Valor de la elastografía por patrones de colores en la reestadificación del cáncer de recto / Value of elastography by color patterns in the restaging of rectal cancer i: en

Introducción: La elastografía cualitativa por ecografía endoscópica es una técnica para examinar las propiedades elásticas de los tejidos, que puede distinguir la fibrosis del tumor mediante patrones de colores. Objetivo: Determinar el valor de la elastografía por patrones de colores en la reestadificación del cáncer de recto. Métodos: Se efectuó un estudio observacional y descriptivo (serie de casos) de 54 pacientes con cáncer de recto atendidos en el Centro Nacional de Cirugía de Mínimo Acceso, en La Habana, entre septiembre del 2018 y diciembre del 2022, a quienes se les realizó elastografía por ecografía endoscópica para la reevaluación del tumor. Para determinar el valor de dicha técnica se calculó la sensibilidad, la especificidad, los valores predictivos positivo y negativo, las razones de verosimilitud positiva y negativa, así como el índice de Youden. Se estableció la concordancia diagnóstica según el índice kappa y el estudio histológico de la muestra tomada fue el estándar de referencia. Resultados: La concordancia de la elastografía con el resultado anatomopatológico fue buena (κ=0,84). La especificidad y el índice de validez resultaron ser de 91,7 y 94,4 %, respectivamente; mientras que el valor predictivo negativo fue de 84,6 %. Los 16 pacientes con patrón elastográfico mixto (ye3) tenían tumor residual localizado en alguna de las capas de la pared del recto. El índice de Youden alcanzó valores cercanos a 1. Conclusiones: El valor de esta técnica radica en su especificidad diagnóstica y en el valor predictivo negativo al diferenciar la fibrosis del tumor residual en la pared rectal.

Introduction: The qualitative elastography by endoscopic echography is a technique to examine the elastic properties of tissues that can distinguish the fibrosis of the tumor by means of color patterns. Objective: To determine the value of elastography by color patterns in the reestadification of the rectum cancer. Methods: An observational and descriptive study (serial cases) of 54 patients with rectum cancer was carried out, who were assisted in the National Center of Minimum Access Surgery, in Havana, between September, 2018 and December, 2022 to whom elastography by endoscopic echography were carried out for the reevaluation of the tumor. To determine the value of this technique the sensibility, specificity, the predictive positive and negative values, the positive and negative true ratio, as well as the index of Youden were calculated. The diagnostic consistency was established according to the kappa index and the histologic study of the sample was the reference standard. Results: The elastography consistency with the pathologic result was good (ĸ=0.84). The specificity and the index of validity were 91.7 and 94.4%, respectively; while the negative predictive value was 84.6%. The 16 patients with mixed elastographic pattern (ye3) had residual tumor located in some of the layers of the rectum wall. The Youden index reached values close to 1. Conclusions: The value of this technique resides in its diagnostic specificity and negative predictive value when differentiating fibrosis from the residual tumor in the rectal wall.

Diagnostic value of ACR TI-RADS combined with three-dimensional shear wave elastography in ACR TI-RADS 4 and 5 thyroid nodules / 中华医学杂志(英文版)

BACKGROUND@#Three-dimensional shear wave elastography (3D-SWE) is a promising method in distinguishing benign and malignant thyroid nodules. By combining with conventional method, it may further improve the diagnostic value. The study aimed to assess the diagnostic value of American College of Radiology (ACR) thyroid imaging reporting and data system (TI-RADS) combined with 3D-SWE in ACR TI-RADS 4 and 5 thyroid nodules.@*METHODS@#All nodules were examined by conventional ultrasonography, ACR TI-RADS classification, and 3D-SWE examination. Conventional ultrasonography was used to observe the location, size, shape, margin, echogenicity, taller-than-wide sign, microcalcification, and blood flow of thyroid nodules, and then ACR TI-RADS classification was performed. The Young's modulus values (3D-C-Emax, 3D-C-Emean, and elastography standard deviation [3D-C-Esd]) were measured on the reconstructed coronal plane images. According to the receiver operating characteristic (ROC) curve, the best diagnostic efficiency among 3D-C-Emax, 3D-C-Emean, and 3D-C-Esd was selected and the cut-off threshold was calculated. According to the surgical pathology, they were divided into benign group and malignant group. And appropriate statistical methods such as t -test and Mann-Whitney U test were used to compare the difference between the two groups. On this basis, 3D-SWE combined with conventional ACR TI-RADS was reclassified as combined ACR TI-RADS to determine benign or malignant thyroid nodules.@*RESULTS@#Of the 112 thyroid nodules, 62 were malignant and 50 were benign. The optimal cut-off value of three-dimensional maximum Young's modulus in coronal plane (3D-C-Emax) was 51.5 kPa and the area under the curve (AUC) was 0.798. The AUC, sensitivity, specificity, and accuracy of conventional ACR TI-RADS were 0.828, 83.9%, 66.0%, and 75.9%, respectively. The AUC, sensitivity, specificity, and accuracy of combined ACR TI-RADS were 0.845, 90.3%, 66.0%, and 79.5%, respectively. The difference between the two AUC values was statistically significant.@*CONCLUSIONS@#Combined ACR TI-RADS has higher diagnostic efficiency than conventional ACR TI-RADS. The sensitivity and accuracy of combined ACR TI-RADS showed significant improvements. It can be used as an effective method in the diagnosis of thyroid nodules.

