Noninvasive Evaluation of Benign and Malignant Superficial Lymph Nodes by Virtual Touch Tissue Quantification: A Pilot Study

Multimodal ultrasound imaging: a method to improve the accuracy of sentinel lymph node diagnosis in breast cancer

Aim

This study assessed the utility of multimodal ultrasound in enhancing the accuracy of breast cancer sentinel lymph node (SLN) assessment and compared it with single-modality ultrasound.

Methods

Preoperative examinations, including two-dimensional ultrasound (2D US), intradermal contrast-enhanced ultrasound (CEUS), intravenous CEUS, shear-wave elastography (SWE), and surface localization, were conducted on 86 SLNs from breast cancer patients. The diagnostic performance of single and multimodal approaches for detecting metastatic SLNs was compared to postoperative pathological results.

Results

Among the 86 SLNs, 29 were pathologically diagnosed as metastatic, and 57 as non-metastatic. Single-modality ultrasounds had AUC values of 0.826 (intradermal CEUS), 0.705 (intravenous CEUS), 0.678 (2D US), and 0.677 (SWE), respectively. Intradermal CEUS significantly outperformed the other methods (p<0.05), while the remaining three methods had no statistically significant differences (p>0.05). Multimodal ultrasound, combining intradermal CEUS, intravenous CEUS, 2D US, and SWE, achieved an AUC of 0.893, with 86.21% sensitivity and 84.21% specificity. The DeLong test confirmed that multimodal ultrasound was significantly better than the four single-modal ultrasound methods (p<0.05). Decision curve analysis and clinical impact curves demonstrated the superior performance of multimodal ultrasound in identifying high-risk SLN patients.

Conclusion

Multimodal ultrasound improves breast cancer SLN identification and diagnostic accuracy.

Evaluation of acoustic radiation force impulse imaging in differentiating benign and malignant cervical lymphadenopathy

Background:

The aim of this study was to assess the diagnostic role of acoustic radiation force impulse imaging (ARFI) in differentiating benign and malignant cervical nodes.

Methods:

This was a diagnostic accuracy cross-sectional study. All patients who underwent ultrasound-guided fine-needle aspiration cytology (FNAC) of cervical nodes were included. Patients without FNAC/biopsy and patients in whom cervical nodes were cystic or completely necrotic were excluded. FNAC was used as reference investigation to predict the diagnostic accuracy. In all cases, FNAC was carried out after the B-mode, color Doppler and the ARFI imaging. In patients with multiple cervical lymph nodes, the most suspicious node based on grayscale findings was chosen for ARFI. ARFI included Virtual Touch imaging (VTI), area ratio (AR), and shear wave velocity (SWV) for each node, and the results were compared with FNAC/biopsy.

Results:

The final analysis included 166 patients. Dark VTI elastograms had sensitivity and specificity of 86.2% and 72.1%, respectively, in identifying malignant nodes. Sensitivity and specificity of AR were 71.3% and 82.3%, respectively, for a cutoff of 1.155. Median SWV of benign and malignant nodes was 1.9 [95% confidence interval (CI), 1.56–2.55] m/s and 6.7 (95% CI, 2.87–9.10) m/s, respectively. SWV >2.68 m/s helped in identifying malignant nodes with 81% specificity, 81.6% sensitivity, and 81.3% accuracy. ARFI was found to be inaccurate in tuberculous and lymphomatous nodes.

Conclusion:

Malignant nodes had significantly darker elastograms, higher AR and SWV compared to benign nodes, and SWV was the most accurate parameter. ARFI accurately identifies malignant nodes, hence could potentially avoid unwarranted biopsy.

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.

Diagnostic Performance of Acoustic Radiation Force Impulse Elastography for the Differentiation of Benign and Malignant Superficial Lymph Nodes: A Meta-analysis

To estimate the diagnostic performance of acoustic radiation force impulse elastography in distinguishing between benign and malignant superficial lymph nodes, relevant articles published before October 31, 2018, in China and other countries were used. Conclusively, a total of 18 articles were analyzed. Sixteen studies used Virtual Touch tissue quantification (Siemens Healthineers, Erlangen, Germany), and 4 studies used Virtual Touch tissue imaging (Siemens Healthineers). After a meta-analysis, it was found that acoustic radiation force impulse elastography is an efficient method for detecting superficial lymph nodes. In addition, if the cutoff value for the shear wave velocity were less than 2.85 m/s, the summary sensitivity would increase, and the heterogeneity would be reduced.

Predictive value of comb-push ultrasound shear elastography for the differentiation of reactive and metastatic axillary lymph nodes: A preliminary investigation

Objectives

To evaluate the predictive performance of comb-push ultrasound shear elastography for the differentiation of reactive and metastatic axillary lymph nodes.

Methods

From June 2014 through September 2018, 114 female volunteers (mean age 58.1±13.3 years; range 28–88 years) with enlarged axillary lymph nodes identified by palpation or clinical imaging were prospectively enrolled in the study. Mean, standard deviation and maximum shear wave elastography parameters from 117 lymph nodes were obtained and compared to fine needle aspiration biopsy results. Mann-Whitney U test and ROC curve analysis were performed.

Results

The axillary lymph nodes were classified as reactive or metastatic based on the fine needle aspiration outcomes. A statistically significant difference between reactive and metastatic axillary lymph nodes was observed based on comb-push ultrasound shear elastography (CUSE) results (p<0.0001) from mean and maximum elasticity values. Mean elasticity showed the best separation with a ROC analysis resulting in 90.5% sensitivity, 94.4% specificity, 0.97 area under the curve, 95% positive predictive value, and 89.5% negative predictive value with a 30.2-kPa threshold.

