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Abstract 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 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 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

Hui Wang,1,* Cui-Ying Li,1,* Hai-Ling Zha,1 Di Xu,1 Zhi-Bin Hu2 1Department of Ultrasound, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, People’s Republic of China; 2Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, 211166, People’s Republic of China*These authors contributed equally to this workCorrespondence: Zhi-Bin HuDepartment of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, No. 101 Longmian Avenue, Jiangning District, Nanjing, 211166, Jiangsu, People’s Republic of ChinaTel +86-25-86868437Email Zhibin_hu@njmu.edu.cnDi XuDepartment of Ultrasound, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu, People’s Republic of ChinaTel +86-25-83714511Email xudi_doctor@163.comPurpose: To investigate the diagnostic and predictive value of strain ratios in the regions of interests (ROIs) in reference tissue for breast tumor.Patients and Methods: A total of 707 lesions in 665 consecutive patients were examined with B-mode Breast Imaging-Reporting and Data System (BI-RADS) and Ultrasonic elastography (UE). Elasticity score (ES) and strain ratio (SR) in each lesion were calculated. Receiver operating characteristic (ROC) curves were used to assess the diagnostic value of BI-RADS, ES, SR1, SR2, BI-RADS combined with ES (BI-RADS+ES), BI-RADS combined with SR1 (BI-RADS+SR1), and BI-RADS combined with SR2 (BI-RADS+SR2). The sensitivity, specificity, and areas under the ROC curves (Az) were obtained. Scatter plots were generated to demonstrate the correlation between SR1 and SR2. Kruskal-Walls H-test, Mann–Whitney U-test and one-way ANOVA were performed to evaluate SRs and tumor-related variables. Multiple linear regression analysis was carried out to determine variables independently associated with SRs.Results: BI-RADS had high sensitivity and low specificity in the diagnosis of breast tumor. The specificity of BI-BADS combined with ES or SR was even higher. The Az value of BI-RADS+ES or BI-RADS+SRs was higher than that of BI-RADS (P < 0.001). The Az value of ES was higher than those of SR1 and SR2 (P < 0.001), and those of SR1 and SR2 were similar. SR1 and SR2 were highly positively correlated. There was no statistical difference between Az values of BI-RADS+ES, BI-RADS+SR1, and BI-RADS+SR2. Indistinct margin, high histologic grade, histological type, and negative human epidermal growth factor receptor (Her-2) were associated with SR1 and SR2. Progesterone receptor (PR) status and molecular subtype were associated with SR2. Histologic grade and tumor margin were significantly associated with SR1, and tumor margin was associated with SR2.Conclusion: SRs in different ROIs in the reference tissue at the same depth showed no different diagnostic value for breast tumor. Both SR1 and SR2 could be useful in assessing the biological characteristics of invasive breast carcinoma.Keywords: conventional ultrasonography, Breast Imaging-Reporting and Data System, ultrasonic elastography, elasticity score, strain ratio

Purpose: To evaluate the role of strain elastography (SE) in reclassification of indeterminate breast lesions placed under BIRADS 3 and 4 categories by conventional ultrasound (US) parameters so as to recourse biopsy only for suspicious stiffer lesions. Methods: 113 breast lesions in 100 women assigned as BIRADS category 3 and 4 on US parameters were prospectively evaluated by SE followed by histo-pathological examination. Strain ratio (SR) and Elastography Score (ES) were determined for each lesion. The sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) were calculated for each modality and diagnostic performance were compared. The best cut-off point was calculated for each of the elastography parameter using the receiver operator curve analysis (ROC). Results: Out of the 113 lesions, 40 were malignant (35.4’) and 73 were benign (64.6’). A statistically significant difference was observed in the AUC for ES and conventional US: 0.98 vs 0.90 (Difference = 0.08, P = 0.02). Elastography parameters were more specific as compared to US (ES-94.5 & SR-93.2’ vs 63’, P < 0.05) with high NPV. SE performed better in BIRADS 4 category lesions. On the basis of elastography parameters, 85’ of BIRADS 4 category lesions were correctly predicted as benign with overall sensitivity, specificity and diagnostic accuracy of elastography being 97’, 84.6’ and 91.9’. Among BIRADS 3 category lesions, 97’ were correctly predicted as benign and 50’ lesions were correctly predicted as malignant with a sensitivity of 50’, specificity of 97.8’ and diagnostic accuracy of 94’. Conclusion: Strain elastography is a useful adjunct to conventional ultrasonography for the assessment of indeterminate breast lesions and may help in avoiding unnecessary follow ups and biopsies. Elastography score is a better parameter as compared to strain ratio.