Transient elastography technology role assessment during the diagnosis and treatment of patients with chronic hepatitis B virus infection / 中华肝脏病杂志

Objective: To explore the role of transient elastography technology in the assessment of disease staging and treatment in patients with chronic hepatitis B virus (HBV) infection. Methods: Patients who were clinically diagnosed with chronic HBV infection at Beijing Tsinghua Changgung Hospital from January 2018 to December 2021 was collected. Liver stiffness measurement (LSM) examination was performed more than once by transient elastography. The count data were expressed as cases (%) and the χ (2) test was made. Fisher's exact test was used with theoretical frequency less than 5. The measurement data between two groups was compared by t-test. Multiple groups were compared with an analysis of variance. Results: 1 055 patients were included in this study, including 669 (63.4%) males and 386 (36.6%) females. 757 (71.8%) patients were untreated. Among the untreated patients, the LSM value in the immune clearance (10.2 ± 3.8) kPa (187 cases, 40.4%), and the reactivation stages (9.1 ± 3.4) kPa (114 cases, 24.6%) was significantly higher than that in the immune tolerance (8.7 ± 3.6) kPa (78 cases, 16.8%) and immune control stages (8.4 ± 3.5) KPa (84 cases, 18.1%), and the difference between the four groups was statistically significant (F = 5.31 and P = 0.03). With ALT (male: 30 U/L, female: 19 U/L) as defined the normal value, the LSM value in the immune tolerance and the immune control stages were (5.8 ± 0.9) kPa and (7.1 ± 2.5) kPa, respectively, which were significantly lower than those of patients in the immune tolerance and immune control stages, and the difference was statistically significant (P < 0.01). There were 294 (38.8%) patients with uncertain period, excluding patients with fatty liver. Patients with uncertain periods were divided into four gray zone (GZ) groups: immune tolerance stage: LSM (5.1 ± 1.3) kPa was significantly lower than GZ-A (6.5 ± 2.4) kPa, t = 2.06, P = 0.03, and the difference was statistically significant; immune control stage: LSM was (5.6 ± 1.5) kPa, which was also lower than GZ-C (6.8 ± 1.3) kPa, t = 3.08, P = 0.02, and the difference was statistically significant; immune clearance stage: LSM > 8.0 kPa. LSM values showed a year-by-year reduction in patients with expanded indications who started antiviral treatment and were followed up for three years. Conclusion: The LSM value is significantly lower after the decrease of the defined high-normal ALT value in patients with the immune tolerance and immune control stages of chronic HBV infection. The LSM values of GZ-A and GZ-C in the uncertain periods of chronic HBV infection are higher than those of patients in the immune tolerance and immune control stages.

Added value of shear-wave elastography in the prediction of extracapsular extension and seminal vesicle invasion before radical prostatectomy / 亚洲男科学杂志(英文版)

The purpose of this study was to analyze the value of transrectal shear-wave elastography (SWE) in combination with multivariable tools for predicting adverse pathological features before radical prostatectomy (RP). Preoperative clinicopathological variables, multiparametric magnetic resonance imaging (mp-MRI) manifestations, and the maximum elastic value of the prostate (Emax) on SWE were retrospectively collected. The accuracy of SWE for predicting adverse pathological features was evaluated based on postoperative pathology, and parameters with statistical significance were selected. The diagnostic performance of various models, including preoperative clinicopathological variables (model 1), preoperative clinicopathological variables + mp-MRI (model 2), and preoperative clinicopathological variables + mp-MRI + SWE (model 3), was evaluated with area under the receiver operator characteristic curve (AUC) analysis. Emax was significantly higher in prostate cancer with extracapsular extension (ECE) or seminal vesicle invasion (SVI) with both P < 0.001. The optimal cutoff Emax values for ECE and SVI were 60.45 kPa and 81.55 kPa, respectively. Inclusion of mp-MRI and SWE improved discrimination by clinical models for ECE (model 2 vs model 1, P = 0.031; model 3 vs model 1, P = 0.002; model 3 vs model 2, P = 0.018) and SVI (model 2 vs model 1, P = 0.147; model 3 vs model 1, P = 0.037; model 3 vs model 2, P = 0.134). SWE is valuable for identifying patients at high risk of adverse pathology.

Nuevos avances en cirugía hepática: evaluación y planificación preoperatoria (Parte 1) / New advances in liver surgery: evaluation and preoperative planning

Resumen Los avances en la cirugía hepática de los últimos años han permitido resecciones hepáticas más extensa y complejas para el tratamiento de diferentes patologías del hígado sin un aumento excesivo de la morbimortalidad perioperatoria. El desarrollo de diferentes técnicas, tecnologías y herramientas para la evaluación preoperatoria han mejorado la planificación quirúrgica con el uso por ejemplo de las tecnologías audiovisuales e impresión de modelos en 3 dimensiones (3D) de alta fidelidad. Otros avances, han permitido realizar una mejor evaluación funcional del parénquima hepático y una caracterización más precisa de las lesiones con el uso por ejemplo de verde de indocianina, cintigrafía hepática y resonancia magnética con contraste hepatoespecífico. Este artículo describe algunos de los nuevos avances en la evaluación y planificación preoperatoria en cirugía hepática.

Advances in liver surgery in recent years have made it possible to achieve more extensive and complex liver resections for the treatment of different liver diseases without an excessive increase in perioperative morbidity and mortality. The development of different techniques, technologies and tools for preoperative evaluation have improved surgical planning with the use, for example, of audiovisual technologies and printing of high-fidelity 3-dimensional (3D) models. Other advances have allowed a better functional evaluation of the liver parenchyma and a more precise characterization of the lesions with the use, for example of indocyanine green or liver scintigraphy and magnetic resonance with hepatospecific contrast. This article describes some of the new advances in preoperative evaluation and planning in liver surgery.

Polycystic Ovary Syndrome and Metabolic Syndrome: Clinical and Laboratory Findings and Non-Alcoholic Fatty Liver Disease Assessed by Elastography / Síndrome dos ovários policísticos e síndrome metabólica: Achados clínicos e laboratoriais e doença hepática gordurosa não alcoólica avaliada por elastografia

