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.

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.

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)

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.

Diagnostic and Prognostic Role of Liver Elastography in Heart Failure

Abstract Background: Hepatic congestion is a frequent finding in patients with heart failure (HF). Physical examination has limitations in quantifying systemic congestion and requires correlation with echocardiographic and laboratory data (usually B-type natriuretic peptide, BNP, or N-terminal pro-B type natriuretic peptide, NT-proBNP). Hepatic elastography evaluates liver stiffness using a transducer that transmits low-frequency vibrations (50 Hz), and the speed of shear waves propagating through the tissues is measured by ultrasound. The faster the vibrations propagate in the hepatic parenchyma, the stiffer the liver, which, in case of HF, can be correlated with hepatic congestion. Objective: In this systematic review, case-controls, cohort studies, and randomized clinical trials were searched in MEDLINE, LILACS and Cochrane Database of Systematic Review, to evaluate the use of elastography in the detection of hepatic congestion in patients with HF. Methods: From the 49 articles retrieved, seven were selected for review, according to the inclusion and exclusion criteria. The most used methods for the diagnosis and evaluation of HF were echocardiography combined with BNP and NT-proBNP measurements. Results: Elastography performed at bedside was able to establish a significant correlation between increased liver stiffness and increased venous capillary pressure. In addition, liver elastography performed at hospital discharge was able to predict rehospitalization and mortality. Conclusion: Liver elastography is a non-invasive method that can be useful in predicting prognosis and mortality of individuals with HF, contributing to the clinical management of these patients.

Effect of the location and size of thyroid nodules on the diagnostic performance of ultrasound elastography: A retrospective analysis

OBJECTIVES: Ultrasound-guided fine-needle aspiration biopsies are recommended for the detection of suspicious thyroid nodules. However, the best approach regarding suspicious ultrasound features for thyroid nodules is still unclear. This study aimed to evaluate the effect of location and size of thyroid nodules on the diagnostic performance of strain ultrasound elastography. In addition, this study evaluated whether ultrasound elastography predicts malignancy in thyroid nodules. METHODS: Data regarding the size, depth, and distance from the carotid artery of nodules, the elasticity contrast index, and the nature of nodules were analyzed. RESULTS: There was no significant difference in the depth (p=0.092) and the distance from the carotid artery (p=0.061) between benign and suspicious nodules. Suspicious nodules were smaller than benign nodules (p<0.0001, q=23.84) and had a higher elasticity contrast index (p<0.0001, q=21.05). The depth of nodules and the size of the nodule were not associated with the correct value of the elasticity contrast index (p>0.05 for both). The diagnostic performance of ultrasound elastography was not affected by the distance of the nodules from the carotid artery if they were located ≥15 mm from the carotid artery (p=0.5960). However, if the suspicious nodules were located <15 mm from the carotid artery, the diagnostic accuracy was hampered (p=0.006). CONCLUSIONS: The strain ultrasound elastography should be carefully evaluated when small thyroid nodules are located near the carotid artery.

Use of strain ultrasound elastography versus fine-needle aspiration cytology for the differential diagnosis of thyroid nodules: a retrospective analysis

OBJECTIVE: Fine-needle aspiration cytology is the risk stratification tool for thyroid nodules, and ultrasound elastography is not routinely used for the differential diagnosis of thyroid cancer. The current study aimed to compare the diagnostic parameters of ultrasound elastography and fine-needle aspiration cytology, using surgical pathology as the reference standard. METHODS: In total, 205 patients with abnormal thyroid function test results underwent ultrasound-guided fine-needle aspiration cytology on the basis of the American College of Radiology Thyroid Imaging-Reporting and Data System classification and strain ultrasound elastography according to the ASTERIA criteria. Histopathological examination of the surgical specimens was performed according to the 2017 World Health Organization classification system. Moreover, a beneficial score analysis for each modality was conducted. RESULTS: Of 265 nodules, 212 measured ≥1 cm. The strain index value increased from benign to malignant nodules, and the presence of autoimmune thyroid diseases did not affect the results (p>0.05 for all categories). The sensitivities of histopathological examination, ultrasound elastography, and fine-needle aspiration cytology for detection of nodules measuring ≥1 cm were 1, 1, and 0.97, respectively. The working area for detecting nodule(s) in a single image was similar between strain ultrasound elastography and fine-needle aspiration cytology for highly and moderately suspicious nodules. However, for mildly suspicious, unsuspicious, and benign nodules, the working area for detecting nodule(s) in a single image was higher in strain ultrasound elastography than in fine-needle aspiration cytology. CONCLUSION: Strain ultrasound elastography for highly and moderately suspicious nodules facilitated the detection of mildly suspicious, unsuspicious, and benign nodules.

