U S performance mixed in breast cancer survivors.

By Kate Madden Yee, AuntMinnie.com staff writer.

February 27, 2020 -- Supplemental screening ultrasound shows a mixed performance in women with a personal history of breast cancer, with lower sensitivity and a higher interval cancer rate. But the modality also had higher specificity, according to a study published online February 25 in Radiology

The findings suggest that the quest for effective ways to follow breast cancer survivors continues, wrote a team led by Dr. Soo-Yeon Kim, PhD, of Seoul National University Hospital in South Korea.

"Further research is needed to more accurately identify women who will benefit from supplemental ultrasound screening," the group wrote.

Breast cancer survivors are more vulnerable to developing second cancers, and they are tracked carefully with regular imaging. But mammography has shown lower sensitivity and higher interval cancer rates in women with a history of the disease compared with those without, Kim and colleagues noted.

Breast MRI is recommended for screening women at high risk of breast cancer, but it has its downsides, including high cost and the need for a contrast agent. Because screening breast ultrasound is readily available, doesn't require contrast, and is cost-effective, interest in using it to track breast cancer survivors has increased.

Kim and colleagues compared the performance of screening breast ultrasound between women with and without personal history of breast cancer. Their study included 3,226 breast cancer survivors and 3,226 women without history of the disease, all of whom underwent supplemental breast ultrasound and mammography between January and December 2013. The women were matched by age and breast density.

Fourteen cancers were identified among the breast cancer survivors (six on screening, eight interval) and 13 among the women with no personal history of the disease (12 on screening, one interval). Supplemental ultrasound's performance among the two groups of women varied.

Performance of supplemental screening ultrasound
Performance measure	Women with no personal history of breast cancer	Breast cancer survivors	p-value
Abnormal interpretation rate	11%	7.3%	< 0.001
Biopsy rate	1.8%	1.2%	0.04
Interval cancer rate per 1,000 women	0.3	2.5	0.02
Sensitivity	92%	43%	0.03
Specificity	89.3%	92.8%	< 0.001

"The low sensitivity and high interval cancer rate in women with a personal history of breast cancer imply that limited sensitivity of mammography in these women might have not been fully overcome by supplemental ultrasound," Kim and colleagues wrote. But, "regarding false-positive findings, supplemental ultrasound in women with a personal history of breast cancer showed lower abnormal interpretation rates, lower biopsy rates, and higher specificity than in women without a personal history of breast cancer."

It's clear that more research is necessary to determine how best to track breast cancer survivors, wrote Drs. Christoph Lee and Janie Lee, both of the University of Washington in Seattle, in an accompanying editorial.

"Additional studies are needed in larger and more diverse settings to better define the benefits and harms of supplemental screening among women with a previous history of breast cancer," they wrote.

Which US method is best for DVT.

By  Theresa Pablos, AuntMinnie Staff writer

February 17, 2020 -- Three different compression ultrasound methods all performed well for imaging deep vein thrombosis (DVT) in a study published online on February 11 by PLOS One. The failure rates for single limited, serial limited, and whole-leg ultrasound ranged from 1% to 2%.

While the three methods are regularly used in clinical practice to help identify DVT, there is no consensus about which one works best. The authors reviewed dozens of studies with thousands of patients and found that no one ultrasound method stood above the rest.

"In the present meta-analysis, more recent studies using clinical follow-up as the reference method showed very comparable failure rates of the three strategies," wrote the authors, led by Dr. Noémie Kraaijpoel from the department of vascular medicine at the University of Amsterdam. "This could imply that there may not be a preferred strategy when taking only safety into account."

The authors searched the scientific literature for compression ultrasound studies from on January 1, 1989, the year the first high-quality research on the modality was published, through July 2019. They included studies using three methods of imaging adults with suspected DVT:

1. Single limited compression ultrasound -- a single examination of the proximal deep veins
2. Serial limited compression ultrasound -- two examinations about five to 10 days apart of proximal deep veins
3. Whole-leg compression ultrasound -- a single examination of both distal and proximal deep veins

Six studies with 2,079 patients assessed single limited compression ultrasound. The analysis showed the modality had a 1.4% failure rate and 6.4% proportion of positive results, although the findings varied among the included individual studies.

For serial limited compression ultrasound, the authors included 11 studies with 3,360 patients. The modality had a 1.9% failure rate and 25% proportion of positive results.

Finally, seven studies with 3,159 evaluated whole-leg compression ultrasound. The findings showed a failure rate of 1% and 25% proportion of positive results.

While all included studies had comparable failure rates (p = 0.36), the proportion of confirmed DVT was significantly higher for serial limited and whole-leg compression ultrasound than for single limited compression ultrasound. The authors noted the difference in prevalence could be the result of patient selection.