Abstract Objective To evaluate the association between polycystic ovary syndrome (PCOS) and metabolic syndrome (MetS), adding liver assessment through elastography and ultrasound, for correlation with non-alcoholic fatty liver disease (NAFLD). Metabolic syndrome occurs in~43% of women with PCOS, and NAFLD is the hepatic expression of MetS. Methods One hundred women, 50 with PCOS and 50 controls, matched by age (18- 35 years) and body mass index (BMI) were included, restricted to patients with overweight and obesity grade 1, at the Assis Chateaubrian Maternity School, Universidade Federal do Ceará, Brazil. For the diagnosis of PCOS, we adopted the Rotterdam criteria, and for the diagnosis of MetS, the criteria of the National Cholesterol Education Program (NCEP/ATP III). Hepatic elastography and ultrasound were performed to assess liver stiffness and echotexture, respectively. Results The average ages were 29.1 (±5.3) and 30.54 (±4.39) years, for the PCOS and the control group, respectively. Patients with PCOS had a risk 4 times higher of having MetS, odds ratio (95% confidence interval)=4.14, than those in the control group. Women with PCOS had higher average of abdominal circumference (100.9±9.08 cm vs 94.96±6.99 cm) and triglycerides (162±54.63 mg/dL vs 137.54±36.91mg/dL) and lower average of HDL cholesterol (45.66±6.88 mg/dL vs 49.78±7.05 mg/dL), with statistically significant difference. Hepatic steatosis was observed on ultrasound in women with PCOS; however, with no statistically significant difference. There was no change to NAFLD at elastography in any group. Conclusion Women with PCOS had 4-fold higher frequency of MetS andmore hepatic steatosis, with no statistically significant difference. There was no change in liver stiffness between the groups at elastography. The results can be extended only to populations of overweight and obesity grade 1, with PCOS or not. They cannot be generalized to other untested groups.

Resumo Objetivo Avaliar a associação entre a síndrome do ovário policístico (SOP) e a síndrome metabólica (SM), agregando avaliação do fígado por elastografia e ultrassonografia, para correlação com doença hepática gordurosa não alcoólica (DHGNA). A SM ocorre em cerca de 43% dasmulheres comSOP, e DHGNA é a expressão hepática da SM. Métodos Foramincluídas 100 mulheres, pareadas por idade (18-35 anos) e índice de massa corporal (IMC), 50 comSOP e 50 controles com sobrepeso e obesidade grau I, na Maternidade-Escola Assis Chateaubriand, Brasil. Para o diagnóstico de SOP, adotamos os critérios de Rotterdam e, para o diagnóstico de SM, os critérios do National Cholesterol Education Program (NCEP/ATP III). Elastografia hepática e ultrassonografia foram realizadas para avaliar a rigidez e a ecotextura do fígado, respectivamente. Resultados As médias de idade foram de 29,1 (±5,3) e 30,54 (±4,39) anos para os grupos SOP e controle, respectivamente. Pacientes com SOP apresentaram risco 4 vezes maior de SM do que aquelas no grupo controle [[razão de chances (intervalo de confiança de 95%) = 4,14]. Mulheres com SOP tiveram maior média de circunferência abdominal (100,9±9,08cm vs 94,96±6,99 cm) e triglicérides (162±54,63 mg/dL vs 137,54±36,91 mg/dL) e menor média de colesterol HDL (45,66±6,88 mg/dL vs 49,78±7,05mg/dL), com diferença estatisticamente significativa. Esteatose hepática foi observada em ultrassonografias de mulheres com SOP, porém sem diferença estatisticamente significativa. Não houve mudança para DHGNA na elastografia em nenhum dos grupos. Conclusão Mulheres com SOP tiveram frequência quatro vezes maior de SM e mais esteatose hepática, sem diferença estatisticamente significativa. Não houve mudança na rigidez do fígado entre os grupos na elastografia. Os resultados podem ser estendidos apenas a populações com sobrepeso e obesidade grau 1, com SOP ou não. Eles não podem ser generalizados para outros grupos não testados.

Applied research of ultrasound attenuation parameter in the diagnosis of metabolic dysfunction-associated fatty liver disease / 中华肝脏病杂志

Objective: To evaluate the efficacy, establish a diagnostic model, and value of ultrasound attenuation parameters (UAP) to diagnose hepatic steatosis in metabolic dysfunction-associated fatty liver disease (MAFLD) and its relevant disorders. Methods: 3770 cases were selected from the Health Examination Center of the Third Hospital of Hebei Medical University between October to December 2020. MAFLD diagnosis was based on the Asia-Pacific region MAFLD clinical diagnosis and treatment guidelines. The degree of hepatic steatosis was divided into mild, moderate and severe according to ultrasound imaging. UAP, clinical characteristic indexes, serum biochemical indexes, characteristics of hepatic steatosis and related factors were compared and analyzed in MAFLD patients and healthy controls. Logistic regression method was used to analyze the independent risk factors affecting the progression of hepatic steatosis in MAFLD to establish the diagnostic model. The clinical efficacy of UAP and the new model in diagnosing MAFLD was evaluated by the receiver operating characteristic curve (ROC). One-way ANOVA was used to compare means among multiple groups. Mann-Whitney U test was used to compare non-normally distributed measurement data between the two groups, and rank-sum test was used to compare multiple groups. χ2 test was used to compare count data between groups. Results: Among the 3 770 cases, 650 were MAFLD, with a prevalence rate of 17.24%, and the highest prevalence was 37.23% in the age group of 60-69. The prevalence rate was significantly higher in male than female (30.34% vs. 9.17%). Age-sex analysis showed that the prevalence rate in males aged 30-69 years was 38.26%, and that in females aged over 60 years was 31.94%. UAP was significantly higher in patients with MAFLD than healthy controls (278.55 dB/m vs. 220.90 dB/m, Z=-12.592, P＜0.001), and an increasing trend with increased degree of hepatic steatosis (mild:257.20 dB/m, moderate:286.20 dB/m, and severe: 315.00 dB/m) were observed. The cut-off values of UAP for the diagnosis of mild, moderate and severe hepatic steatosis were 243≤UAP＜258 dB/m, 258≤UAP＜293 dB/m, ≥293 dB/m in MAFLD. The sensitivity and specificity were 67.20%, 93.60%, 95.90%, and 82.10%, 72.00%, and 84.80%, respectively. UAP, alanine aminotransferase and fasting blood glucose were independent risk factors for the progression of hepatic steatosis in MAFLD. The combined MAFLD classification model (UAG model) was established. The AUC of mild, moderate and severe hepatic steatosis in MAFLD were 0.906, 0.907, and 0.946, respectively, and the sensitivity and specificity were 76.50%, 82.10%, 98.00%, and 90.80%, 83.30% and 76.10%, respectively. Conclusion: MAFLD is a common disease in the general population, with a higher incidence in male and elderly female over 30 years of age. UAP can be used as a new noninvasive diagnostic technique to evaluate hepatic steatosis in MAFLD. The UAG model has a good diagnostic efficacy on MAFLD and its relevant disorders, and thus can be used as a guide for evaluating clinical diagnosis and prognosis.