Application of acoustic radiation force impulse elastography combined with serum markers in Child-Pugh grading

OBJECTIVES: Acoustic radiation force impulse (ARFI) elastography, the aspartate aminotransferase-to-alanine aminotransferase ratio (AAR), aspartate aminotransferase-to-platelet ratio index (APRI), and the fibrosis-4 (FIB-4) index are widely used to assess liver fibrosis. However, efficacies of these methods in the evaluation of hepatic functional reserve remain unclear. In this study, we investigated the relationship between ARFI elastography combined with either AAR, APRI, or FIB-4 index and Child-Pugh (CP) class for the evaluation of hepatic functional reserve in patients with chronic hepatitis B (CHB)-related cirrhosis. METHODS: The shear wave velocities of 104 patients with clinically confirmed CHB-related cirrhosis were determined using the ARFI; and clinical serum markers (e.g. ALT, AST, PLT) were used to calculate the AAR, APRI, and FIB-4 index. Cirrhosis patients were scored according to their CP class. The ARFI, AAR, APRI, and FIB-4 index were compared with the CP class. The efficacy of each indicator in diagnosis was analyzed using the receiver operating characteristic (ROC) curve and the ARFI combined with either the AAR, APRI, or FIB-4 index, which is used to predict decompensated cirrhosis. RESULTS: No significant differences were observed in gender and age among CP classes A, B, and C patients (p>0.05). The ARFI values and the AAR, APRI, and FIB-4 index of patients with CP classes A, B, and C were significantly different (p<0.05). With an increasing CP class, the ARFI, AAR, APRI, and FIB-4 values increased. The correlation between the ARFI and the CP class was stronger than that between the AAR, APRI, and FIB-4 index and the CP class. The area under the ROC curve for the diagnosis of decompensated cirrhosis using the ARFI was 0.841, which was higher than that for the AAR, APRI, and FIB-4 index. According to the area under the curve results, no significant differences were found when the ARFI was combined with either the AAR, APRI, or FIB-4 index and when the ARFI alone was used. CONCLUSIONS: The ARFI value has a strong correlation with the CP class. Therefore, ARFI elastography complements CP class in the assessment of the hepatic functional reserve in patients with CHB-related cirrhosis.

Could semiquantitative analysis of real-time ultrasound elastography distinguish more liver parenchyma alterations of nonalcoholic fatty liver disease in patients with polycystic ovary syndrome?

ABSTRACT Objective: Nonalcoholic fatty liver disease is the commonest diffuse liver disease, of which women with polycystic ovary syndrome are at an increased risk. The aim of the present study was to assess the diagnostic value of the semiquantitative strain parameters of real-time ultrasound elastography for nonalcoholic fatty liver disease in patients with polycystic ovary syndrome. Subjects and methods: Thirty-five polycystic ovary syndrome patients with nonalcoholic fatty liver disease, 70 polycystic ovary syndrome patients without nonalcoholic fatty liver disease, and 70 healthy female controls of reproductive age were included. All participants underwent ultrasonic examination and semiquantitative analysis of real-time ultrasound elastography of the liver. Results: Main semi quantitative strain parameters, such as average strain value, differed significantly among groups polycystic ovary syndrome with nonalcoholic fatty liver disease, polycystic ovary syndrome without nonalcoholic fatty liver disease, and control (87.02 ± 10.16 vs. 96.31 ± 11.44 vs. 104.49 ± 7.28, p < 0.001). Clinical and laboratory parameters differed significantly between the two subgroups with low or high average strain value. For diagnostic value of average strain value for elevated aminotransferase, the area under the curve was 0.808 (range 0.721-0.895). In multiple linear regression analysis, polycystic ovary syndrome, waist circumference, and metabolic syndrome were stand-alone independent factors associated with average strain value among subjects without nonalcoholic fatty liver disease. Conclusion: Semiquantitative real-time ultrasound elastography analysis could distinguish liver parenchyma alterations in patients with polycystic ovary syndrome more sensitively. The diagnostic value of the proposed method for nonalcoholic fatty liver disease need further research.

