading the lesions with Emax 30 kPa or less, and upgrading the lesions with Emax 160 kPa or more helped discriminate low suspicion lesions from benign lesions in order to decrease false-positive findings and avoid missing cancer diagnosis.

Second-Look Ultrasound Using Shear-Wave Elastography in MRI-Suspected Locoregional Recurrence of Breast Carcinoma

PURPOSE

To investigate if second-look US using shear-wave elastography (SWE) can help to differentiate between benign and malignant changes in the postoperative breast after surgical treatment of breast carcinoma.

MATERIALS AND METHODS

SWE and related sonographic features were reviewed in 90 female patients with a history of surgical treatment of breast carcinoma and a suspicious lesion detected on a follow-up MRI scan. A single experienced radiologist performed all second-look US exams with SWE measurements placing a circular region of interest measuring 2 mm in diameter over the stiffest part of the lesion. Tissue samples for histopathological analysis were obtained during the same US examination via core-needle biopsy.

RESULTS

Out of 90 lesions, 39 were proven malignant on histopathological analysis. 50 % of malignant lesions had El_max values ranging from 128 to 199 kPa, and 50 % of benign lesions had El_max values ranging from 65 to 169 kPa. The cut-off value of 171.2 kPa for El_max shows a sensitivity of 59 % and specificity of 78.4 % for carcinoma recurrence, area under the curve 0.706 (CI95 % 0.6-0.81), P = 0.001. In univariate logistic models, restricted diffusion and stiffness on SWE, El_max > 171.2 kPa, were shown as significant recurrence predictors. In the multivariate model, restricted diffusion remains significant independent recurrence predictor. With a recurrence prevalence of 43 %, the test sensitivity is 95 % (CI95 % 81-99 %) and the specificity is 75 % (CI95 % 60-85 %).

CONCLUSION

Stiffer lesions should be considered suspicious on second-look US in the postoperative breast and SWE can be a helpful tool in identifying malignant lesions, especially if this is related to restricted diffusion on MRI exam. Lesion stiffness, however, should not be considered as an independent predictor of lesion malignancy in the postoperative breast, because of benign changes that can appear stiff on SWE, as well as carcinoma recurrences that may appear soft.

The Role of Superb Microvascular Imaging and Shearwave Elastography in the Evaluation of Intraductal Papilloma-Like Lesions

OBJECTIVES

The aim of this study was to investigate the role of quantitative values obtained by superb microvascular imaging (SMI) and shearwave elastography (SWE) in the prediction of malignancy in intraductal papilloma-like lesions (IDPL).

METHODS

In the study, 61 patients between the ages of 14 to 73 years (mean age 44) diagnosed with IDPL on ultrasound (US) examination between the years 2020 and 2021 were included. The B-Mode US findings (shape, margins, size, echo pattern, and accompanying ductal dilatation), SMI vascular index (SMIvi), E-mean, and SWE-ratio values were recorded.

RESULTS

There was a statistically significant difference between malignant (n = 14) and benign (n = 47) groups in terms of symptoms (P = .005), size (P = .042), shape (P = .002), margins (P =  .001), echogenicity (P = .023), microcalcifications (P = .009), SMIvi (P = .031), E-mean (P < .005), and SWE-ratio (P = .007). According to receiver operating characteristic (ROC) curve analysis, sensitivity, specificity, accuracy, area under the curve (AUC), positive predictive values (PPV), and negative predictive values (NPV) were 57.1%, 87.2%, 80%, 0.722, 57.1%, 87.2% for US; 71.4%, 49%, 55.7%, 0.692, 30.3%, 85.7% for SMIvi; 85.7%, 71%, 74%, 0.864, 46%, 94.3% for E-mean, and 50%, 75.4%, 83%, 0.707, 91.5%, and 50% for SWE-ratio, respectively. Best results were obtained when SMI and SWE values were used together, achieving a sensitivity, specificity, accuracy, AUC, PPD, NPD of 78.6%, 93.6%, 93.4%, 0.872, 91.7%, and 93.9%, respectively.

CONCLUSIONS

The SMI and SWE examinations are successful in the differentiation of benign and malignant intraductal lesions. They complement each other and contribute to B-mode US in managing IDPLs especially when used together. Our study is the first to compare the quantitative data of SWE and SMI in the differentiation of IDPLs.

Stiffness Could be a Predictor of AJCC Prognostic Stage Groups in Preoperative Invasive Ductal Carcinoma

OBJECTIVES

This study aimed to evaluate the stiffness of 2-dimensional (2D) shear wave elastography (SWE) in preoperatively predicting the prognostic stage groups of invasive ductal carcinoma (IDC).

METHODS

Eighty-six newly diagnosed lesions on 83 patients with IDCs were analyzed. All parameters from conventional ultrasound and stiffness to virtual touch tissue imaging and quantification were collected, and mean shear wave velocity (SWVmean) was calculated. Data on maximum diameter, estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 2 (HER2), histologic grading system and Tumor Node Metastasis (TNM) stages were collected. The levels of maximum shear wave velocity (SWVmax), minimum shear wave velocity (SWVmin) and SWVmean were compared. In receiver operating characteristic (ROC) curves analysis, the diagnostic efficacy was found in area under the curve (AUC). Parallel mode was used to improve the predictive value of sensitivity.

RESULTS

The median stiffness of SWVmax and SWVmean for IDCs were 9.38 and 6.32 m/s for late stage (stages II, III, IV) and 6.39 m/s and 4.72 m/s for early stage (stage I) of the prognostic stage groups, respectively. The median stiffness values in the late stage were significantly higher than those in the early stage (P = .003, P = .005). The optimal cutoff stiffness of SWVmax and SWVmean were 8.62 and 6.13 m/s, respectively. In ROC curves analysis, the AUC for SWVmax was 0.742, and it showed a better diagnostic value than SWVmean (0.725). In predictive diagnosis, the sensitivity for SWVmax and SWVmean were both 62.50%. The parallel mode improved the prediction power of sensitivity to 68.75%.

CONCLUSIONS

Preoperative SWV level may serve as a promising prognostic imaging indicator for breast IDCs.