Conclusions

CUSE provided a quantifiable parameter that can be used for the assessment of enlarged axillary lymph nodes to differentiate between reactive and metastatic processes.

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

BACKGROUND The aims of this preliminary study were to evaluate contrast-enhanced ultrasound (CEUS) imaging and the therapeutic response of enlarged superficial lymph nodes in patients with lymphoma before and after chemotherapy and to determine the most useful CEUS response parameters. MATERIAL AND METHODS Forty-three patients with lymphoma, with 43 enlarged superficial lymph nodes, underwent CEUS and conventional ultrasound (US), before treatment and after the first three cycles of chemotherapy. Clinical responses included overall response (OR) and no response (NR). Imaging parameters by time-intensity curve (TIC) included basic intensity (B), wash-out slope and/or decent slope (K), wash-in slope or rise slope (C), time to peak (TTP), area under the gamma curve (Area), arrive time(ATM), peak intensity (PI), change of peak intensity (I) were compared. And receiver operating characteristic (ROC) curve analysis was operated. RESULTS Quantitative parameters of CEUS before and after the first three cycles of chemotherapy showed a significant difference in the AreaΔ, PID, and IΔ in the OR group compared with NR group (P<0.05). There was a significant difference in the Cpre, Areain, PIin, Iin, AreaΔ, PIΔ, and IΔ in the OR group compared with NR group (P<0.05). The effectiveness of the therapeutic response was predicted by the CEUS parameters of IΔ (P<0.05). And ΔArea has the highest diagnostic performance of ineffectiveness. CONCLUSIONS The findings of this study have shown that quantitative analysis by CEUS may be a useful, and objective, imaging method for the evaluation of the therapeutic response of enlarged superficial lymph nodes in lymphoma before and after chemotherapy.

Diagnostic value of acoustic radiation force impulse imaging for assessing superficial lymph nodes: A diagnostic accuracy study

The aim of this study was to assess the diagnostic value of acoustic radiation force impulse (ARFI) imaging for differentiating superficial lymph nodes.Virtual touch tissue imaging (VTI) grade and shear wave velocity (SWV) were analyzed and compared in 97 patients (65 women, 32 men; mean age, 49 y; range, 23-72 y) with 97 lymph nodes [23 chronic nonspecific reactive lymph nodes (CLNs), 38 metastatic lymph nodes (MLNs), and 36 blood and lymphatic system diseases lymph nodes (BLLNs)]. The elastography characteristics in patients with CLNs, MLNs, and BLLNs were compared using the nonparametric Kruskal-Wallis test and Mann-Whitney U test for continuous variables and categorical variables. The diagnostic performance of VTI grade and SWV were evaluated using the area under the receiver operating characteristic curve (AUC).The median of SWV of MLNs was significantly higher (2.90 m/s) than those of CLNs (2.15 m/s) and BLLNs (2.52 m/s). The VTI grade of MLNs was significantly higher than those of CLNs (P < .001) and BLLNs (P < .001). The sensitivity, specificity, accuracy, and AUC were 81.58%, 95.65%, 86.89%, and 0.904, respectively, at a cutoff level of grade IV for VTI grade in differentiating MLNs from CLNs, whereas those of SWV were 57.89%, 86.96%, 68.85%, and 0.752, respectively, at a cutoff level of 2.76 m/s.The diagnostic performance of VTI grade was significantly higher than that of SWV in differentiating MLNs from CLNs. The diagnostic performance of VTI grade and SWV were lower intermediate in differentiating MLNs from BLLNs and in differentiating BLLNs from CLNs, and there was no significant difference between VTI grade and SWV. ARFI imaging may be a feasible method for differentiating MLNs from CLNs.

Acoustic Radiation Force Impulse Imaging for the Differentiation of Benign and Malignant Lymph Nodes: A Systematic Review and Meta-Analysis

Objective

To evaluate the overall performance of acoustic radiation force impulse imaging (ARFI) in differentiating between benign and malignant lymph nodes (LNs) by conducting a meta-analysis.

Methods

PubMed, Embase, Web of Science, the Cochrane Library and the China National Knowledge Infrastructure were comprehensively searched for potential studies through August 13th, 2016. Studies that investigated the diagnostic power of ARFI for the differential diagnosis of benign and malignant LNs by using virtual touch tissue quantification (VTQ) or virtual touch tissue imaging quantification (VTIQ) were collected. The included articles were published in English or Chinese. Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) was used to evaluate the methodological quality. The pooled sensitivity, specificity, and the area under the summary receiver operating characteristic (SROC) curve (AUC) were calculated by means of a bivariate mixed-effects regression model. Meta-regression analysis was performed to identify the potential sources of between study heterogeneity. Fagan plot analysis was used to explore the clinical utilities. Publication bias was assessed using Deek’s funnel plot.

Results

Nine studies involving 1084 LNs from 929 patients were identified to analyze in the meta-analysis. The summary sensitivity and specificity of ARFI in detecting malignant LNs were 0.87 (95% confidence interval [CI], 0.83–0.91) and 0.88 (95% CI, 0.82–0.92), respectively. The AUC was 0.93 (95% CI, 0.90–0.95). The pooled DOR was 49.59 (95% CI, 26.11–94.15). Deek’s funnel plot revealed no significant publication bias.

Conclusion

ARFI is a promising tool for the differentiation of benign and malignant LNs with high sensitivity and specificity.