Background: Axillary lymph node (ALN) enlargement with diffuse cortical thickening and conserved echogenic hilum may represent a diagnostic and therapeutic challenge. Sonographic strain elastography may help the characterization of borderline ALN. Aim: To evaluate the strain elastography of borderline ALN and to calculate a cutoff value of strain ratio (SR) that can identify suspicious ALN with the highest sensitivity and specificity to reduce unnecessary invasive procedures. Subjects and Methods: A prospective study included 45 patients who attended the Breast clinic in Oncology Teaching Hospital with borderline axillary lymphadenopathy (intact hilum and diffusely thickened cortex more than 3mm) who had normal ipsilateral breast, suspicious ipsilateral breast lesion, or who had ipsilateral mastectomy. B-mode sonography and elastography were performed for all participants. Four-point elasticity score (ES), and SR were obtained for the targeted lymph node followed by ultrasound-guided fine need aspirate (FNA) biopsy.. Results: Malignant ALN constituted 20% of the cohort. B mode measurements were not able to differentiate between cytologically confirmed benign and malignant ALN in terms of axis ratio (mean ± standard deviation, 0.46 ± 0.08 vs 0.50 ± 0.12) and cortical thickness (4.88 ± 1.93 vs 6.27 ± 2.46). The mean SR of all samples was 2.66 ± 2.25. Metastatic ALN depicted significantly higher SR (P

Thyroid nodule elastography has been exceedingly used for the differentiation of benign and malignant nodules. Determination of confounding factors of the results of sonoelastography in thyroid nodules when assessing the probability of malignancy is an issue of importance, and this matter needs further research. In this study, the contributing factors to the results of strain sonoelastography in cases of thyroid nodules were assessed in order to help the clinicians for better management and decision making. In this diagnostic study in Taleghani Hospital, Tehran, Iran, in 2018 and 2019, a total of 92 consecutive patients with thyroid nodules were assessed by grayscale ultrasound and strain sonoelastogaphy, and the contributing factors to the results of sonoelastography were determined according to low and high malignancy probability elasticity scores. The results in this study demonstrated that there were 57 cases (62%) with low probability scores and 35 patients (38%) with high probability scores according to strain sonoelastogaphy. The patient’s age and nodule grayscale characteristics such as shape, echogenicity, margin, composition, size, and calcification were not related to sonoelastography results (P>0.05). This study showed that results of sonoelastography are not related to demographic factors and gray-scale sonographic features of the nodules.

Thyroid nodule elastography has been exceedingly used for the differentiation of benign and malignant nodules. Determination of confounding factors of the results of sonoelastography in thyroid nodules when assessing the probability of malignancy is an issue of importance, and this matter needs further research. In this study, the contributing factors to the results of strain sonoelastography in cases of thyroid nodules were assessed in order to help the clinicians for better management and decision making. In this diagnostic study in Taleghani Hospital, Tehran, Iran, in 2018 and 2019, a total of 92 consecutive patients with thyroid nodules were assessed by grayscale ultrasound and strain sonoelastogaphy, and the contributing factors to the results of sonoelastography were determined according to low and high malignancy probability elasticity scores. The results in this study demonstrated that there were 57 cases (62%) with low probability scores and 35 patients (38%) with high probability scores according to strain sonoelastogaphy. The patient's age and nodule grayscale characteristics such as shape, echogenicity, margin, composition, size, and calcification were not related to sonoelastography results (P>0.05). This study showed that results of sonoelastography are not related to demographic factors and gray-scale sonographic features of the nodules. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

ObjectiveThis study aimed to explore the value of elasticity score (ES) and strain ratio (SR) combined with conventional ultrasound in distinguishing benign and malignant breast masses and reducing biopsy of BI-RADS (Breast Imaging Reporting and Data System) 4a lesions.MethodsThis prospective, multicenter study included 910 patients from nine different hospitals. The acquisition and analysis of conventional ultrasound and strain elastography (SE) were obtained by radiologists with more than 5 years of experience in breast ultrasound imaging. The diagnostic sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under curve (AUC) of conventional ultrasound alone and combined tests with ES and/or SR were calculated and compared.ResultsThe optimal cutoff value of SR for differentiating benign from malignant masses was 2.27, with a sensitivity of 60.2% and a specificity of 84.8%. When combined with ES and SR, the AUC of the new BI-RADS classification increased from 0.733 to 0.824 (p < 0.001); the specificity increased from 48.1% to 68.5% (p < 0.001) without a decrease in the sensitivity (98.5% vs. 96.4%, p = 0.065); and the PPV increased from 52.2% to 63.7% (p < 0.001) without a loss in the NPV (98.2% vs. 97.1%, p = 0.327). All three combinations of conventional ultrasound, ES, and SR could reduce the biopsy rate of category 4a lesions without reducing the malignant rate of biopsy (from 100% to 68.3%, 34.9%, and 50.4%, respectively, all p < 0.001).ConclusionsSE can be used as a useful and non-invasive additional method to improve the diagnostic performance of conventional ultrasound by increasing AUC and specificity and reducing the unnecessary biopsy of BI-RADS 4a lesions.