Study on the diagnostic value of transient elastography, APRI and FIB-4 for liver fibrosis in children with non-alcoholic fatty liver disease / 中华肝脏病杂志

Objective: To evaluate the diagnostic value of transient elastography, aspartate aminotransferase-to-platelet ratio index (APRI), and fibrosis index based on 4 factors (FIB-4) for liver fibrosis in children with non-alcoholic fatty liver disease (NAFLD). Methods: A retrospective study was conducted on 100 cases of nonalcoholic fatty liver disease in Hunan Children's Hospital between August 2015 to October 2020 to collect liver tissue pathological and clinical data. The receiver operating characteristic curve (ROC curve) was used to analyze the diagnostic value of liver stiffness measurement (LSM), APRI and FIB-4 in the diagnosis of different stages of liver fibrosis caused by NAFLD in children. Results: The area under the ROC curve (AUC) value of LSM, APRI and FIB-4 for diagnosing liver fibrosis (S≥1) were 0.701 [95% confidence interval (CI): 0.579 ~ 0.822, P = 0.011], 0.606 (95%CI: 0.436 ~ 0.775, P = 0.182), and 0.568 (95%CI: 0.397 ~ 0.740, P = 0.387), respectively. The best cut-off values were 6.65 kPa, 21.20, and 0.18, respectively. The AUCs value of LSM, APRI, and FIB-4 for diagnosing significant liver fibrosis (S≥ 2) were 0.660 (95% CI: 0.552 ~ 0.768, P = 0.006), 0.578 (95% CI: 0.464 ~ 0.691, P = 0.182) and 0.541 (95% CI: 0.427 ~ 0.655, P = 0.482), respectively. The best cut-off values were 7.35kpa, 24.78 and 0.22, respectively. The AUCs value of LSM, APRI and FIB-4 for the diagnosis of advanced liver fibrosis (S≥ 3) were 0.639 (95% CI: 0.446 ~ 0.832, P = 0.134), 0.613 (95% CI: 0.447 ~ 0.779, P = 0.223) and 0.587 (95% CI: 0.411 ~ 0.764, P = 0.346), respectively. The best cut-off values were 8.55kpa, 26.66 and 0.27, respectively. Conclusion: The transient elastography technique has a better diagnostic value than APRI and FIB-4 for liver fibrosis in children with NAFLD.

Experimental investigation of early assessment of corpora cavernosa fibrosis with two-dimensional shear wave elastography / 亚洲男科学杂志(英文版)

This study explored the usefulness of two-dimensional shear wave elastography (2D-SWE) in the early assessment of corpora cavernosa fibrosis (CCF). New Zealand male rabbits were randomly assigned to an experimental group or a control group. Recombinant human transforming growth factor beta 1 (TGF-β1) was injected into the dorsal penis tissue of rabbits in the experimental group. Conventional ultrasound and 2D-SWE examinations were performed before and 20 days after injection. Penile histological analysis was performed by hematoxylin-eosin staining, sirius red staining, and immunohistochemistry. Measurement of 2D-SWE examination results was performed using shear wave elastography quantitative measurement (SWQ). Histological analysis outcomes were the proportion of smooth muscle cells (SMCs), collagen fibers (CFs), collagen type I (Col I), and collagen type III (Col III), as well as the SMCs/CFs ratio, measured by sirius red staining. Other histological analysis outcomes were the positive area proportion (PAP) of TGF-β1 (PAPT), fibronectin (PAPF), and Col III (PAPC), measured by immunohistochemistry. After recombinant human TGF-β1 injection, SWQ was higher in the experimental group than that in the control group (P < 0.001); however, there were no differences in conventional ultrasound results. There were significant differences in histological outcomes between the two groups (all P < 0.05). These results indicated that 2D-SWE was superior for identifying early histological changes in CCF.

Non-invasive tests of non-alcoholic fatty liver disease / 中华医学杂志(英文版)

For the detection of steatosis, quantitative ultrasound imaging techniques have achieved great progress in past years. Magnetic resonance imaging proton density fat fraction is currently the most accurate test to detect hepatic steatosis. Some blood biomarkers correlate with non-alcoholic steatohepatitis, but the accuracy is modest. Regarding liver fibrosis, liver stiffness measurement by transient elastography (TE) has high accuracy and is widely used across the world. Magnetic resonance elastography is marginally better than TE but is limited by its cost and availability. Several blood biomarkers of fibrosis have been used in clinical trials and hold promise for selecting patients for treatment and monitoring treatment response. This article reviews new developments in the non-invasive assessment of non-alcoholic fatty liver disease (NAFLD). Accumulating evidence suggests that various non-invasive tests can be used to diagnose NAFLD, assess its severity, and predict the prognosis. Further studies are needed to determine the role of the tests as monitoring tools. We cannot overemphasize the importance of context in selecting appropriate tests.

Acoustic radiation force impulse elastography and liver fibrosis risk scores in severe obesity

ABSTRACT Objective: Identifying significant fibrosis is crucial to evaluate the prognosis and therapeutic interventions in patients with nonalcoholic fatty liver disease (NAFLD). We assessed the performance of acoustic radiation force impulse (ARFI) elastography, APRI, FIB-4, Forns, NFS and BARD scores in determining liver fibrosis in severe obesity. Subjects and methods: A prospective study included 108 patients undergoing bariatric surgery. Liver biopsy specimens were obtained intraoperatively and classified according to the NAFLD Activity Score. Patients were assessed with serological markers and shear wave velocity of the liver was measured with the Siemens S2000 ultrasound system preoperatively. Optimal cut-off values were determined using the area under the receiver operating characteristic curves (AUROC). Results: In the entire cohort prevalence of NAFLD was 80.6%, steatohepatitis 25.9% and significant fibrosis 19.4%. The best tests for predicting significant fibrosis were FIB-4 and Forns scores (both AUROC 0.78), followed by APRI (AUROC 0.74), NFS (AUROC 0.68), BARD (AUROC 0.64) and ARFI (AUROC 0.62). ARFI elastography was successful in 73% of the patients. Higher body mass index (BMI) correlated with invalid ARFI measurements. In patients with BMI < 42 kg/m2, ARFI showed 92.3% sensitivity and 82,6% specificity for the presence of significant fibrosis, with AUROC 0.86 and cut-off 1.32 m/s. Conclusions: FIB-4 and Forns scores were the most accurate for the prediction of significant fibrosis in bariatric patients. Applicability and accuracy of ARFI was limited in individuals with severe obesity. In patients with BMI < 42 kg/m2, ARFI elastography was capable for predicting significant fibrosis with relevant accuracy.