Classification of Breast Cancer Lesions in Ultrasound Images by Using Attention Layer and Loss Ensemble in Deep Convolutional Neural Networks

The reliable classification of benign and malignant lesions in breast ultrasound images can provide an effective and relatively low-cost method for the early diagnosis of breast cancer. The accuracy of the diagnosis is, however, highly dependent on the quality of the ultrasound systems and the experience of the users (radiologists). The use of deep convolutional neural network approaches has provided solutions for the efficient analysis of breast ultrasound images. In this study, we propose a new framework for the classification of breast cancer lesions with an attention module in a modified VGG16 architecture. The adopted attention mechanism enhances the feature discrimination between the background and targeted lesions in ultrasound. We also propose a new ensembled loss function, which is a combination of binary cross-entropy and the logarithm of the hyperbolic cosine loss, to improve the model discrepancy between classified lesions and their labels. This combined loss function optimizes the network more quickly. The proposed model outperformed other modified VGG16 architectures, with an accuracy of 93%, and also, the results are competitive with those of other state-of-the-art frameworks for the classification of breast cancer lesions. Our experimental results show that the choice of loss function is highly important and plays a key role in breast lesion classification tasks. Additionally, by adding an attention block, we could improve the performance of the model.

Presurgical tear characteristics and estimated shear modulus as predictors of repair integrity and shoulder function one year after rotator cuff repair

Background

Rotator cuff repair provides pain relief for many patients; however, retears are relatively common and affect approximately 20%-70% of patients after repair. Although magnetic resonance imaging (MRI) offers the ability to assess tissue characteristics such as tear size, retraction, and fatty infiltration, it provides little insight into the quality of the musculotendinous tissues the surgeon will encounter during surgery. However, shear wave elastography (SWE) could provide an indirect assessment of quality (ie, stiffness) by measuring the speed of shear waves propagating through tissue. The objective of this study was to determine the extent to which estimated shear modulus predicts repair integrity and functional outcomes 1 year after rotator cuff repair.

Methods

Thirty-three individuals scheduled to undergo arthroscopic rotator cuff repair were enrolled in this study. Before surgery, shear modulus of the supraspinatus tendon and muscle was estimated using ultrasound SWE. MRIs were obtained before and 1 year after surgery to assess tear characteristics and repair integrity, respectively. Shoulder strength, range of motion, and patient-reported pain and function were assessed before and after surgery. Functional outcomes were compared between groups and across time using a two-factor mixed model analysis of variance. Stepwise regression with model comparison was used to investigate the extent to which MRI and shear modulus predicted repair integrity and function at 1 year after surgery.

Results

At 1 year after surgery, 56.5% of patients had an intact repair. No significant differences were found in any demographic variable, presurgical tear characteristic, or shear modulus between patients with an intact repair and those with a recurrent tear. Compared with presurgical measures, patients in both groups demonstrated significant improvements at 1 year after surgery in pain (P < .01), self-reported function (P < .01), range of motion (P < .01), and shoulder strength (P < .01). In addition, neither presurgical MRI variables (P > .16) nor shear modulus (P > .52) was significantly different between groups at 1 year after surgery. Finally, presurgical shear modulus generally did not improve the prediction of functional outcomes above and beyond that provided by MRI variables alone (P > .22).

Conclusion

Although SWE remains a promising modality for many clinical applications, this study found that SWE-estimated shear modulus did not predict repair integrity or functional outcomes at 1 year after surgery, nor did it add to the prediction of outcomes above and beyond that provided by traditional presurgical MRI measures of tear characteristics. Therefore, it appears that further research is needed to fully understand the clinical utility of SWE for musculoskeletal tissue and its potential use for predicting outcomes after surgical rotator cuff repair.

Prediction of Invasive Breast Cancer Using Mass Characteristic Frequency and Elasticity in Correlation with Prognostic Histologic Features and Immunohistochemical Biomarkers

This purpose of this study is to correlate a new shear-wave elastography (SWE) parameter, mass characteristic frequency (fmass) and other elasticity measure with the prognostic histological factors and immunohistochemical (IHC) biomarkers for the evaluation of heterogeneous breast carcinomas. The new parameter, fmass, first introduced in this paper, is defined as the ratio of the averaged minimum shear wave speed taken spatially within regions of interest to the largest mass dimension. 264 biopsy-proven breast cancerous masses were included in this study. Mean (Emean), maximum (Emax), minimum (Emin) shear wave elasticity and standard deviation (Esd) of shear wave elasticity were found significantly correlated with tumor size, axillary lymph node (ALN) status, histological subtypes and IHC subtypes. The areas under the curve for the ALN prediction are 0.73 (95% confidence interval [CI]: 0.67-0.80) and 0.75 (95% CI: 0.69-0.81) for the combination of Emean with Breast Imaging Reporting and Data System (BI-RADS) score and Emax with BI-RADS score, respectively. fmass was significantly correlated with the presence of calcifications, ALN status, histological grade, the expressions of IHC biomarkers and IHC subtypes. To conclude, poor prognostic factors were associated with high shear wave elasticity values and low mass characteristic frequency value. Therefore, SWE provides valuable information that may help with prediction of breast cancer invasiveness.

Comparison of the Effectiveness of Shear Wave Elastography and Superb Microvascular Imaging in the Evaluation of Breast Masses

ABSTRACT

This study aims to determine the diagnostic performance of superb microvascular imaging (SMI) and shear wave elastography methods in evaluating breast lesions. We will also compare the effectiveness of the stiffness, velocity, and vascular index (VI) parameters in distinguishing malignancy.From January to June 2019, 121 patients with 121 solid breast masses (category 4 and 5 lesions according to the Breast Imaging-Reporting and Data System) detected during the routine grayscale sonographic examination were included in the study. Stiffness and velocity values were obtained using shear wave elastography for all lesions, and VI was obtained using SMI. The receiver operating characteristic curves were obtained to set the best cutoff values for the stiffness, velocity, and VI to differentiate patients with malignant breast lesions.All 121 lesions were pathologically verified by US-guided core needle biopsy. Forty-seven (38.9%) of the lesions were malignant, and 74 (61.1%) were benign. Median stiffness, velocity, and VI values were significantly lower in benign masses compared with malignant masses (P < 0.001). The optimum cutoff values for the stiffness, velocity, and VI were determined to be 58.3 kPa, 4.5 m/s, and 1.1%, respectively. The areas under the curves were 0.897 for stiffness, 0.884 for velocity, and 0.687 for VI.Shear wave elastography and SMI are noninvasive methods that may be used to evaluate breast masses. Although both methods' quantitative data are beneficial in differentiating malignant from benign masses, stiffness is the best parameter to be used.

Application value of shear wave elastography in salivary gland tumors

OBJECTIVE

The aims of this study were to retrospectively analyse the values of shear wave elastography (SWE) in differential diagnosis of salivary gland tumors (SGT).

METHODS

A total of 56 patients with salivary gland lump(s) were examined by SWE for measuring and comparing the differences in various Young's modules (malignant tumor (MT) and benign tumor (BT), parotid tumor (PA) and adenolymphomas (AL), etc.). All the cases were confirmed by surgery or fine needle aspiration pathology.