Objective: This study aimed to explore the value of elasticity score (ES) and strain ratio (SR) combined with conventional ultrasound in distinguishing benign and malignant breast masses and reducing biopsy of BI-RADS (Breast Imaging Reporting and Data System) 4a lesions. Methods: This prospective, multicenter study included 910 patients from nine different hospitals. The acquisition and analysis of conventional ultrasound and strain elastography (SE) were obtained by radiologists with more than 5 years of experience in breast ultrasound imaging. The diagnostic sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under curve (AUC) of conventional ultrasound alone and combined tests with ES and/or SR were calculated and compared. Results: The optimal cutoff value of SR for differentiating benign from malignant masses was 2.27, with a sensitivity of 60.2% and a specificity of 84.8%. When combined with ES and SR, the AUC of the new BI-RADS classification increased from 0.733 to 0.824 (p < 0.001); the specificity increased from 48.1% to 68.5% (p < 0.001) without a decrease in the sensitivity (98.5% vs. 96.4%, p = 0.065); and the PPV increased from 52.2% to 63.7% (p < 0.001) without a loss in the NPV (98.2% vs. 97.1%, p = 0.327). All three combinations of conventional ultrasound, ES, and SR could reduce the biopsy rate of category 4a lesions without reducing the malignant rate of biopsy (from 100% to 68.3%, 34.9%, and 50.4%, respectively, all p < 0.001). Conclusions: SE can be used as a useful and non-invasive additional method to improve the diagnostic performance of conventional ultrasound by increasing AUC and specificity and reducing the unnecessary biopsy of BI-RADS 4a lesions. [ABSTRACT FROM AUTHOR]

Background/aim: Strain elastography has the disadvantage of being operator-dependent. Interobserver variability is observed during image acquisition and interpretation. This study aimed to analyze the interobserver and intermethod variability of strain elastography in image interpretation and evaluate the diagnostic performance combining elasticity score and strain ratio with ultrasonography. Materials and methods: A retrospective study was conducted on 70 breast lesions evaluated with B-mode ultrasonography and strain elastography. B-mode ultrasonography findings, elasticity scores, and strain ratio values were evaluated using static images by two radiologists. BI-RADS assessment of the lesions and the decision of both observers as to whether the biopsy was required using B-mode ultrasonography, and the combined ultrasonography+elasticity score, and the combined ultrasonography+elasticity score+strain ratio were compared with the histopathological results. Also, the interobserver agreement was analyzed for all the combinations. Results: There was very good agreement (weighted κ = 0.865) between the observers for the elasticity scores. Very good agreement was observed between the observers for BI-RADS assessments using the combined ultrasonography+elasticity score and the combined ultrasonography+elasticity score+strain ratio (weighted κ = 0.848, and 0.902, respectively). Area under the curve of B-mode ultrasonography, the combined B-mode ultrasonography+elasticity score, and the combined B-mode ultrasonography+elasticity score+strain ratio, were calculated as 0.859, 0.866, and 0.916 for observer 1, and 0.851, 0.829, and 0.916 for observer 2, respectively. There were no statistically significant differences between the observers' diagnostic performances in any of the combinations (P = 0.703, 0.067, and 0.972, respectively). Conclusion: In the evaluation and further assessment of breast lesions, semiquantitative strain ratio calculation may help improve diagnostic accuracy by reducing interpretational variety, when used together with B-mode ultrasonography and elasticity scoring, especially for inexperienced individuals. [ABSTRACT FROM AUTHOR]

Background: Elastography is a new promising ultrasonographic technique which is used to differentiate benign and malignant breast lesions based on the stiffness of the lesion. Purpose: To determine the role of strain elastography in characterisation of breast lesions and to compare the diagnostic performances of strain elastography and conventional ultrasound (US). Methods: In total, 113 breast lesions in 100 women were prospectively evaluated by US and strain elastography followed by the histopathological examination. Elastography score based on the Tsukuba colour scale and strain ratio were determined for each lesion. The sensitivity, specificity, accuracy, positive predictive value and negative predictive value were calculated for each modality and the diagnostic performances were compared. The best cut-off point was calculated for each of the elastography parameters using the receiver operator curve analysis. Results: Out of the 113 lesions, 40 were malignant (35.4%) and 73 were benign (64.6%). The area under the curve for elastography score showed significant difference with that of US: 0.98 versus 0.90 (Difference = 0.08, p =0.02). The elastography parameters were more specific as compared to US (ES-95 and SR-93% vs. 63%, p < 0.05) with a high negative predictive value. The combined use of elastography and US gave better results with 95% sensitivity, 94% specificity, 94% accuracy and negative predictive value reaching 97%. Conclusion: Strain elastography is a useful adjunct to conventional ultrasonography. The combined use of strain elastography and ultrasound improves the characterisation of breast lesions and helps in down-staging of assigned BI-RADS category, thereby avoiding unnecessary biopsies. ES is the most useful elastography parameter to differentiate between benign and malignant breast lesions. [ABSTRACT FROM AUTHOR]

Purpose: This research aimed to study the correlation between the normal testicular tissue elasticity as detected by real time sonoelastography with the age. Materials and methods: The study was conducted upon 63 adult healthy volunteers. Each volunteer was subjected to real time sonoelastography measuring the strain ratio of testicular tissues and their elasticity scores. Result: Strain ratios of the examined testes ranged from 0.27 to 0.38, with a mean strain of 0.33 and a standard deviation of 0.03. Elasticity score of the examined testes included ES1 in 62 testes (49%), ES2 in 58 testes (46%) and ES3 in 6 testes (5%). No ES4 or ES5 was elicited in this group. High negative correlation is found between the age and both the testicular volume and the strain ratio, while there is no correlation between age and the elasticity score of testes. Conclusion: Normal testicular tissues as studies by sonoelastography show strong correlation between the age and the testicular volume as well as the strain ratio.