Elastografía hepática y otras secuencias avanzadas de RM (RM multiparamétrica) / Hepatic Elastography and Other Advanced MRI Sequences (Multiparametric MRI)

La fibrosis es un destino donde convergen variados trastornos hepáticos. Al tratarse de un proceso dinámico y reversible, su detección temprana y una intervención terapéutica oportuna, pueden frenar su progresión. La elastografía por resonancia magnética (ERM), es un método no invasivo con notable eficacia para la valoración del grado de fibrosis hepática. La tendencia actual es combinar esa técnica con secuencias de cuantificación de lípidos y hierro, lo cual permite un abordaje multiparamétrico de los trastornos difusos del hígado.

Fibrosis is a common destination where multiple liver disorders converge. Due to its dynamic and reversible process, an early detection and timely therapeutic intervention can interrupt its progression. Magnetic Resonance Elastography (MRE) is a non-invasive method with remarkable efficacy for assessing the degree of liver fibrosis. The current trend is to combine this technique with lipid and iron quantification sequences, which allows a multiparametric approach to diffuse liver disorders.

Accuracy of transient elastography-FibroScan®, acoustic radiation force impulse (ARFI) imaging, the enhanced liver fibrosis (ELF) test, APRI, and the FIB-4 index compared with liver biopsy in patients with chronic hepatitis C

OBJECTIVES: Although liver biopsy is the gold standard for determining the degree of liver fibrosis, issues regarding its invasiveness and the small amount of liver tissue evaluated can limit its applicability and interpretation in clinical practice. Non-invasive evaluation methods for liver fibrosis can address some of these limitations. The aim of this study was to evaluate the accuracy of transient elastography-FibroScan®, acoustic radiation force impulse (ARFI), enhanced liver fibrosis (ELF), the aspartate aminotransferase-to-platelet ratio index (APRI), and the FIB-4 index compared with liver biopsy in hepatitis C. METHODS: We evaluated chronic hepatitis C patients who were followed at the Division of Clinical Gastroenterology and Hepatology, Hospital das Clínicas, Department of Gastroenterology of University of São Paulo School of Medicine, São Paulo, Brazil, and who underwent liver biopsy. The accuracy of each method was determined by a receiver operating characteristic (ROC) curve analysis, and fibrosis was classified as significant fibrosis (≥F2), advanced fibrosis (≥F3), or cirrhosis (F4). The Obuchowski method was also used to determine the diagnostic accuracy of each method at the various stages of fibrosis. In total, 107 FibroScan®, 51 ARFI, 68 ELF, 106 APRI, and 106 FIB-4 analyses were performed. RESULTS: A total of 107 patients were included in the study. The areas under the ROC curve (AUROCs) according to fibrosis degree were as follows: significant fibrosis (≥F2): FibroScan®: 0.83, FIB-4: 0.76, ELF: 0.70, APRI: 0.69, and ARFI: 0.67; advanced fibrosis (≥F3): FibroScan®: 0.85, ELF: 0.82, FIB-4: 0.77, ARFI: 0.74, and APRI: 0.71; and cirrhosis (F4): APRI: 1, FIB-4: 1, FibroScan®: 0.99, ARFI: 0.96, and ELF: 0.94. The accuracies of transient elastography, ARFI, ELF, APRI and FIB-4 determined by the Obuchowski method were F0-F1: 0.81, 0.78, 0.44, 0.72 and 0.67, respectively; F1-F2: 0.73, 0.53, 0.62, 0.60, and 0.68, respectively; F2-F3: 0.70, 0.64, 0.77, 0.60, and 0.67, respectively; and F3-F4: 0.98, 0.96, 0.82, 1, and 1, respectively. CONCLUSION: Transient elastography remained the most effective method for evaluating all degrees of fibrosis. The accuracy of all methodologies was best at F4.