Utilidad de la elastografía cuantitativa por ultrasonografía endoscópica (USE) para el diagnóstico de las lesiones sólidas del páncreas (LSP) / Utility of quantitative elastography by Endoscopic Ultrasound (EUS) to diagnose solid pancreatic lesions (SPL)

Resumen Introducción: la punción con aguja fina guiada por ultrasonografía endoscópica (PAF-USE) permite un diagnóstico de las lesiones sólidas del páncreas (LSP) con una sensibilidad de alrededor del 85 % en la literatura mundial y aún más baja en nuestro medio, por lo cual se requiere explorar nuevos accesorios (agujas) o técnicas tales como la elastografía, que mejoren esta sensibilidad. Esta última permite la cuantificación de la rigidez del tejido con altos grados de precisión y desde 2001 se ha aplicado al diagnóstico de tumores sólidos de diversos órganos como mama y tiroides, músculo, entre otros; y desde 2006 se ha empleado para las LSP y ha demostrado su utilidad como complemento a las herramientas diagnósticas disponibles, ya que mejora la precisión de la biopsia por PAF-USE al seleccionar el área más sospechosa para ser puncionada y también guía el manejo clínico cuando la PAF-USE es negativa o no concluyente. Objetivo: evaluar el rendimiento diagnóstico de la elastografía cuantitativa de strain ratio (SR) obtenida por ecoendoscopia en las LSP teniendo como patrón de oro el diagnóstico citopatológico. Métodos: 71 pacientes (rango de edad: 35-89, media: 62,2 años); de estos, 35 mujeres fueron sometidas a USE para la evaluación de LSP. El diseño del estudio fue de corte transversal, prospectivo y de un solo centro. La USE se realizó con un ecoendoscopio Pentax lineal y un procesador Hitachi-Noblus. La lesión (área A) y un área de referencia B se seleccionaron para calcular la relación de deformación (B/A, SR expresada en %). Se tomó como punto de corte SR para definir las lesiones malignas (duras) SR > 22 teniendo en cuenta la evidencia actualmente disponible; estos resultados se compararon con la citopatología de las muestras obtenidas por punción guiada por USE. Después de la aplicación de criterios de exclusión, se realiza el análisis estadístico de 56 pacientes y se considera el valor p < 0,05. Se calculó la sensibilidad, especificidad, valor predictivo positivo (VPP), valor predictivo negativo (VPN) y precisión diagnóstica comparando la elastografía SR con los diagnósticos finales por citopatología. Resultados: la elastografía cuantitativa SR (%) permite detectar las LSP malignas con sensibilidad del 94,6 % (intervalo de confianza [IC] del 95 %: 85,4 %-98,2 %), especificidad del 89,3 % (IC 95 %: 78,5 %-95,0 %), VPP del 89,8 % (IC 95 %: 79,5 %-95,3 %); VPN del 94,3 % (IC 95 %: 84,6 %-98,1 %) y exactitud del 92,0 % (IC 95 %: 85,4 %-95,7 %). Conclusión: la elastografía cuantitativa SR por USE en LSP es un complemento útil que mejora la precisión de la PAF-USE al seleccionar el área más sospechosa para ser puncionada y guiar el manejo clínico cuando la PAF-USE es negativa o no concluyente, ya que tiene una alta sensibilidad y especificad en el diagnóstico de las LSP malignas.

Abstract Introduction: Endoscopic ultrasonography with fine-needle aspiration allows performing a diagnosis of solid pancreatic lesions with an approximate 85% sensitivity, as referenced in specialized literature, and even lower sensitivity as per local research. To yield better sensitivity and to improve the results, it is required to examine new elements (needles) and techniques like elastography. Elastography helps in the quantification of tissue stiffness with a high level of accuracy. Since 2001, elastography has been applied in diagnosing solid forms of cancer (tumors) that affect organs like breasts, the thyroid, and some muscles. This method which has been used to diagnose solid pancreatic lesions (SPL) since 2006 has proved to be useful as a complementary method to the existing diagnostic techniques. It improves the accuracy of the endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA) by selecting the more suspicious area to be punctured, and it also guides the clinical treatment after getting a negative EUS-FNA or a non-conclusive result. Objective: To evaluate the diagnostical performance of the strain ratio (SR) quantitative elastography by ecoendoscopy in solid pancreatic lesions, considering the cytopathologic diagnostic as the gold standard. Methods: 71 patients (age range: 35-89 years old, mean: 62.2 years old); out of those 71 patients, The EUS to diagnose SPL, was performed on 35 women. This was a single-center, prospective cross-sectional study design. The EUS was performed with a Pentax linear endoscope and a Hitachi-Noblus ultrasound. The lesion (area A) and a reference area B were selected to calculate the deformation ratio (B/A, SR expressed as a percentage). SR > 22 was selected as a cut-off point to determine the malignant lesions (solid lesions), considering the evidence currently available. The results were compared with their cytopathology interpretation once that the EUS was performed. After the exclusion criteria was applied, a statistical analysis of 56 patients was performed, considering p < 0,05. The sensitivity, the specificity, the positive predictive value (PPV), the negative predictive value (NPV) and the diagnostic accuracy, were calculated, comparing the elastography SR with the final diagnostics with the cytopathology interpretation. Results: Quantitative elastography SR (%) allows to detect the malignant SPL with sensitivity 94.6% (95% confidence interval [CI]: 85.4%-98.2%), specificity of 89.3% (CI 95%: 78,5 %-95,0 %), PPV of 89.8% (CI 95 %: 79,5 %-95,3 %); NPV of 94.3% (IC 95 %: 84,6 %-98,1 %) and an accuracy of 92.0% (CI 95 %: 85,4 %-95,7 %). Conclusion: SR quantitative elastography by Endoscopic Ultrasound, EUS is a suitable complement method that improves the EUS-FNA accuracy, by selecting the most suspicious area to be punctured, and it also guides clinical treatment after getting a negative EUS-FNA or a non-conclusive result, due to its high sensitivity and specificity levels to diagnose malignant SPL.