Objective: To analyze the observer reproducibility of breast strain elastography in elasticity image acquisition and elasticity image interpretation.Methods: This was an institutional ethics committee approved prospective study. One hundred twenty-four breast lesions in 118 women (mean age 45.39 ± 12.97 years old, range 21-77 years old) were examined with strain elastography by two blinded radiologists in turn. Three blinded observers separately reviewed and recorded the elasticity score of each lesion obtained by the two performers. The interobserver reproducibility of elasticity image acquisition between the two performers, the interobserver and intraobserver reproducibility of elasticity image interpretation among observers were evaluated. The diagnostic performance of strain elastography was compared between the two performers.Results: Fifty-three lesions were malignant and 71 were benign. The interobserver kappa value was 0.438 for the elasticity score between the two performers. Between the three observers, the overall interobserver and intraobserver kappa value was 0.365 and 0.655, respectively. There was no significant difference of the area under the receiver operator characteristic curve (Az) value for the elasticity score between performer 1 and 2 (P = 0.143).Conclusions: Our results suggested moderate interobserver reproducibility in breast strain elasticity image acquisition, poor interobserver and good intraobserver agreement in image interpretation. [ABSTRACT FROM AUTHOR]

Real-time elastography (RTE) and elasticity scoring system is a new diagnostic tool in the evaluation of enlarged cervical lymph nodes (LNs). The aim of the study was to investigate the validity and reliability of two elasticity scoring systems in discriminating cervical lymphadenopathies. Materials and methods: The study protocol was approved by the institutional review board of the local ethics committee. Ninety-eight consecutive patients underwent ultrasound-guided fine needle aspiration biopsy after conventional ultrasound and RTE evaluation. Elasticity scores were divided into four and five categories according to signal distribution, based on previously determined models. Two independent raters analyzed the elastographic data. Results: Final histology revealed 60 benign and 38 malignant cervical LNs. In the four-point scoring system, 41/60 benign LNs were classified as score 1 or 2 and 28/38 malignant nodes as score 3 or 4 [sensitivity 73.7%, specificity 68.3%, positive predictive value (PPV) 59.6%, negative predictive value (NPV) 80.4%]. Using the five-point scoring system, 28/60 benign nodes were classified as score 1 or 2 and 31/38 malignant nodes as score 3–5 (sensitivity 79.0%, specificity 45.0%, PPV 47.6%, NPV 80.4%). In the four-point scoring system, rates of concordance between raters (κ = 0.63) and with the same rater (κ = 0.75) were both good with statistical significance (both p

AIM: Comparison of different ultrasound elastography techniques for detection of changes after sclerotherapy within venous malformations. MATERIALANDMETHODS:In patients with venous malformations sonographywas executed at exactly the same position prior to and after ethanol-gel sclerotherapy. Both examinations included B-Mode, vascular sonography with Color-Coded Duplex Sonography, and additional sonography with different elastography techniques (strain, qualitative and quantitative Acoustic Radiation Force Impulse (ARFI) elastography) with a linear transducer (6-9 MHz). Qualitative elastograms were read in consensus and scored. Differences of elasticity scores were statistically analyzed, p-values < 0.05 were regarded significant. RESULTS: Elasticity scores of strain and qualitative ARFI elastography in 25 patients (21 females, averagely 24.4 years old) were comparable before treatment (p = 0.69). After therapy qualitative ARFI scores changed significantly compared to pre-treatment scores (p = 0.0017), whereas strain elastography scores revealed no significant changes (p = 0.13). Quantitative ARFI values obtained after sclerotherapy within the venous malformations were significantly higher compared to pretreatment values (p = 0.049), and significantly higher to values obtained in surrounding tissue (p = 0.030). Comparison of preand post-treatment ARFI values of the surrounding tissue was not significant (p = 0.67). CONCLUSION: Elasticity scores of qualitative ARFI elastography reliably detect ethanol-gel induced changes in venous malformations. Quantitative ARFI may be a tool for therapy planning, and for monitoring sclerotherapy outcome as well as the effect of sclerosing agents on malformation and surrounding tissue in patients with venous malformations. [ABSTRACT FROM AUTHOR]