RESULTS

The 56 SGT cases included 10 cases MT, 27 cases of PA, 11 cases of AL, and 8 cases of other BT. There was no statistical significance in Young's modules between group BT and group MT (both P > 0.05); the differences between group PA and group AL were statistically significant (P < 0.05), and the corresponding ROC curve analysis found that the diagnostic value of the maximum Young's modulus was the highest with the best cut-off values and AUC as 32.4 KPa and 0.805. The sensitivity, specificity, and Yoden index of the diagnosis of PA and AL were 70.4%, 81.8%, and 0.522, respectively.

CONCLUSIONS

SWE can differentially diagnose PA and AL while not MT and BT in SGT.

Automated breast ultrasound: Supplemental screening for average-risk women with dense breasts

OBJECTIVE

We review ultrasound (US) options for supplemental breast cancer screening of average risk women with dense breasts.

CONCLUSION

Performance data of physician-performed handheld US (HHUS), technologist-performed HHUS, and automated breast ultrasound (AUS) indicate that all are appropriate for adjunctive screening. Volumetric 3D acquisitions, reduced operator dependence, protocol standardization, reliable comparison with previous studies, independence of performance and interpretation, and whole breast depiction on coronal view may favor selection of AUS. Important considerations are workflow adjustments for physicians and staff.

Combination of Quantitative Parameters of Shear Wave Elastography and Superb Microvascular Imaging to Evaluate Breast Masses

Objective

This study aimed to evaluate the diagnostic value of combining the quantitative parameters of shear wave elastography (SWE) and superb microvascular imaging (SMI) to breast ultrasound (US) to differentiate between benign and malignant breast masses.

Materials and Methods

A total of 200 pathologically confirmed breast lesions in 192 patients were retrospectively reviewed using breast US with B-mode imaging, SWE, and SMI. Breast masses were assessed based on the breast imaging reporting and data system (BI-RADS) and quantitative parameters using the maximum elasticity (Emax) and ratio (Eratio) in SWE and the vascular index in SMI (SMI_VI). The area under the receiver operating characteristic curve (AUC) value, sensitivity, specificity, accuracy, negative predictive value, and positive predictive value of B-mode alone versus the combination of B-mode US with SWE or SMI of both parameters in differentiating between benign and malignant breast masses was compared, respectively. Hypothetical performances of selective downgrading of BI-RADS category 4a (set 1) and both upgrading of category 3 and downgrading of category 4a (set 2) were calculated.

Results

Emax with a cutoff value of 86.45 kPa had the highest AUC value compared to Eratio of 3.57 or SMI_VI of 3.35%. In set 1, the combination of B-mode with Emax or SMI_VI had a significantly higher AUC value (0.829 and 0.778, respectively) than B-mode alone (0.719) (p < 0.001 and p = 0.047, respectively). B-mode US with the addition of Emax, Eratio, and SMI_VI had the best diagnostic performance of AUC value (0.849). The accuracy and specificity increased significantly from 68.0% to 84.0% (p < 0.001) and from 46.1% to 79.1% (p < 0.001), respectively, and the sensitivity decreased from 97.6% to 90.6% without statistical loss (p = 0.199).

Conclusion

Combining all quantitative values of SWE and SMI with B-mode US improved the diagnostic performance in differentiating between benign and malignant breast lesions.

Reducing Unnecessary Biopsy of Breast Lesions: Preliminary Results with Combination of Strain and Shear-Wave Elastography

The aim of our study was to compare strain elastography (SE), acoustic radiation force impulse-inducing Virtual Touch Imaging ([VTI] Siemens Medical Solutions, Mountain View, CA, USA), Virtual Touch Imaging Quantification ([VTIQ] Siemens Medical Solutions) and combined methods in the evaluation of ultrasound (US) Breast Imaging-Reporting and Data System (BI-RADS) category 4 lesions to explore an applicable way to reduce unnecessary biopsy by reducing false positives of conventional US without yielding false-negative cases. A total of 267 patients with 278 BI-RADS category 4 lesions (151 benign and 127 malignant) were evaluated with conventional B-mode US, SE, VTI and VTIQ implemented on a Siemens Acuson S2000 US system. Diagnostic performance, including area under the receiver operating characteristic curve, sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) were evaluated. Overall, VTI alone exhibited the highest NPV (91.74%), although combined elastic methods exhibited higher NPV than single methods, with the highest NPV at 100% when the VTI, SE and VTIQ methods were combined. Compared with conventional US, PPV increased from 45.7% (127 of 278) to 63.18% (127 of 201) when adding combined elastography (VTI + SE +VTIQ). In addition, 52.5% (63/120) and 50.8% (61/120) of BI-RADS 4 A lesions were downgraded when using combined methods (VTI + SE and VTI + SE + VTIQ, respectively) without missing any cancer. However, 2 intraductal papillomas and 1 phyllodes tumor were not identified. In conclusion, the combination of different elastic methods have the potential to downgrade BI-RADS 4A lesions to reduce false-positive biopsies without increasing the risk of missing cancers.

Piezoelectric needle sensor reveals mechanical heterogeneity in human thyroid tissue lesions

Palpable thyroid lesions are common, and although mostly benign, lethal malignant nodules do occur and may be difficult to differentiate. Here, we introduce the use of a piezoelectric system called Smart-touch fine needle (or STFN) mounted directly onto conventional biopsy needles, to evaluate abnormal tissues, through quantitative real-time measurements of variations in tissue stiffness as the needle penetrates tissue. Using well-characterized biomaterials of known stiffness and explanted animal tissue models, we first established experimental protocols for STFN measures on biological tissues, as well as optimized device design for high signal-to-noise ratio. Freshly excised patient thyroids with varying fibrotic and malignant potential revealed discrete variations in STFN based tissue stiffness/stiffness heterogeneity and correlated well with final histopathology. Our piezoelectric needle sensor reveals mechanical heterogeneity in thyroid tissue lesions and provides a foundation for the design of hand-held tools for the rapid, mechano-profiling of malignant lesions in vivo while performing fine needle aspiration (FNA).