Elastografía cualitativa por ultrasonido endoscópico en la reestadificación del tumor de recto irradiado / Qualitative elastography by endoscopic ultrasound in the restaging of the irradiated rectal tumor

Introducción: En la reestadificación del paciente con tumor de recto irradiado, la elastografía cualitativa por ultrasonido endoscópico puede identificar la fibrosis y diferenciarla del tumor residual. Objetivo: Determinar la utilidad de la elastografía cualitativa por ultrasonido endoscópico en la reestadificación del tumor de recto irradiado. Métodos: Estudio observacional y descriptivo (serie de casos), en 31 pacientes con tumor de recto irradiado, reestadificados mediante elastografía cualitativa por ultrasonido endoscópico. Para determinar la utilidad de la elastografía se calcularon: sensibilidad, especificidad, valor predictivo positivo, valor predictivo negativo, índice de Youden y concordancia diagnóstica según índice kappa, de la elastografía y del ultrasonido endoscópico por separado, estos resultados fueron comparados en ambas pruebas diagnósticas. El estudio histológico de la pieza quirúrgica fue el estándar de referencia. Resultados: El índice de concordancia del ultrasonido endoscópico (77,4 por ciento), por elastografía (87,1 por ciento). El ultrasonido endoscópico mostró mayor sensibilidad y valor predictivo negativo que la elastografía, por lo que la posibilidad de descartar presencia de tumor con un resultado negativo fue superior. La elastografía tuvo mayor especificidad (77,78 por ciento) y valor predictivo positivo (90,91 por ciento) que el ultrasonido endoscópico (22,22 y 75,86 por ciento); fue más útil para confirmar el diagnóstico de tumor. Conclusiones: La utilidad de la elastografía cualitativa asociada al ultrasonido endoscópico, en la reestadificación del tumor de recto irradiado, consiste en incrementar la especificidad del estudio y discernir mejor entre la fibrosis y el tumor residual(AU)

Introduction: Qualitative endoscopic ultrasound elastography can identify fibrosis and differentiate it from residual tumor in the re-staging of patients with irradiated rectal tumors. Objective: To determine the usefulness of qualitative endoscopic ultrasound elastography in the re-staging of the irradiated rectal tumor. Methods: An observational and descriptive study (series of cases) was carried out in 31 patients with irradiated rectal tumor, restaged by means of Qualitative elastography by endoscopic ultrasound. To determine the usefulness of elastography, the following were calculated: sensitivity, specificity, positive predictive value, negative predictive value, Youden index and diagnostic agreement according to kappa, elastography and endoscopic ultrasound separately; these results were compared in both diagnostic tests. The histological study of the surgical specimen was the reference standard. Results: The concordance index of endoscopic ultrasound (77.4 percent), that obtained by elastography (87.1 percent). Endoscopic ultrasound showed greater sensitivity and negative predictive value than elastography, so the possibility of ruling out the presence of a tumor with a negative result was higher. Elastography had greater specificity (77.78 percent) and positive predictive value (90.91 percent) than endoscopic ultrasound (22.22 and 75.86 percent); it was most helpful in confirming the tumor diagnosis. Conclusions: The usefulness of qualitative elastography associated with endoscopic ultrasound, in the re-staging of the irradiated rectal tumor, consists in increasing the specificity of the study, thus allowing a better discernment between fibrosis and residual tumor(AU)

Evaluación de la fibrogénesis hepática en pacientes con esteatohepatitis no alcohólica tratados con propóleos rojo oral cubano / Evaluation of hepatic fibrogenesis in patients with nonalcoholic steatohepatitis treated with cuban oral red propolis

Introducción: La enfermedad por depósito graso no alcohólica constituye una pandemia del mundo contemporáneo. Su espectro silente atraviesa estadios de cronicidad y puede llegar a la cirrosis hepática y sobre esta pudiera desarrollarse un hepatocarcinoma. No existen tratamientos y solo se puede actuar sobre los factores de riesgo. Objetivo: Evaluar el efecto citohepatoprotector y antifibrótico del propóleos rojo cubano oral en pacientes con esteatohepatitis no alcohólica. Métodos: Se realizó un estudio longitudinal prospectivo en pacientes seleccionados de las consultas de Gastroenterología, Endocrinología y Medicina Interna del Hospital Clínico Quirúrgico Hermanos Ameijeiras durante el periodo de abril 2017 a abril 2018. El universo de estudio fue de 120 pacientes con diagnóstico imagenológico de hígado graso. La muestra quedó conformada por 70 pacientes con diagnóstico de hígado graso, y que cumplieron criterios de inclusión y exclusión. Las pruebas estadísticas aplicadas fueron análisis de frecuencia y porcentaje para las variables demográficas. La prueba T para las muestras relacionadas evaluó el comportamiento enzimático al inicio y al final del tratamiento y los cambios elastográficos fueron analizados mediante test de Kappa y porcentaje. Resultados: Las variables bioquímicas estudiadas mostraron una disminución estadísticamente significativa al final del tratamiento. Los cambios elastográficos al final del estudio evidenciaron la efectividad del tratamiento, en el cual el 91,4 por ciento de los pacientes evolucionaron hacia el menor grado de fibrosis. Conclusiones: El propóleos rojo cubano demostró ser un apifármaco con acción citohepatoprotectora y antifibrótica de valor terapéutico(AU)