This study investigates the usefulness of contrast-enhanced ultrasound (CEUS) and real-time elastography (RTE) for the characterization of testicular masses by comparing pre-operative ultrasound findings with post-operative histology. Sixty-seven patients with 68 sonographically detected testicular masses underwent B-mode, color-coded Doppler sonography (CCDS), CEUS and RTE according to defined criteria. For RTE, elasticity score (ES), difference of elasticity score (D-ES), strain ratio (SR) and size quotient (Qsize) were evaluated. Histopathologically, 54/68 testicular lesions were neoplastic (47 malignant, 7 benign). Descriptive statistics revealed the following results (neoplastic vs. non-neoplastic) for sensitivity, specificity, positive predictive value, negative predictive value and accuracy, respectively: B-mode, 100%, 43%, 87%, 100%, 88%; CCDS 81%, 86%, 96%, 55%, 82%; CEUS 93%, 85%, 96%, 73%, 91%; ES 98%, 25%, 85%, 75%, 85%; D-ES 98%, 50%, 90%, 83%, 89%; SR 90%, 45%, 86%, 56%, 81%; and Qsize 57%, 83%, 94%, 28%, 61%. B-mode with CCDS remains the standard for assessing testicular masses. In characterization of testicular lesions, CEUS clearly outperformed all other modalities. Our study does not support the routine use of RTE in testicular ultrasonography because of its low specificity. [ABSTRACT FROM AUTHOR]

Purpose This research aimed to study the correlation between the normal testicular tissue elasticity as detected by real time sonoelastography with the age. Materials and methods The study was conducted upon 63 adult healthy volunteers. Each volunteer was subjected to real time sonoelastography measuring the strain ratio of testicular tissues and their elasticity scores. Result Strain ratios of the examined testes ranged from 0.27 to 0.38, with a mean strain of 0.33 and a standard deviation of 0.03. Elasticity score of the examined testes included ES1 in 62 testes (49%), ES2 in 58 testes (46%) and ES3 in 6 testes (5%). No ES4 or ES5 was elicited in this group. High negative correlation is found between the age and both the testicular volume and the strain ratio, while there is no correlation between age and the elasticity score of testes. Conclusion Normal testicular tissues as studies by sonoelastography show strong correlation between the age and the testicular volume as well as the strain ratio. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to evaluate how the reference fat position influenced the calculation of the sonoelastographic strain ratio.Methods: Three hundred fifty-eight breast masses (256 benign lesions and 102 malignant lesions) in 300 women (mean age 47.4 years; age range 17-82 years) who had been scheduled for a percutaneous needle biopsy or surgical excision were examined using B-mode ultrasonography and elastography. The sonoelastographic strain ratio was calculated twice per lesion; once by dividing the strain value of the fat near the mass by that of the mass (FLR 1) and once by dividing the strain value of the subcutaneous fat by that of the mass (FLR 2).Results: Most (91.9 %) showed a difference of less than 0.5 between FLR 1 and FLR 2 values. Regardless of the position of reference fat, there was no statistically significant difference between the FLR 1 and FLR 2 values (p value = 0.077 and 0.0825, respectively). According to the pathology of the lesion, a difference between FLR 1 and FLR 2 less than 0.5 occurred in 95.3 % of the benign lesions and 84 % of the malignant lesions (p < 0.001).Conclusions: The sonoelastographic strain ratio was not significantly affected by the position of reference fat. [ABSTRACT FROM AUTHOR]

Objectives: In this paper we describe sonoelastography findings for idiopathic granulomatous mastitis (IGM), the clinical and radiological features of which often mimic those of breast carcinoma. Materials and methods: In this retrospective study, sonoelastography findings for patients with pathologically proved IGM were studied. Twenty-seven patients with pathologically proved IGM were enrolled in the study. All were female, and the mean age was 37.81 years (standard deviation 7.10 years; range 24 to 56 years). Elasticity scores (ES), strain ratios (SR), and elastic diameters (ED) were evaluated for the lesions. Results: Ten lesions (37.0 %) were diffuse, six (22.2 %) were tubular, six (22.2 %) were a mass, and five (18.5 %) were cystic in appearance on ultrasonography. On sonoelastography, mean ES ± standard deviation was 1.66 ± 0.55 (between 1.00 and 3.00); mean SR ± standard deviation was 1.10 ± 0.79 (between 0.29 and 4.00). ED was no different between grey-scale and sonoelastogram images. Conclusions: The features of idiopathic granulomatous mastitis suggest it is benign in nature. [ABSTRACT FROM AUTHOR]