SONOELASTOGRAPHIC FEATURES OF HIGH-RISK BREAST LESIONS AND DUCTAL CARCINOMA IN SITU - A PILOT STUDY

The aim of this study was to evaluate the quantitative sonoelastographic values recorded on shear-wave sonoelastography (SWE) of high-risk breast lesions and ductal carcinoma in situ (DCIS). We retrospectively analyzed histopathologic and SWE data (quantitative maximum, minimum and mean stiffness, lesion-to-fat ratio (E-ratio), lesion size) of 228 women referred to our Department for core needle breast biopsy during a four-year period. Among 230 lesions, histopathologic findings showed 34 high-risk breast lesions and 29 DCIS, which were compared with 167 ductal invasive carcinomas. High-risk lesions had lower values of all sonoelastographic features than ductal in situ and invasive carcinoma, however, only E-ratio showed a statistically significant difference in comparison to DCIS (3.7 vs. 6, p<0.001). All sonoelastographic features showed significant difference between in situ and invasive carcinoma. There was a significant correlation between lesion size and stiffness (r=0.36; p<0.001). Stiffness measured by SWE is an effective predictor of the histopathologic severity of sonographically detectable breast lesions. Elasticity values of high-risk lesions are significantly lower than those of malignant lesions. Furthermore, we showed that along with the sonographic appearance, which in most cases shows typical microcalcifications, DCIS had significantly different elasticity parameters than invasive carcinoma.

Imaging in the diagnosis of idiopathic inflammatory myopathies; indications and utility

INTRODUCTION

Idiopathic inflammatory myopathies (IIM) are a heterogeneous group of muscle diseases that carry a significant morbidity and mortality risk. The utilization of imaging in the diagnostic pathway of IIM is therefore important to obtain early diagnosis and even monitor patients over time. Areas covered: Magnetic resonance imaging (MRI) has been the main imaging modality used to detect myositis but limitations include cost and accessibility, leading to delays in time to scan, and patient contraindications. This has led to the exploration of other imaging techniques to diagnose and monitor response to therapy. This article is based primarily on a literature search via PubMed using Boolean terms 'myositis' and the various imaging modalities. Expert opinion: Imaging is sensitive to pathology in IIM and may contribute to the diagnostic process. Learning how specific imaging features can distinguish different forms of IIM may allow more rapid diagnosis of myositis subtype and treatment planning, and to monitor disease activity particularly in patients who respond poorly to treatment. However, more work is needed to investigate the validity and relative utility of these imaging modalities.

Predictors of Invasive Breast Cancer in Patients With Ductal Carcinoma In Situ in Ultrasound-Guided Core Needle Biopsy

OBJECTIVES

To determine predictors of invasiveness of lesions with US-guided biopsy-confirmed ductal carcinoma in situ (DCIS), focusing on US features, including shear wave elastography (SWE).

METHODS

From January 2015 to September 2016, a total of 80 lesions with US-guided biopsy-confirmed DCIS were detected in patients who underwent preoperative mammography, B-mode US, and SWE. Data were retrospectively reviewed from clinical records, pathologic reports, and imaging assessments. Imaging data included mammographic findings, B-mode US findings based on the American College of Radiology Breast Imaging Reporting and Data System (BI-RADS), and the mean and maximum elasticity values on SWE. The final BI-RADS assessment, including the degree of elasticity of the mass, was evaluated. Continuous variables were examined by an independent t test, and categorical variables were examined by the Fisher exact test. The independent factors for predicting a histologic upgrade were evaluated by a multivariate logistic regression analysis.

RESULTS

Among the 80 lesions, 27 (33.8%) showed an invasive component after surgical excision. None of the BI-RADS US descriptors, which include shape, orientation, margin, and echogenicity, showed a significant correlation with the rate of a histologic upgrade to invasive cancer. However, the BI-RADS assessment category (P = .015) and nuclear grade (P = .005) were significantly correlated with invasiveness of the mass. The maximum stiffness value was lower in the pure DCIS group (119.04 vs 85.33 kPa; P = .041).

CONCLUSIONS

The BI-RADS category based on US findings, maximum stiffness value on SWE, and nuclear grade of DCIS are predictive of invasive components in DCIS.

Comparison of Ultrasound Elastography and Color Doppler Ultrasonography for Distinguishing Small Triple-Negative Breast Cancer From Fibroadenoma

OBJECTIVES

To compare the performance of ultrasound elastography and color Doppler ultrasonography (US) in distinguishing small, oval, or round triple-negative breast cancer from fibroadenoma and the influence on the further management decision at US.

METHODS

In total, 131 biopsy-proven oval or round fibroadenomas (n = 68) and triple-negative breast cancers (n = 63) smaller than 2 cm were included. Three blinded readers assessed the images from US, elastography, and color Doppler imaging according to the Breast Imaging Reporting and Data System lexicon independently. Interobserver agreement was assessed, and sensitivity, specificity, accuracy, and area under the receiver operating characteristic curve values for each data set were compared. Pathologic results were reference standards.

RESULTS

The interobserver agreements were excellent (intraclass correlation coefficients, 0.856 for US, 0.948 for elastography, and 0.864 for color Doppler). The specificity and accuracy of US with elastography were increased compared with US alone or US with Doppler imaging without statistically significant differences in sensitivity. The average area under the curve for US with elastography (0.869) was increased compared with US alone (0.650) or US with color Doppler (0.576).

CONCLUSIONS

Elastography is more useful than color Doppler imaging for distinguishing small, oval, or round triple-negative breast cancer from fibroadenoma, and elastography can help avoid biopsy of benign masses.

Complex cystic and solid breast lesions: Diagnostic performance of conventional ultrasound, strain imaging and point shear wave speed measurement

OBJECTIVE

To assess the performance of conventional high frequency ultrasound (US) and US elastography in diagnosis of complex cystic and solid breast lesions.

METHODS

Ninety three lesions in 93 patients underwent conventional US and US elastography, including strain elastography, acoustic radiation force impulse (ARFI) imaging, and point shear wave speed (SWS) measurement.

RESULTS

Pathological examination revealed 31 (33.3%) of the 93 lesions were malignant and the remaining 62 (66.7%) were benign. Multivariate analysis showed that elder patient (OR: 25.301), internal vascularity (OR: 4.518), and not circumscribed margin (OR: 3.813) were independent predictors for malignancy, while predominately cystic lesions (OR: 0.178) was a predictor for benign lesions (all p < 0.05). Invalid SWS measurement was occurred in 19 of 31 (61.3%) malignant lesions and 16 of 62 (25.8%) benign lesions, respectively (p < 0.05). The mean SWS value for malignant lesions was significantly lower than that for benign ones, being 1.60±0.63 m/s (range, 0.68-2.70 m/s) versus 2.33±0.77 m/s (range, 0.67-3.97 m/s) (p < 0.05). Areas under the ROC curve (Azs) for Breast Imaging Reporting and Data System (BI-RADS) assessment, strain elasticity score, ARFI imaging and valid point SWS measurement were 0.844, 0.734, 0.763 and 0.778,respectively.

CONCLUSIONS

US BI-RADS category, strain elastography score, ARFI imaging patterns and point SWS measurement are useful for malignancy prediction of complex cystic and solid breast lesions. The result that SWS for malignant lesions is lower than benign one should be carefully interpreted since invalid SWS measurement is excluded for analysis. The true stiffness of malignant cystic and solid lesions should be further evaluated with a new generation of two-dimensional SWS imaging.