Introduction: Nonalcoholic fat deposition disease is a pandemic in the contemporary world. Its silent spectrum goes through stages of chronicity and it can reach liver cirrhosis and on this a hepatic carcinoma could develop. There are no treatments and medical handling can act on only risk factors. Objective: To evaluate cytohepatoprotective and antifibrotic effect of oral Cuban red propolis in patients with nonalcoholic steatohepatitis. Methods: A prospective longitudinal study was carried out in selected patients from the Gastroenterology, Endocrinology and Internal Medicine consultations at Hermanos Ameijeiras Clinical Surgical Hospital from April 2017 to April 2018. The study universe was 120 patients with imaging diagnosis of fatty liver. The sample consisted of 70 patients with fatty liver diagnosis, who met the inclusion and exclusion criteria. Frequency and percentage analysis for the demographic variables were the statistical tests applied. The T test for the related samples evaluated the enzymatic behavior at the beginning and at the end of the treatment and the elastography changes were analyzed using Kappa and percentage tests. Results: The biochemical variables studied showed statistically significant decrease at the end of the treatment, which evidenced the effectiveness of the treatment. 91.4 percent of the patients progressed to a lower degree of fibrosis. Conclusions: Cuban red propolis proved to be a therapeutic drug with cytohepathoprotective and antifibrotic action(AU)

Automated breast volume scanning combined with shear wave elastography for diagnosis of triple-negative breast cancer and human epidermal growth factor receptor 2-positive breast cancer

SUMMARY OBJECTIVE To explore the values of automated breast volume scanning (ABVS) combined with shear wave elastography (SWE) in the differential diagnosis of triple-negative breast cancer (TNBC) and human epidermal growth factor receptor 2-positive breast cancers (HER2+BC). METHODS In this study, 28 patients with TNBC and 32 patients with HER2+BC were enrolled. The characteristics of ABVS and virtual touch quantification (VTQ) in SWE of all patients were reviewed. The multivariate logistic regression analysis was carried out and the receiver operating characteristic curves of ABVS and ABVS+VTQ were drawn. RESULTS In ABVS imaging, the microcalcification, posterior echo, internal echo, shape, and edge had significant difference between TNBC and HER2+BC groups (p<0.05). The regular shape was the independent factor for TNBC (p=0.04, odds ratio [OR]=4.479), and the microcalcification in mass was the independent factor for HER2+BC (p=0.01, OR=2.997). In VTQ imaging, the shear wave velocity (SWV)max, SWVmin, and SWVmean in TNBC group were significantly lower than those in HER2+BC group (p<0.001). The sensitivity, specificity, and accuracy of ABVS+VTQ in diagnosing TNBC were higher than those of ABVS alone. CONCLUSIONS ABVS combined with SWE has certain advantages in differentiating TNBC from HER2+BC, which is helpful for the treatment planning and prognosis judgment.

Can the unnecessary operations for suspected thyroid nodules be avoided by the combined use of the strain ratio and elastography score? / As cirurgias desnecessárias para nódulos tireoidianos suspeitos podem ser evitadas pelo uso combinado da razão de compressão e do escore da elastografia?

Abstract Introduction Only 5%-15% of thyroid surgical specimens are reported as malignant. Most of the operations are performed due to suspicion of malignancy as a result of fine needle aspiration biopsy but invasiveness, non-diagnostic results and potential repeat biopsies are disadvantages of fine needle aspiration biopsy. Objective The aim of this study was to investigate the effectiveness of simultaneously using both the strain ratio and elasticity score in the differential diagnosis of thyroid nodules, as well as to assess the compatibility of these two methods. Methods A total of 144 nodules were included in the study. The final histopathologic diagnosis was used as the reference standard. The area under the curve sensitivity, specificity, and cut-off values of the strain ratio and elasticity score were determined using receiver operating characteristic curve analysis. The compatibility and comparison of strain ratio and elasticity score were also performed. Results Twenty eight nodules (19.4%) were malignant. The strain ratio and elasticity score results were found to be significantly successful in predicting thyroid malignancy (p < 0.001 for both). Moreover, the area under the curve for the strain ratio and elasticity score were found to be 0.944 and 0.960, respectively. The diagnostic accuracy of the elasticity score was found to be superior to that of the strain ratio, but this difference was not statistically significant (p = 0.456). When the compatibility of the strain ratio and elasticity score was examined, the two evaluations were revealed to be statistically consistent with each other (Kappa = 0.767; p < 0.001). When the strain ratio and the elasticity score were used together, the specificity of capturing the correct diagnosis increased from 84.5% to 93.1%. Conclusion When the strain ratio an elasticity score were used together for the differential diagnosis of thyroid nodules, more accurate results were obtained. Thus, combining both methods may be a promising alternative to fine needle aspiration biopsy in order to prevent unnecessary surgical interventions for suspected thyroid nodules.

Resumo Introdução Apenas 5% a 15% das amostras cirúrgicas de tireoide são relatadas como malignas. A maioria das cirurgias é feita devido à suspeita de lesão maligna como resultado da biópsia por punção aspirativa com agulha fina. Entretanto, invasividade, resultados não diagnósticos e biópsias repetidas são desvantagens desse procedimento. Objetivo Investigar a eficácia do uso simultâneo da razão de compressão e do escore de elasticidade no diagnóstico diferencial de nódulos tireoidianos, bem como avaliar a compatibilidade desses dois métodos. Método Foram incluídos no estudo 144 nódulos. O diagnóstico histopatológico final foi usado como padrão de referência. A área sob a curva sensibilidade, especificidade e valores de corte da razão de compressão e do escore de elasticidade foram determinados com a análise da curva Receiver Operating Characteristic. A compatibilidade e comparação da razão de compressão e do escore de elasticidade também foram feitas. Resultados Eram malignos 28 nódulos (19,4%). Os resultados da razão de compressão e do escore de elasticidade foram significantemente bem-sucedidos em prever a lesão maligna de nódulos da tireoide (p < 0,001 para ambos). Além disso, as áreas sob a curva para a razão de compressão e o escore de elasticidade foram de 0,944 e 0,960, respectivamente. A acurácia diagnóstica escore de elasticidade foi superior à da razão de compressão, mas essa diferença não foi estatisticamente significante (p = 0,456). Quando a compatibilidade da razão de compressão e do escore de elasticidade foi examinada, as duas avaliações mostraram-se estatisticamente consistentes (Kappa = 0,767; p < 0,001). Quando a razão de compressão e o escore de elasticidade foram usados em conjunto, a especificidade de captar o diagnóstico correto aumentou de 84,5% para 93,1%. Conclusão Quando a razão de compressão e o escore de elasticidade foram usados juntos para o diagnóstico diferencial de nódulos tireoidianos, resultados mais precisos foram obtidos. Assim, o uso combinado dos dois métodos pode ser uma opção promissora à biópsia por punção aspirativa com agulha fina e evitar intervenções cirúrgicas desnecessárias para nódulos tireoidianos suspeitos.