Objective: To compare the diagnostic performance of the fat-to-lesion strain ratio (FLR) and gland-to-lesion strain ratio (GLR) in the diagnosis of breast lesions. Methods: This was an institutional ethics committee approved prospective study. One hundred and ninety-three breast lesions in 193 women (mean age, 46.03 ± 13.60 years, range 18-82 years) were examined with conventional and elastographic US. Both the FLR and GLR of the lesions were calculated. The elasticity scores of the lesions were also evaluated using the five-point elasticity scoring system. For diagnostic performance, the sensitivity, specificity and receiver operating characteristic (ROC) analysis were obtained. Results: Seventy lesions were malignant and 123 were benign. Both the FLR and GLR of the lesions were significantly higher in malignant cases than in benign ones ( P < 0.001 for both). The Az values for the FLR (0.847) and the elasticity score (0.829) were significantly higher than that for the GLR (0.752) ( P = 0.009, P = 0.029, respectively). However, there was no significant difference in the Az value between the FLR and the elasticity score ( P = 0.443). Conclusion: The FLR yielded better diagnostic performance than GLR in breast lesions; the fatty tissue was better than glandular tissue as the reference normal tissue for calculating strain ratio in breast elastography. Key Points: • FLR was higher than GLR in both malignant and benign breast lesions. • Both FLR and GLR were higher in malignant than in benign breast lesions. • FLR yielded better diagnostic performance than GLR in breast lesions. [ABSTRACT FROM AUTHOR]

Objective: To assess the diagnostic value of elastosonography for thyroid microcarcinoma (TMC), particularly with regard to elasticity score (ES) and strain ratio (SR). Methods: Conventional ultrasound and elastosonography were performed for 487 thyroid micronodules before surgery. We set the histology as the reference standard. The ES and SR values, as well as their diagnostic threshold and efficiency, were compared and analyzed by the receiver-operating characteristic (ROC) curve. Additional comparisons between TMC patients with and without extracapsular extension were also performed. Results: Statistically significant differences (P<0.05) in both ES and SR values were detected among the TMC and benign groups. The area under the ROC curve of SR was significantly greater than that of ES (0.956 and 0.844, respectively; P<0.05). Using ES≥3 and SR≥3.65 as diagnostic threshold values, the diagnostic sensitivity, specificity, and accuracy of ES for differentiating benign and malignant nodules were 79.9%, 72.3%, and 80.5%, respectively, whereas those of SR were 86.6%, 85.3%, and 89.4%, respectively. The maximum diameter, microcalcification status, aspect ratio, bilateral cervical lymph node metastasis, and SR values of nodules with extracapsular extension (A1 subgroup) were greater than those of nodules without extracapsular extension (A2 subgroup). Conclusions: Elasticity imaging technology not only can help differentiate between benign and malignant thyroid micronodules but also allow SR values to provide accurate and objective information on tissue hardness and to predict TMC extracapsular extension or even bilateral cervical lymph node metastasis. [ABSTRACT FROM AUTHOR]

Background Real-time elastography (RTE) and elasticity scoring system is a new diagnostic tool in the evaluation of enlarged cervical lymph nodes (LNs). The aim of the study was to investigate the validity and reliability of two elasticity scoring systems in discriminating cervical lymphadenopathies. Materials and methods The study protocol was approved by the institutional review board of the local ethics committee. Ninety-eight consecutive patients underwent ultrasound-guided fine needle aspiration biopsy after conventional ultrasound and RTE evaluation. Elasticity scores were divided into four and five categories according to signal distribution, based on previously determined models. Two independent raters analyzed the elastographic data. Results Final histology revealed 60 benign and 38 malignant cervical LNs. In the four-point scoring system, 41/60 benign LNs were classified as score 1 or 2 and 28/38 malignant nodes as score 3 or 4 [sensitivity 73.7%, specificity 68.3%, positive predictive value (PPV) 59.6%, negative predictive value (NPV) 80.4%]. Using the five-point scoring system, 28/60 benign nodes were classified as score 1 or 2 and 31/38 malignant nodes as score 3–5 (sensitivity 79.0%, specificity 45.0%, PPV 47.6%, NPV 80.4%). In the four-point scoring system, rates of concordance between raters ( κ = 0.63) and with the same rater ( κ = 0.75) were both good with statistical significance (both p < 0.01). With the five-point scoring system, both kappa statistic tests between raters ( κ = 0.68) and with the same rater ( κ = 0.68) were also good with statistical significance (both p < 0.01). Conclusion For qualitative RTE, the four-point scoring system had value similar to the five-point scoring system in predicting malignancy in cervical LNs. Furthermore, the reliability was comparable in both scoring systems. For the purpose of simplified evaluation, we suggested using the four-point scoring system to rate the qualitative RTE in the future. [ABSTRACT FROM AUTHOR]