Comparison of strain and shear wave elastography for qualitative and quantitative assessment of breast masses in the same population

We investigated addition of strain and shear wave elastography to conventional ultrasonography for the qualitative and quantitative assessment of breast masses; cut-off points were determined for strain ratio, elasticity ratio, and visual score for differentiating between benign and malignant masses. In all, 108 masses from 94 patients were evaluated with strain and shear wave elastography and scored for suspicion of malignancy, visual score, strain ratio, and elasticity ratio. The diagnostic performance between ultrasonography alone and ultrasonography combined with either type of elastography was compared; cut-off points were determined for strain ratio, elasticity ratio, and visual score. Of the 108 masses, 44 were malignant and 64 were benign. The areas under the curves were significantly higher for strain and shear wave elastography-supplemented ultrasonography (0.839 and 0.826, respectively; P = 0.656) than for ultrasonography alone (0.764; P = 0.018 and 0.035, respectively). The diagnostic performances of strain and elasticity ratios were similar when differentiating benign from malignant masses. Cut-off values for strain ratio, elasticity ratio, and visual scores for strain and shear wave elastography were 2.93, 4, 3, and 2, respectively. Both forms of elastography similarly improved the diagnostic performance of conventional ultrasonography in the qualitative and quantitative assessment of breast masses.

Ultrasound shear wave elastography of breast lesions: correlation of anisotropy with clinical and histopathological findings

Background

Ultrasound shear-wave elastography (SWE) may increase specificity of breast lesion assessment with ultrasound, but elasticity measurements may change with transducer orientation, defined as anisotropy. In this study, we aimed to observe the anisotropy of SWE of breast lesions, and its correlation with clinical and histopathological findings.

Methods

This retrospective study was approved by institutional review board. From June 2014 to June 2015, a total of 276 women (mean age, 48.75 ± 12.12 years) with 276 breast lesions (174 malignant, 102 benign) were enrolled for conventional ultrasound and SWE before surgical excision. Elasticity modulus in the longest diameter and orthogonal diameter were recorded, including maximum elasticity (Emax), mean elasticity (Emean), standard deviation (Esd) and ratio between mean elasticity of lesion and normal fatty tissue (Eratio). Anisotropy coefficients including anisotropic difference (AD) and anisotropy factors (AF) were calculated, and correlations with malignancy, tumor size, palpability, movability, lesion location and histopathology were analyzed.

Results

The average Emax, Emean, Esd and Eratio of the longest diameter were significantly higher than orthogonal diameter (P < 0.05). AUCs of ADs and AFs were inferior to quantitative parameters (P < 0.001), with AUCs of AFs superior to ADs (P < 0.001). ADs showed no significant correlation with malignancy, palpability, movability, distance from nipple and skin, and histopathological patterns. ADmean was significantly higher in inner half than outer half of the breast (P = 0.034). Higher AFs were significantly correlated with larger lesion size (P = 0.042), palpability (P < 0.05), shorter distance from nipple and skin (P < 0.05) and higher suspicion for malignancy (P < 0.001). AFs were significantly higher in IDC than DCIS (P < 0.05), higher in Grade II/III than Grade I IDC (P < 0.001), and correlated with ER/PR(+) (P < 0.05).

Conclusions

AF of SWE was an indicator for malignancy and more aggressive breast cancer.

Breast lesions diagnosed by ultrasound-guided core needle biopsy: Can shearwave elastography predict histologic upgrade after surgery or vaccuum assisted excision?

PURPOSE

To compare breast stiffness based on shear-wave elastography (SWE) quantitative parameters with histopathologic results diagnosed by ultrasound (US)-guided core needle biopsy (CNB) to determine their association with upgrade rates after surgical excision or follow-up US as well as clinico-radiologic differences between upgrade and non-upgrade groups.

MATERIALS AND METHODS

This retrospective study enrolled 225 breast lesions from 225 patients, including 159 benign lesions, 38 high risk lesions and 28 ductal carcinoma in situ (DCIS) diagnosed by US-guided CNB. Quantitative SWE parameters of breast lesions were measured before CNB and compared according to histopathologic results (benign, high risk and DCIS) and lesion size (<20 mm and >20 mm). Clinico-radiologic and pathologic factors were compared between upgrade and non-upgrade groups after surgical excision or follow-up US.

RESULTS

After surgical excision or follow-up US after more than one year, 29 lesions were upgraded for an overall upgrade rate of 12.9% (29/225). There were significant differences between upgrade and non-upgrade groups in age, mammographic category, US category, and sonographic features, including shape, margin, orientation, imaging-histologic correlation and E ratio. Patients with lesion upgrade were much older and had lesions characterized by significantly higher mammographic and US category (>4b), irregular shape, nonparallel orientation, microlobulated or angular margin, calcification in a mass, larger size on US (>20 mm) and greater imaging-histologic discordance. Multivariate analysis showed only mean and minimum elasticity values displayed a borderline association with histologic underestimation.

CONCLUSION

Upgrade of breast lesions diagnosed by US-guided CNB can be predicted using E_mean and E_min among quantitative SWE parameters.

Effects of age and pathology on shear wave speed of the human rotator cuff

Rotator cuff tears are common and often repaired surgically, but post-operative repair tissue healing, and shoulder function can be unpredictable. Tear chronicity is believed to influence clinical outcomes, but conventional clinical approaches for assessing tear chronicity are subjective. Shear wave elastography (SWE) is a promising technique for assessing soft tissue via estimates of shear wave speed (SWS), but this technique has not been used extensively on the rotator cuff. Specifically, the effects of age and pathology on rotator cuff SWS are not well known. The objectives of this study were to assess the association between SWS and age in healthy, asymptomatic subjects, and to compare measures of SWS between patients with a rotator cuff tear and healthy, asymptomatic subjects. SWE images of the supraspinatus muscle and intramuscular tendon were acquired from 19 asymptomatic subjects and 11 patients with a rotator cuff tear. Images were acquired with the supraspinatus under passive and active (i.e., minimal activation) conditions. Mean SWS was positively associated with age in the supraspinatus muscle and tendon under passive and active conditions (p ≤ 0.049). Compared to asymptomatic subjects, patients had a lower mean SWS in their muscle and tendon under active conditions (p ≤ 0.024), but no differences were detected under passive conditions (p ≥ 0.783). These findings identify the influences of age and pathology on SWS in the rotator cuff. These preliminary findings are an important step toward evaluating the clinical utility of SWE for assessing rotator cuff pathology. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:282-288, 2018.