Transient Elastography vs Aspartate Aminotransferase to Platelet Ratio Index in Hepatitis C: A Meta-Analysis

ABSTRACT Background and rationale. Many different non-invasive methods have been studied with the purpose of staging liver fibrosis. The objective of this study was verifying if transient elastography is superior to aspartate aminotransferase to platelet ratio index for staging fibrosis in patients with chronic hepatitis C. Material and methods. A systematic review with meta-analysis of studies which evaluated both non-invasive tests and used biopsy as the reference standard was performed. A random-effects model was used, anticipating heterogeneity among studies. Diagnostic odds ratio was the main effect measure, and summary receiver operating characteristic curves were created. A sensitivity analysis was planned, in which the meta-analysis would be repeated excluding each study at a time. Results. Eight studies were included in the meta-analysis. Regarding the prediction of significant fibrosis, transient elastography and aspartate aminotransferase to platelet ratio index had diagnostic odds ratios of 11.70 (95% confidence interval = 7.13-19.21) and 8.56 (95% confidence interval = 4.90-14.94) respectively. Concerning the prediction of cirrhosis, transient elastography and aspartate aminotransferase to platelet ratio index had diagnostic odds ratios of 66.49 (95% confidence interval = 23.71- 186.48) and 7.47 (95% confidence interval = 4.88-11.43) respectively. Conclusion. In conclusion, there was no evidence of significant superiority of transient elastography over aspartate aminotransferase to platelet ratio index regarding the prediction of significant fibrosis, but the former proved to be better than the latter concerning prediction of cirrhosis.

Aplicación de la técnica de árboles de clasificación y regresión en la valoración ecográfica de los nódulos tiroideos / Using Classification and Regression Trees in the ultrasound evaluation of thyroid nodules

Objetivo: Evaluar la capacidad de los árboles de clasificación y regresión (CART) en la valoración ecográfica de los nódulos tiroideos malignos. Materiales y métodos: Se realizaron 404 punciones aspiración con aguja fina (PAAF) a 384 pacientes. De los nódulos analizados, se registraron las características ecográficas (localización, tamano, morfología, contorno, consistencia, ecoestructura, ecogenicidad, calcificaciones y vascularización) y los resultados de la elastografía. Se aplicó el CART para investigar la relación entre los hallazgos ecográficos, la elastografía y el cáncer de tiroides. Resultados: El análisis CART determinó que la realización de una elastografía no aporta datos relevantes y que las zonas homogéneas pueden clasificar a los nódulos tiroideos en: 1.ª zona) caracterizada por ausencia de áreas de degeneración coloide e hipoecogenicidad asociada a malignidad; 2.ª zona) diferenciada por presencia de áreas de degeneración coloide combinada con ausencia de microcalcificaciones, constituyendo un indicador fiable de benignidad de los nódulos tiroideos; y 3.ª zona) la ausencia de hipoecogenicidad y una lesión menos alta que ancha deparan un indicador fiable de benignidad. El árbol de clasificación alcanzó una sensibilidad del 87,5% y un valor predictivo negativo del 98,8%. Discusión: El CART muestra una elevada capacidad de predicción de los nódulos malignos frente a otras técnicas lineales. Conclusión: La utilización de los árboles de clasificación provee una herramienta simple para la toma de decisión clínica con el objeto de reducir las PAAF innecesarias, con una elevada sensibilidad.

Objective: To evaluate the use of Classification and Regression Trees (CART) in the ultrasound evaluation of malignant thyroid nodules. Materials and methods: A study was performed on 404 fine needle aspirates (FNA), with biopsies being performed on 384. The information collected about the thyroid nodules was: ultrasound features (location, size, morphology, contour, consistency, echo-structure, echogenicity, calcification, and vascularisation) and elastography results. The CART technique was used to investigate the relationship between ultrasound findings and the thyroid cancer. Results: The CART analysis showed that elastography does not provide any relevant data, and that the homogeneous areas could classified the thyroid nodules into: 1st area) characterised by the absence of colloid degeneration areas and a hypo-echogenicity associated with malignancy; 2nd area) differentiated by the presence of colloid degeneration areas combined with absence of microcalcifications, constituting a reliable indicator of benign thyroid nodules; and a 3rd area) the absence of hypo-echogenicity and a lesion wider than it is long that provides a reliable indicator of being benign. The optimum tree produced a sensitivity of 87.5% and negative predictive value of 98.8%. Discussion: The CART technique demonstrated a high predictive capacity for malignant nodules compared to other linear techniques. Conclusion: The use of classification trees provides us with a simple tool for clinical decision making, in order to reduce unnecessary FNA biopsies, as well as achieving a high sensitivity.