Objectives: To determine the efficacy of real-time elastography (RTE), compared with our previously proposed prediction model, in the detection of malignancy in cervical lymph nodes (LNs). Methods: One hundred and thirty-one patients underwent ultrasound-guided fine needle aspiration biopsy (ultrasound FNAB) after ultrasound and RTE evaluation. The formula of the RTE scoring system was a four-point visual scale, based on a previously determined model. The formula of the prediction model was: $$ 0.06\times \left( {\mathrm{age}} \right)+4.76\times \left( {{{{\mathrm{short}-\mathrm{axis}}} \left/ {{\mathrm{long}-\mathrm{axis}\;\mathrm{ratio}}} \right.}} \right)+2.15\times \left( {\mathrm{internal}\;\mathrm{echo}} \right)+1.80\times \left( {\mathrm{vascular}\;\mathrm{pattern}} \right) $$. An extended model was constructed with four previous predictors and elasticity scores, using a logistic regression model. Results: Final histology revealed 77 benign and 54 malignant LNs. In the elasticity score system, sensitivity was 66.7 %, specificity was 57.1 %, the positive predictive value (PPV) was 52.2 % and the negative predictive value (NPV) was 71.0 %. In the prediction model system, sensitivity was 79.6 %, specificity was 92.2 %, the PPV was 87.8 % and the NPV was 86.6 %. When the extended and the original model were compared, the areas under the receiver operating characteristic curve (c-statistic) was 0.94 and 0.95, respectively ( P > 0.05). Conclusions: Qualitative RTE offers no additional value over conventional ultrasound in predicting malignancy in cervical LNs. Key Points: • An ultrasound system can help in the assessment of cervical lymph nodes. • Grey-scale and power Doppler ultrasound remain fundamental for neck nodal evaluation. • Qualitative real-time elastography provided no additional value compared with current prediction models. [ABSTRACT FROM AUTHOR]

Abstract: Aim of the work: To detect the diagnostic performance of the combined use of sonoelastographic scoring and strain ratio in differentiation of benign and malignant breast masses with the histopathology is the standard reference. Patients and methods: One hundred and seventy-two women with 190 breast masses were enrolled in this prospective study. Conventional US (B-mode and color Doppler US) and sonoelastography (elasticity score “ES” and calculation of strain ratio “SR”) were performed. B-mode images were classified according to the Breast Imaging Recording and Data System. The hardness was determined with 5-point scoring method and SRs of the lesions were calculated. Receiver operating characteristic (ROC) curves were performed and the cutoff point for differentiation of benign and malignant masses was detected. Results: There was a significant difference (P =0.02) in the mean SRs between benign and malignant breast masses. The area under the curve (AUC) for combination of ES and SR (0.964) was higher than for ES alone (0.852) and B-mode US (0.823). A cutoff value of 3.6 for the SR allowed the best differentiation of benign and malignant breast lesions. Conclusion: The combined use of elasticity score and strain ratio of sonoelastography increased the diagnostic performance in distinguishing benign from malignant breast masses. [Copyright &y& Elsevier]

Introduction: Breast cancer is the most frequent cancer in women and the third most frequent cancer in the Romanian population. The diagnosis is based on three aspects: physical examination, imagistic investigations and histopathological examination. The mammary elastography is an echographic technique able to differentiate between normal and pathological tissue based on their elasticity; it can provide information about the hardness of the tissue. The method relies on the principle that most malignant tumours have an increased hardness. The purpose of the method is to improve the differential diagnosis between benign and malignant tumours, especially those classified as BI RADS 3. Material and method: In march 2019, we performed mammographies, echographies and elstographies (using the S1-S5 score) for a total of 20 patients aged 30 to 68. Furthermore, echo-guided mammary biopsies were performed for likely benign masses (BI RADS 3), malignancy- suspect masses (BI RADS 4) and highly malignancy-suspect masses (BI RADS 5). The sensibility of elastography in breast cancer diagnosis varies with the size of the lesion, the method which is chosen and the specialist's experience. Often, a special attention needs to be paid to administrative issues and to the on-going education and training of medical personnel. It is essential to have a standardized approach based on national healthcare programs and protocols when managing a patient with a mammary pathology. Conclusion: The elasticity score is important when evaluating a lesion, but it does not replace the histopathological examination. The mammary elastography is complementary to conventional echography and mammography. The method has its limits when examining breast implants, hematomas, scar tissue, lesions that are larger than the scanning area and especially dense breasts, while also having a lower sensibility for microcalcifications (which sometimes are an early sign of malignant tumours). [ABSTRACT FROM AUTHOR]

Objective: To investigate diagnostic value of ultrasonic elastic strain ratio and elasticity score for thyroid micronodules of TI-RADS 4. Method: In total, 211 consecutive patients with 225 thyroid micronodules were enroled in the study, all the nodules were evaluated by TI-RADS criteria before and all of them were examined by elastic imaging. We set the histology as the reference standard. The elastic strain ratio and elasticity score values, as well as their diagnostic threshold and efficiency, were compared and analyzed by the receiver operating characteristic(ROC) curve. Result: Statistically significant differences( P <0.05) in both elastic strain ratio and elasticity score values were detected among the thyroid microcarcinoma and benign groups. The area under the ROC curve of elastic strain ratio was significantly greater than that of elasticity score(0.935 and 0.825, respectively; P <0.05). Using elastic strain ratio ≥3.45 and elasticity score ≥3.00 as diagnostic threshold values, the diagnostic sensitivity, specificity, and accuracy of elastic strain ratio for differentiating benign and malignant nodules were 86.51%, 90.32%, and 87.56%, respectively, whereas those of elasticity score were 80.98%, 79.03% and 80.44%, respectively. Conclusion: Ultrasonic elastic strain ratio and elasticity score have very high diagnostic value for the thyroid micronodules of TI-RADS 4, and strain ratio has more advantages., Competing Interests: The authors of this article and the planning committee members and staff have no relevant financial relationships with commercial interests to disclose., (Copyright© by the Editorial Department of Journal of Clinical Otorhinolaryngology Head and Neck Surgery.)