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

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

Shear-wave elastography quantitative assessment of the male breast: added value to distinguish benign and malignant palpable masses

OBJECTIVE

To evaluate the ability of shear-wave elastography (SWE) to distinguish between benign and malignant palpable masses of the adult male breast.

METHODS

Clinical examination, mammography, B-mode and Doppler ultrasound findings and SWE quantitative parameters were compared in 50 benign lesions (including 40 gynaecomastias) and 15 malignant lesions (invasive ductal carcinomas) from 65 patients who were consecutively addressed for specialized advice at our comprehensive cancer centre. Mean elasticity (El mean), maximum elasticity (El max), El mean of the surrounding fatty tissue and lesion to fat ratio (El ratio) were reported for each patient.

RESULTS

Malignant masses displayed significantly higher El mean (p < 0.0001), El max (p < 0.0001) and El ratio (p < 0.0001) compared to benign masses without overlap of values between the two groups. By adding SWE to clinical examination, mammography and ultrasound, all the lesions would have been retrospectively correctly diagnosed as benign or malignant. One false positive could have been downstaged, 14/65 undetermined masses could have been correctly reclassified as 4 malignant and 10 benign lesions, for which biopsies could have consequently been avoided.

CONCLUSION

Evaluation of male breast palpable masses by SWE demonstrates that malignant masses are significantly stiffer lesions and may improve diagnostic management when clinical examination, mammography and conventional ultrasound are doubtful. Advances in knowledge: Quantitative SWE is feasible in male breast and could be of great interest to help classify doubtful lesions after classical clinical and radiological evaluations, probably because of different anatomy and different tumours epidemiology compared with female breast.

Three-dimensional versus two-dimensional shear-wave elastography: Associations of mean elasticity values with prognostic factors and tumor subtypes of breast cancer

PURPOSE

To explore associations between prognostic factors and subtypes of invasive breast cancer (IBC) and elasticity values using three-dimensional (3D) and two-dimensional (2D) shear-wave elastography (SWE).

MATERIALS AND METHODS

Mean elasticity values (kPa) of 121 IBCs were measured using both 3D and 2D SWE. Associations between these values and prognostic factors and subtypes were analyzed using linear regression model.

RESULTS

In both 3D and 2D SWE, larger size and presence of lymphovascular invasion were independent factors influencing higher mean elasticity on multivariate analyses (all p values<0.05).

CONCLUSIONS

Using either 3D or 2D SWE, higher mean elasticity values are associated with poor prognostic factors of IBC.

Association Between Years of Competition and Shoulder Function in Collegiate Swimmers

BACKGROUND

Shoulder injuries are common among competitive swimmers, and the progression of shoulder pathology is not well understood. The objective of this study was to assess the extent to which years of competitive swim training were associated with physical properties of the supraspinatus muscle and tendon, shoulder strength, and self-reported assessments of shoulder pain and function.

HYPOTHESIS

Increasing years of competition will be associated with declining physical properties of the supraspinatus muscle/tendon and declining self-reported assessments of pain and function.

STUDY DESIGN

Descriptive epidemiology study.

LEVEL OF EVIDENCE

Level 4.

METHODS

After institutional approval, 18 collegiate female swimmers enrolled in the study. For each swimmer, supraspinatus tendon thickness was measured; tendinosis was assessed using ultrasound imaging, supraspinatus muscle shear wave velocity was assessed using shear wave elastography, isometric shoulder strength was measured using a Biodex system, and self-reported assessments of pain/function were assessed using the Western Ontario Rotator Cuff (WORC) score. All subjects were tested before the start of the collegiate swim season. Linear regression was used to assess the association between years of competition and the outcome measures.

RESULTS

Years of participation was positively associated with tendon thickness ( P = 0.01) and negatively associated with shear wave velocity ( P = 0.04) and WORC score ( P < 0.01). Shoulder strength was not associated with years of participation ( P > 0.39).

CONCLUSION

Long-term competitive swim training is associated with declining measures of supraspinatus muscle/tendon properties and self-reported measures of pain and function. Although specific injury mechanisms are still not fully understood, these findings lend additional insight into the development of rotator cuff pathology in swimmers.

CLINICAL RELEVANCE

Lengthy swimming careers may lead to a chronic condition of reduced mechanical properties in the supraspinatus muscle and tendon, thereby increasing the likelihood of rotator cuff pathology.

Virtual touch tissue imaging and quantification: value in malignancy prediction for complex cystic and solid breast lesions

This study was aimed to evaluatethe usefulness of conventional ultrasound (US) and US elastography, including the latest virtual touch tissue imaging and quantification (VTIQ), in malignancy prediction for complex cystic and solid breast lesions. Eighty-nine complex cystic and solid breast lesions were subject to conventional US and US elastography, including strain elastography (SE), virtual touch tissue imaging (VTI) and VTIQ. Among the 89 lesions, thirty-four (38.2%) lesions were malignant and 55 (61.8%) lesions were benign. Sixteen variables were subject to multivariate logistic regression analysis. Pattern 4b in VTI (odds ratio, OR:15.278), not circumscribed margin of lesion (OR:12.346), SWS mean >4.6 m/s in VTIQ (OR:11.896), and age elder than 50 years (OR:6.303) were identified to be independent predictors for malignancy. In receiver operating characteristic (ROC) curve analyses, associated areas under the ROC curve (Az) for conventional US could be significantly elevated, from 0.649 to 0.918, by combining with US elastography (p < 0.0001). The combined diagnostic method was able to improve the specificity (32.7% vs. 87.3%, p < 0.0001) without sacrificing the sensitivity (97.1% vs. 85.3%, p = 0.075). Both conventional US and US elastography contribute substantially to malignancy prediction in complex cystic and solid lesions. The diagnostic efficacy of conventional US in terms of Az and specificity could be significantly improved by combining with US elastography.

Mechanotransduction Dynamics at the Cell-Matrix Interface

The ability of cells to sense and respond to mechanical cues from the surrounding environment has been implicated as a key regulator of cell differentiation, migration, and proliferation. The extracellular matrix (ECM) is an oft-overlooked component of the interface between cells and their surroundings. Cells assemble soluble ECM proteins into insoluble fibrils with unique mechanical properties that can alter the mechanical cues a cell receives. In this study, we construct a model that predicts the dynamics of cellular traction force generation and subsequent assembly of fibrils of the ECM protein fibronectin (FN). FN fibrils are the primary component in primordial ECM and, as such, FN assembly is a critical component in the cellular mechanical response. The model consists of a network of Hookean springs, each representing an extensible domain within an assembling FN fibril. As actomyosin forces stretch the spring network, simulations predict the resulting traction force and FN fibril formation. The model accurately predicts FN fibril morphometry and demonstrates a mechanism by which FN fibril assembly regulates traction force dynamics in response to mechanical stimuli and varying surrounding substrate stiffness.