Elastografía en tiempo real (Supersonic), experiencia de un centro en Bogotá / Real-time elastography (Supersonic), experience of a medical center in Bogotá

Resumen Introducción: la elastografía en tiempo real, 2D-SWE (Supersonic), es una prueba no invasiva que se utiliza para determinar la elasticidad del hígado y, de esa forma, calcular el grado de fibrosis hepática. En Colombia, la prueba se introdujo en 2016 y no existen hasta el momento estudios del comportamiento de la prueba en todos los pacientes hepáticos, solo se han publicado en pacientes sanos y cirróticos. Objetivo: analizar la experiencia de la aplicación de la elastografía en tiempo real, en sujetos atendidos en el centro de enfermedades hepáticas y digestivas de Bogotá, Colombia. Materiales y métodos: estudio descriptivo retrospectivo de una cohorte de sujetos atendidos entre marzo de 2016 y julio de 2017. Se realizó una historia clínica completa y una prueba de elastografía en tiempo real (Supersonic). Resultados: se incluyeron 654 sujetos, con una mediana de edad de 55 años (rango intercuartílico [RIC]: 45-64). La mediana de valores de fibrosis expresada en kilopascales (kPs) fue de 8,3, con un promedio de 5 mediciones. Se observó una diferencia significativa en el grado de fibrosis entre los grupos de edad y en relación con el diagnóstico final, donde se evidenció una mayor fibrosis en el grupo de enfermedades colestásicas (autoinmune, colangitis biliar primaria [CBP] y superposición autoinmune-CBP). La tasa global de fracaso fue menor al 1%. Conclusiones: es la primera descripción del comportamiento de la prueba a nivel nacional. Los valores de rigidez hepática observados en los diferentes estadios demuestran la utilidad de la prueba para la determinación de la fibrosis hepática en pacientes con diferentes patologías.

Abstract Introduction: Real-time two-dimensional shear wave elastography (2D-SWE) (Supersonic Imagine SA), is a non-invasive test used to determine liver elasticity and calculate the degree of liver fibrosis. In Colombia, this test was introduced in 2016 and, to date, no study has tested its behavior in all liver patients, only in healthy and cirrhotic patients. Objective: To analyze the experience of real-time elastography implementation in subjects treated at the Centro de Enfermedades Hepáticas y Digestivas in Bogotá, Colombia. Materials and methods: This is a retrospective descriptive study of a cohort of subjects treated between March 2016 and July 2017. A complete medical report and a real-time elastography (Supersonic) test were performed. Results: 654 subjects were included, with a median age of 55 years (interquartile range [IQR]: 45-64). The median fibrosis values expressed in kilopascals (kPs) were 8.3, with an average of 5 measurements. There was a significant difference in the degree of fibrosis between the age groups and in relation to the final diagnosis, where there was a greater fibrosis in the cholestatic disease group (autoimmune, primary biliary cholangitis [PBC], and overlap). The overall failure rate was less than 1%. Conclusions: This is the first description of this test behavior in the country. Hepatic stiffness values observed in the different stages demonstrate the usefulness of the test to establish the degree of liver fibrosis in patients with multiple diseases.

Elastografía por ondas de corte como herramienta en la evaluación de los nódulos tiroideos / Shear-wave elastography as a tool in the assessment of thyroid nodules

Resumen Introducción: La elastografía por ondas de corte (SWE) ha demostrado ser predictiva de malignidad en nódulos tiroideos. Objetivo: Determinar mediante SWE, el punto de corte de la rigidez con mayor especificidad y sensibilidad para detectar nódulos tiroideos que requieren cirugía. Métodos: Estudio transversal de pacientes con nódulos tiroideos evaluados ultrasonográficamente en un periodo de tres años; se empleó la clasificación TI-RADS y mediante SWE se determinó la rigidez de los nódulos. Con el sistema Bethesda se clasificaron las muestras histopatológicas y mediante curva ROC se obtuvo el punto de corte de la rigidez con mayor especificidad y sensibilidad. Resultados: 41 % de los nódulos fue TI-RADS 5 y 59 %, TI-RADS 1-4. En los TI-RADS 5, la mediana de rigidez de los nódulos con categoría IV-VI del sistema Bethesda fue de 35.9 kPa y en los nódulos con TI-RADS 1-4, 21.6 kPa. En los nódulos TI-RADS 5, la rigidez > 32.5 kPa tuvo especificidad de 75 % y sensibilidad de 57 % para detectar los que requieren cirugía; en los TI-RADS 1-4, el valor de corte de 21.5 kPa tuvo especificidad de 63 % y sensibilidad de 51 %. Conclusión: La rigidez determinada por SWE es útil para detectar nódulos que requerirán exploración quirúrgica.

Abstract Introduction: Shear-wave elastography (SWE) has been shown to be predictive of malignancy in thyroid nodules. Objective: To determine, by SWE, the stiffness cutoff point with the highest specificity and sensitivity to detect thyroid nodules that require surgery. Methods: Cross-sectional study of ultrasonographically-evaluated patients for thyroid nodules over a period of three years; the TI-RADS classification system was used, and nodule stiffness was determined by SWE. Histopathological specimens were classified using the Bethesda system, and the stiffness cutoff point with the highest specificity and sensitivity was obtained using ROC curves. Results: Forty-one percent of the nodules were classified as TI-RADS 5, and 59 %, as TI-RADS 1-4. In TI-RADS 5 nodules, median stiffness of those in Bethesda system IV-VI categories was 35.9 kPa; in nodules with TI-RADS 1-4, 21.6 kPa. In TI-RADS 5 nodules, a cutoff point > 32.5 kPa had a specificity of 75 % and sensitivity of 57 % to detect those requiring surgery; in TI-RADS 1 to 4 nodules, a cutoff point of 21.5 kPa had a specificity of 63 % and sensitivity of 51 %. Conclusion: SWE-determined stiffness is useful to detect nodules that require surgical evaluation.