Abstract: Purpose: To develop and evaluate a computer-assisted method of quantifying five-point elasticity scoring system based on ultrasound real-time elastography (RTE), for classifying benign and malignant breast lesions, with pathologic results as the reference standard. Materials and methods: Conventional ultrasonography (US) and RTE images of 145 breast lesions (67 malignant, 78 benign) were performed in this study. Each lesion was automatically contoured on the B-mode image by the level set method and mapped on the RTE image. The relative elasticity value of each pixel was reconstructed and classified into hard or soft by the fuzzy c-means clustering method. According to the hardness degree inside lesion and its surrounding tissue, the elasticity score of the RTE image was computed in an automatic way. Visual assessments of the radiologists were used for comparing the diagnostic performance. Histopathologic examination was used as the reference standard. The Student's t test and receiver operating characteristic (ROC) curve analysis were performed for statistical analysis. Results: Considering score 4 or higher as test positive for malignancy, the diagnostic accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were 93.8% (136/145), 92.5% (62/67), 94.9% (74/78), 93.9% (62/66), and 93.7% (74/79) for the computer-assisted scheme, and 89.7% (130/145), 85.1% (57/67), 93.6% (73/78), 92.0% (57/62), and 88.0% (73/83) for manual assessment. Area under ROC curve (A z value) for the proposed method was higher than the A z value for visual assessment (0.96 vs. 0.93). Conclusion: Computer-assisted quantification of classical five-point scoring system can significantly eliminate the interobserver variability and thereby improve the diagnostic confidence of classifying the breast lesions to avoid unnecessary biopsy. [Copyright &y& Elsevier]

Objectives: This study aimed to evaluate the clinical value of ultrasound elastography in the differential diagnosis of benign and malignant cervical lesions and to compare the accuracy of the elasticity score and strain ratio in differentiating cervical lesions., Methods: B-mode sonography and ultrasound elastography were performed on 84 cervical lesions (40 benign and 44 malignant) in 84 patients. All of the images were obtained transvaginally. The elasticity score was determined by a 5-point scoring method. Calculation of the strain ratio was based on a comparison of the average strain measured in the lesion with the adjacent tissue of the same depth, size, and shape. The findings were compared with histopathologic results. With the use of receiver operating characteristic curves, the diagnostic value of the elasticity score and strain ratio methods was determined., Results: The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of the elasticity score in the differential diagnosis of cervical lesions were 81.8%, 85.0%, 83.3%, 85.7%, and 81.0%, respectively, whereas those of the strain ratio were 90.9%, 90.0%, 90.5%, 90.9%, and 90.0%. A strain ratio cutoff value of 4.525 was used as a standard to distinguish benign from malignant lesions. The strain ratio values of malignant lesions were much higher than those of benign lesions (range, 4.85-8.91 versus 0.62-4.50). The differences were statistically significant (P < .01)., Conclusions: Ultrasound elastography is a promising technique that is easy and rapid to perform and can help identify cervical lesions that are likely to be malignant. It is obvious that the strain ratio yielded better results than the elasticity score. Both methods are semiquantitative, but quantification of the strain ratio is finer than that of the elasticity score.

Objectives: The clinical challenge of managing thyroid nodules nowadays is to diagnose the minority of malignant disease. Real-time ultrasound elastography, which can measure tissue elasticity, is used as a complement to conventional sonography for improving the diagnosis of thyroid tumors. There are 2 common criteria for evaluating an elastogram: the elasticity score and strain ratio. This meta-analysis was performed to expand on a previous meta-analysis to assess the diagnostic power of ultrasound elastography in differentiating benign and malignant thyroid nodules for elasticity score and strain ratio assessment., Methods: The MEDLINE, EMBASE, PubMed, and Cochrane Library databases up to January 31, 2013, were searched. The pooled sensitivity, specificity, and summary receiver operating characteristic curve were obtained from individual studies with a random-effects model. The extent and sources of heterogeneity were explored., Results: A total of 5481 nodules in 4468 patients for elasticity score studies and 1063 nodules in 983 patients for strain ratio studies were analyzed. The overall mean sensitivity and specificity of ultrasound elastography for differentiation of thyroid nodules were 0.79 (95% confidence interval [CI], 0.77-0.81) and 0.77 (95% CI, 0.76-0.79) for elasticity score assessment and 0.85 (95% CI, 0.81-0.89) and 0.80 (95% CI, 0.77-0.83) for strain ratio assessment, respectively. The areas under the curve for the elasticity score and strain ratio were 0.8941 and 0.9285., Conclusions: These results confirmed those obtained in the previous meta-analysis. Ultrasound elastography has high sensitivity and specificity for identification of thyroid nodules. It is a promising tool for reducing unnecessary fine-needle-aspiration biopsy.