Quantification of breast stiffness using MR elastography at 3 Tesla with a soft sternal driver: A reproducibility study

PURPOSE

Previous studies of breast MR elastography (MRE) evaluated the technique at magnetic field strengths of 1.5 Tesla (T) with the breast in contact with the driver. The aim of this study is to evaluate breast stiffness measurements and their reproducibility using a soft sternal driver at 3T and compare the results with qualitative measures of breast density.

MATERIALS AND METHODS

Twenty-two healthy volunteers each underwent two separate breast MRE scans in a 3T MRI. MRE vibrations were introduced into the breasts at 60 Hz using a soft sternal driver and axial slices were collected using a gradient echo MRE sequence. Mean stiffness measurements were calculated for each volunteer as well as a measure of reproducibility using concordance correlation between scans. Mean stiffness values for each volunteer were assessed and related to amounts of fibroglandular tissue (i.e., breast lobules, ducts, and fibrous connective tissue).

RESULTS

The stiffness values were reproducible with a significant P-value < 0.0001 between two scans with concordance correlation of 0.87 and 0.91 for center slice and grouping all slices, respectively. Volunteers with dense breasts (i.e., higher grades of fibroglandular tissue) had mean stiffness values of 0.96 kPa (center slice) and 0.92 kPa (all slices) while those without dense breasts had mean stiffness values of 0.85 kPa (center slice) and 0.83 kPa (all slices) (P ≤ 0.05).

CONCLUSION

Breast MRE is a reproducible technique at 3T using a soft sternal driver. Dense breasts had significantly higher stiffness measurements compared with nondense breasts.

LEVEL OF EVIDENCE

2 J. MAGN. RESON. IMAGING 2017;45:1379-1384.

Shear-Wave Elastography: Could it be Helpful for the Diagnosis of Non-Mass-Like Breast Lesions?

The goal of this study was to analyze the diagnostic performance of shear wave elastography (SWE) in differentiation of benign and malignant non-mass-like (NML) breast lesions. Three hundred sixteen consecutive breast lesions in 305 patients who have been scheduled for ultrasound (US)-guided core needle biopsy or vacuum-assisted biopsy or surgical excision between January 2013 and August 2013 were initially included in this study. Finally, 63 patients with 67 lesions classified as NML lesions comprised our study population. The features of SWE and its diagnostic performance in NML lesions were analyzed. Among the 67 NML lesions, 33 were malignant and 34 were benign. The maximum elastic modulus, mean elastic modulus, minimum elastic modulus, elastic modulus ratio and stiff rim sign of the malignant lesions were all significantly higher than those of benign lesions (p < 0.05). The combination of conventional US with maximum elastic modulus and stiff rim sign got significantly higher diagnostic specificity and positive predictive value (PPV) than conventional US (p < 0.05 for both). In the benign lesions, 23 (67.6%) unnecessary biopsies could have been eliminated after the combination of conventional US and SWE. SWE could increase diagnostic specificity and positive predictive values of NML breast lesions. The combination of conventional US and SWE could reduce unnecessary benign biopsies of NML lesions.

Deep learning based classification of breast tumors with shear-wave elastography

This study aims to build a deep learning (DL) architecture for automated extraction of learned-from-data image features from the shear-wave elastography (SWE), and to evaluate the DL architecture in differentiation between benign and malignant breast tumors. We construct a two-layer DL architecture for SWE feature extraction, comprised of the point-wise gated Boltzmann machine (PGBM) and the restricted Boltzmann machine (RBM). The PGBM contains task-relevant and task-irrelevant hidden units, and the task-relevant units are connected to the RBM. Experimental evaluation was performed with five-fold cross validation on a set of 227 SWE images, 135 of benign tumors and 92 of malignant tumors, from 121 patients. The features learned with our DL architecture were compared with the statistical features quantifying image intensity and texture. Results showed that the DL features achieved better classification performance with an accuracy of 93.4%, a sensitivity of 88.6%, a specificity of 97.1%, and an area under the receiver operating characteristic curve of 0.947. The DL-based method integrates feature learning with feature selection on SWE. It may be potentially used in clinical computer-aided diagnosis of breast cancer.

Comparison of strain and shear-wave ultrasounic elastography in predicting the pathological response to neoadjuvant chemotherapy in breast cancers

OBJECTIVE

To compare the diagnostic performances of strain elastography (SE) and shear-wave elastography (SWE) for predicting response to neoadjuvant chemotherapy (NACT) in patients with breast cancer.

METHODS

This prospective study recruited 71 eligible patients from June 2014 to May 2016. All patients provided written informed consent. Tumour stiffness was assessed by the SE strain ratio (R), SWE maximum elasticity (E_max) and SWE mean elasticity (E_mean). Ultrasonic elastography (UE) assessments were performed at each NACT cycle (t1 - t6). For the purpose of predicting, the relative changes in elastographic parameters after the first and second NACT cycles were considered as the variables [Δ(t1) and Δ(t2)]. The area under the receiver operating characteristics (AUC) curve was compared.

RESULTS

ΔE_mean(t2) and R2 displayed the best diagnostic performances within their own modalities (AUC = 0.93 and 0.90 for predicting favourable response to NACT; AUC = 0.92 and 0.78 for predicting NACT resistance, respectively). There were no significant differences in AUCs for ΔE_mean(t2) and some UE parameters (P > 0.05). By contrast, ΔE_mean(t2) was significantly superior to all other SE parameters for predicting resistance (P < 0.05).

CONCLUSIONS

SE and SWE exhibited similar performances for predicting favourable NACT responses; SWE was better than SE for predicting NACT resistance.

KEY POINTS

• Elastography parameters after the second NACT cycle showed the best diagnostic performances. • SWE and SE yielded similar diagnostic performances in predicting favourable responses. • SWE performed better than SE in predicting the pathological resistance to NACT. • Discrepant results may be due to the breast thickness and lesion depth.

Shear Wave Elastography (SWE) for the Evaluation of Patients with Tendinopathies

RATIONALE AND OBJECTIVES

Shear wave elastography (SWE) has been shown to be a powerful tool to estimate tissue stiffness. The aim of this study was to compare the diagnostic accuracy of SWE to that of standard ultrasound (US) (combined use of B-mode US and power Doppler [PD] US) for diagnosing tendinopathies.