Acoustic radiation force impulse (ARFI) elastography compared with biopsy for evaluating hepatic fibrosis after liver transplantation: a cross-sectional diagnostic study / Elastografia ARFI (acoustic radiation force impulse ) comparada com biópsia na avaliação de fibrose hepática após transplante: estudo transversal diagnóstico

ABSTRACT CONTEXT AND OBJECTIVE: Biopsies are used after liver transplantation to evaluate fibrosis. This study aimed to evaluate the elasticity of transplanted livers by means of a non-invasive examination, acoustic radiation force imaging (ARFI) elastography, correlating the results with the histological analysis. DESIGN AND SETTING: Cross-sectional study in a public university hospital. METHODS: All patients consecutively operated between 2002 and 2010 with an indication for biopsy were evaluated by means of elastography. The radiologist evaluating ARFI and the pathologist doing anatomopathological examinations were blinded to each other's evaluations. RESULTS: During the study period, 33 patients were included. The indication for transplantation was cirrhosis due to hepatitis C in 21 cases (63%). Liver biopsies showed absence of fibrosis (F0) in 10 patients, F1 in 11, F2 in 8 and F3 in 4. There were no cases of F4 (cirrhosis). The difference in ARFI values (degree of fibrosis) was 0.26 (95% confidence interval, CI: 0.07-0.52) between the groups F0-F1 and F2-F4 (P = 0.04). An area under the curve of 0.74 (CI: 0.55-0.94) and a cutoff of 1.29 m/s between the groups resulted in the best relationship between sensitivity and specificity. Sensitivity (0.66; CI: 0.50-0.83) was lower than specificity (0.85; CI: 0.72-0.97). There was no significant difference in ARFI between patients with hepatitis C and those with other diseases. CONCLUSIONS: The values obtained from elastography were not affected by inflammatory reaction or anatomical alterations. A cutoff point of 1.29 m/s separating patients with or without significant fibrosis was identified.

RESUMO CONTEXTO E OBJETIVO: Biópsias são utilizadas para avaliar fibrose após transplante de fígado. O estudo objetivou avaliar a elasticidade hepática após transplante por meio de um exame não invasivo, a elastografia ARFI (acoustic radiation force imaging ), correlacionando-a com a análise histológica. TIPO DE ESTUDO E LOCAL: Estudo transversal em hospital público universitário. MÉTODOS: Todos os pacientes consecutivamente operados entre 2002 e 2010, com indicação para biópsia, foram avaliados por elastografia. O radiologista avaliando ARFI e o patologista fazendo exames anatomopatológicos estavam cegos para as avaliações um do outro. RESULTADOS: No período do estudo, 33 pacientes foram incluídos. A indicação para o transplante foi cirrose por hepatite C em 21 (63%). As biópsias mostraram ausência de fibrose (F0) em 10 pacientes, F1 em 11, F2 em 8, F3 em 4 e nenhum caso de F4 (cirrose). A diferença nos valores de ARFI (grau de fibrose) foi de 0,26 (intervalo de confiança, IC, de 95%: 0,07-0,52) entre os grupos F0-F1 e F2-F4 (P = 0,04). A área sob a curva de 0,74 (IC: 0,55-0,94) e o valor de corte de 1,29 m/s entre os grupos resultaram na melhor relação entre sensibilidade e especificidade, de 0,57. A sensibilidade (0,66; IC: 0,50-0,83) foi menor que a especificidade (0,85; IC: 0,72-0,97). Não houve diferença significativa em ARFI entre pacientes com hepatite C e aqueles com outras doenças. CONCLUSÕES: Os valores obtidos com a elastografia não foram afetados por reação inflamatória ou alterações anatômicas. Foi identificado ponto de corte de 1,29 m/s que separa pacientes com ou sem fibrose significativa.