MATERIALS AND METHODS

This is a prospective institutional review board-approved study on 112 participants (mean age 42 ± 13.4 years) with chronic (>6 months) tendon pain in Achilles, patellar, or epicondylar tendons. Participants were systematically examined with US, PD, and SWE using a high-resolution linear 15 MHz probe (SuperSonic Imagine). A semiquantitative analysis of SWE color charts and a quantitative region of interest-based analysis of tendon elasticity were performed. SWE values of symptomatic and healthy tendons were compared by using Student t test. Clinical symptom scores served as the standard of reference. US findings were compared to clinical symptom scores by using Spearman correlation.

RESULTS

At semiquantitative analysis of SWE color charts, symptomatic tendons were rated as "soft" in 80/140 (57.1%), as "intermediate" in 54/140 (38.6%), and as "rigid" in 6/140 (4.3%). Healthy tendons were rated as "soft" in 8/84 (10%), as "intermediate" in 31/84 (37%), and as "rigid" in 45/84 (53%). At quantitative analysis, symptomatic tendons exhibited significantly lower mean SWE values (60.3 kPa/4.48 m/s; range 15.3-201.4 kPa/2.26-14.18 m/s) than healthy tendons (185 kPa/7.85 m/s; range 56-265 kPa/4.32-9.23 m/s) (P = 0.0004). SWE values correlated closely with patients' clinical symptoms obtained by clinical scores (r = 0.81). Overall sensitivity of conventional US and PD in detecting tendinopathies could be enhanced from 67.1% (94/140) to 94.3% (132/140) when combined with SWE.

CONCLUSIONS

SWE is a simple way to estimate tissue stiffness and, by reduced tissue rigidity, to identify tendon pathology. SWE significantly increases the diagnostic accuracy of tendon sonography and may prove to be a sensitive tool to early detect or monitor tendinopathy.

Stiffness at shear-wave elastography and patient presentation predicts upgrade at surgery following an ultrasound-guided core biopsy diagnosis of ductal carcinoma in situ

AIM

The aim of this study is to establish predictors of invasion in lesions yielding an ultrasound-guided biopsy diagnosis of ductal carcinoma in situ (DCIS).

MATERIALS AND METHODS

Patients subjected to ultrasound-guided core biopsy yielding DCIS were studied. At shear-wave elastography (SWE) a threshold of 50 kPa was used for mean elasticity (Emean) to dichotomise the elasticity data between invasive and non-invasive masses. Data recorded included the mammographic and ultrasound features, the referral source, and grade of DCIS in the biopsy. The chi-square test was used to detect statistical significance.

RESULTS

Of 57 lesions, 24 (42%) had invasion at excision. Symptomatic patients and patients with stiff lesions were more likely to have invasion than patients presenting through screening and with soft lesions (58% [14 of 24] versus 30% [10 of 33], p=0.03) and (51% [20 of 39] versus 22% [4 of 18], p=0.04). No other factors showed a relationship with invasion. Combining the two predictors of invasion improved risk stratification with symptomatic and stiff lesions having a risk of invasion of 67% (12 of 18) and soft lesions presenting at screening having only a 17% (2 of 12) risk of invasion (p=0.02).

CONCLUSION

Stiffness on SWE and the referral source of the patient are predictors of occult invasion in women with an ultrasound-guided core biopsy diagnosis of DCIS.

Prediction of invasive breast cancer using shear-wave elastography in patients with biopsy-confirmed ductal carcinoma in situ

OBJECTIVES

To investigate whether mass stiffness measured by shear-wave elastography (SWE) can predict the histological upgrade of ductal carcinoma in situ (DCIS) confirmed through ultrasound (US)-guided core needle biopsy (CNB).

METHODS

The institutional review board approved this study and informed consent was waived. A database search revealed 120 biopsy-confirmed DCIS in patients who underwent B-mode US and SWE prior to surgery. Clinicopathologic results, B-mode findings, size on US, and mean and maximum elasticity values on SWE were recorded. Associations between upgrade to invasive cancer and B-mode US findings, SWE information, and clinical variables were assessed using univariate, multivariate logistic regression, and multiple linear regression analysis.

RESULTS

The overall upgrade rate was 41.7 % (50/120). Mean stiffness value (P = .014) and mass size (P = .001) were significantly correlated with histological upgrade. The optimal cut-off value of mean stiffness value, yielding the maximal sum of sensitivity and specificity, was 70.7 kPa showing sensitivity of 72 % and specificity of 65.7 % for detecting invasiveness. Qualitative elasticity colour scores were significantly correlated with the histological upgrade, mammographic density, and B-mode category (P < .04).

CONCLUSION

Mean stiffness values evaluated through SWE can be utilized as a preoperative predictor of histological upgrade to invasive cancer in DCIS confirmed at US-guided needle biopsy.

KEY POINTS

• Higher stiffness values were noted in invasive cancer than DCIS. • Qualitative SWE colour scores significantly correlated with the histological upgrade. • Qualitative SWE colour scores had excellent interobserver agreement.

Shear-wave sonoelastographic features of invasive lobular breast cancers

Aim

To evaluate shear-wave elastographic (SWE) and related gray-scale features of pure invasive lobular breast carcinoma (ILC) and compare them with invasive ductal breast cancers (IDC).

Methods

Quantitative SWE features of mean (El-mean), maximum (El-max), minimum (El-min) elasticity values of the stiffest portion of the mass, and lesion-to-fat elasticity ratio (E-ratio) were measured in 40 patients with pure ILC and compared with 75 patients with IDC. Qualitative gray-scale features of lesion size, echogenicity, orientation, and presence of distal shadowing were determined and compared between the groups.

Results

ILC were significantly larger than IDC (P = 0.008) and exhibited significantly higher El-max (P = 0.015) and higher El-mean (P = 0.008) than IDC. ILC were significantly more often horizontally oriented, while IDC were significantly more often vertically oriented (P < 0.001); ILC were significantly more often hyperechoic than IDC (P < 0.001). Differences in stiffness between ILC and IDC determined by quantitative SWE parameters were present only in small tumors (≤1.5 cm in size), ie, small ILC had significantly higher El-max (P = 0.030), El-mean (P = 0.014), and El-min (P = 0.045) than small IDC, while tumors larger than 1.5 cm had almost equal stiffness, without significant differences between the groups.

Conclusion

Specific histopathologic features of ILC are translated into their qualitative sonographic and quantitative sonoelastographic appearance, with higher stiffness of small ILC compared to small IDC. Gray-scale and sonoelastographic features may help in diagnosing ILC.

The extracellular matrix in breast cancer predicts prognosis through composition, splicing, and crosslinking

The extracellular matrix in the healthy breast has an important tumor suppressive role, whereas the abnormal ECM in tumors can promote aggressiveness, and has been linked to breast cancer relapse, survival and resistance to chemotherapy. This review article gives an overview of the elements of the ECM which have been linked to prognosis of breast cancers, including changes in ECM protein composition, splicing, and microstructure.