Utilidad de la elastografía en cáncer de mama a propósito de dos casos / Elastography Usefulness in Breast Cancer In Relation To Two Cases

La ecografía es una técnica fundamental en el estudio morfológico y anatómico de la mama. En los últimos años, se ha visto complementada desde un punto de vista más funcional con la elastografía. Esta modalidad diagnóstica añade información estructural a las propiedades morfológicas que muestra la ecografía y permite alcanzar mejores resultados de especificidad, pues las lesiones malignas muestran dureza significativamente superiores a las lesiones benignas. La elastografía ha venido a fortalecer el diagnóstico en etapas tempranas de las neoplasias malignas. Este hecho repercute en un incremento notable en el índice de curación y en el decrecimiento de la mortalidad por esta causa. El objetivo es mostrar el valor de la elastografía en el diagnóstico de la neoplasia de mama, al ser una nueva herramienta que permite discriminar o corroborar el diagnóstico ecográfico, y evitar al paciente la biopsia innecesaria(AU)

Ultrasound is a fundamental technique in breast morphological and anatomical study. In recent years, elastography has supplemented it from a functional point of view. This diagnostic modality adds structural information to the morphological properties that ultrasound shows and it allows us to achieve better results of specificity, since malignant lesions show significantly higher hardness than benign lesions. Elastography has come to strengthen the diagnosis in early stages of malignancy. This fact that affects a significant increase in the cure rate and the decrease in mortality from this cause. The purpose is to show the value of elastography in breast neoplasia diagnosis, being a new tool to discriminate or confirm the ultrasound diagnosis, and avoid unnecessary biopsy(AU)

Lymphangiogenesis in Breast Cancer Correlates with Matrix Stiffness on Shear-Wave Elastography

PURPOSE: To correlate tumor stiffness and lymphangiogenesis in breast cancer and to find its clinical implications. MATERIALS AND METHODS: A total of 140 breast cancer patients were evaluated. Tumor stiffness was quantitatively measured by shear-wave elastography in preoperative ultrasound examination, calculated as mean elasticity value (kPa). Slides of resected breast cancer specimens were reviewed for most fibrotic area associated with tumor. D2-40 immunohistochemical staining was applied for fibrotic areas to detect the lymphatic spaces. Microlymphatic density, tumor stiffness, and clinicopathologic data were analyzed. RESULTS: Higher elasticity value was associated with invasive size of tumor, microlymphatic density, histologic grade 3, absence of extensive intraductal component, presence of axillary lymph node metastasis, and Ki-67 labeling index (LI) in univariate regression analysis, and associated with Ki-67 LI and axillary lymph node metastasis in multivariate regression analysis. Microlymphatic density was associated histologic grade 3, mean elasticity value, and Ki-67 LI in univariate regression analysis. In multivariate regression analysis, microlymphatic density was correlated with mean elasticity value. CONCLUSION: In breast cancer, tumor stiffness correlates with lymphangiogenesis and poor prognostic factors.

Factors Influencing the Diagnostic Accuracy of Acoustic Radiation Force Impulse Elastography in Patients with Chronic Hepatitis B

BACKGROUND/AIMS: To determine factors predictive of discordance in staging liver fibrosis using liver biopsy (LB) and acoustic radiation force impulse (ARFI) elastography in patients with chronic hepatitis B (CHB). METHODS: Consecutive patients with CHB who underwent LB and ARFI elastography on the same day from November 2010 to March 2013 were prospectively recruited from three tertiary hospitals. RESULTS: We analyzed 105 patients (median age of 47 years). The F0-1, F2, F3, and F4 fibrosis stages were identified in 27 (25.7%), 27 (25.7%), 21 (20.0%), and 30 (28.6%) patients, respectively. The areas under the receiver operating characteristics curves for ARFI elastography in assessing ≥F2, ≥F3, and F4 was 0.814, 0.848, and 0.752, respectively. The discordance of at least one stage between LB and ARFI was observed in 68 patients (64.8%) and of at least two stages in 16 patients (15.2%). In a multivariate analysis, advanced fibrosis stage (F3-4) was the only factor that was negatively correlated with one-stage discordance (p=0.042). Moreover, advanced fibrosis stage was negatively (p=0.016) correlated and body mass index (BMI) was positively (p=0.006) correlated with two-stage discordance. CONCLUSIONS: Advanced fibrosis stage (F3-4) was a predictor of nondiscordance between LB and ARFI elastography; BMI also influenced the accuracy of ARFI elastography.