Notably, single limited compression ultrasound had a lower DVT prevalence -- likely due to the selection of patients with a lower DVT risk. As a result, the modality could theoretically have a higher failure rate if more DVTs had been found in the group.

Nevertheless, the compression ultrasound methods produced similar results and may be considered equivalent for clinical practice.

"The failure rates of single limited, serial limited, and whole-leg [compression ultrasound] for DVT were found to be quite comparable in patients selected as per the individual study diagnostic algorithms," the authors wrote. "Preference for one of the strategies should be based on probability assessment, feasibility, and expertise."

Penile Ultrasound Integral to Diagnosing Erectile Dysfunction Cause

Ultrasound of the penis can play a vital role in determining the underlying cause of erectile dysfunction in men who don’t respond to medication.

Although prescription drugs have significantly – and successfully – changed how providers treat erectile dysfunction (ED), for those men who don’t see improvement, relying on ultrasound can be the key to identifying next steps and possible treatments, according to an article published in the American Journal of Roentgenology.

“Radiologists must be familiar with the imaging protocol, the limitations of the technique, and the interpretations of its findings, to warrant an accurate diagnosis and appropriate patient management,” said lead study author Cristian Gómez Varela, from the radiology department in Complejo Hospitalario Universitario de Pontevedra in Spain. “It is essential to differentiating between the vascular and nonvascular causes of the ED and, therefore, determining appropriate management of the patient.”

The Conditions

When used correctly – with a high-frequency linear array (7.5-12 MHz) and full-length images of the penis in both flaccid and erect states – ultrasound can contribute to successfully diagnosing three vascular-related causes of ED, Varela said.

Peyronie’s Disease (PD): This penile deformity caused by scar tissue that develops after repeated injury results in painful erections. In most cases, MRI is the preferred modality to assess PD. But, gray-scale ultrasound can be very helpful in diagnosis and follow-up, assessing size and location of plaques, detecting small non-palpable lesions or the involvement of the penile septum, or evaluating disease progression. In addition, sonoelastography can estimate tissue stiffness, as well as identify plaques that go undetected on gray-scale ultrasound.

Penile Fracture: Caused by trauma to the penis, usually during sexual intercourse, fracture can cause a rupture in the membrane responsible for trapping blood in the penis to sustain an erection. Ultrasound can make pinpointing any ruptures easier, as fractures are seen as dark breaches in the membrane.

Priapism: This condition can occur in two forms – both high-flow and low-flow. Low-flow priapism is considered a medical emergency as it can cause tissue death and, if left untreated, permanent ED. Ultrasound can identify tissue thickening and scarring in the arteries of the penis, and Doppler ultrasound can also pinpoint inadequate blood retention.
Given its effectiveness is identifying these vascular-related conditions behind ED, according to Varela and colleagues, ultrasound is the preferred method for initially evaluating the penile anatomy and blood flow. Not only is it readily available, but it is minimally invasive and can be well tolerated by patients.

AI helps characterize breast masses on ultrasound

By Erik L. Ridley, AuntMinnie staff writer

February 4, 2020 -- A breast ultrasound artificial intelligence (AI) algorithm was able to differentiate breast masses at a high level of accuracy by combining analysis of B-mode and color Doppler images, according to research published online January 31 in European Radiology. It even yielded comparable performance to experienced radiologists.

A research team led by Xuejun Qian, PhD, of the University of Southern California and Bo Zhang, PhD, of Central South University in Hunan, China, found that their deep-learning algorithm had substantial agreement with radiologists for providing BI-RADS categorization. It also yielded high sensitivity and specificity.

"The decisions determined by the model and quantitative measurements of each descriptive category can potentially help radiologists to optimize clinical decision-making," the authors wrote.

Breast ultrasound interpretation has been characterized by variable inter- and intrareader reproducibility, with higher false positives than other imaging tests, according to the researchers. Seeking to develop an automated breast classification system that could improve consistency and performance, they gathered a training set of 103,212 breast masses and a validation set of 2,748 independent breast masses at two Chinese hospitals between August 2014 and March 2017. They also assembled a test set of biopsy-proven 605 breast masses classified as BI-RADS 2 to 5 from March 2017 to September 2017.

Next, the researchers trained two convolutional neural networks: one based just on B-mode images and the other based on both B-mode and color Doppler images. On the validation cases, the model based on both B-mode and color Doppler image analysis had a higher level of agreement (kappa = 0.73) with the original interpreting radiologists for BI-RADS categorization than the network based only on B-mode images (kappa = 0.58). The difference was statistically significant (p < 0.001).

They then evaluated the performance of both models on the test set of 605 masses.

Performance of neural networks for classifying breast masses on test set
	Model based on B-mode images	Model based on both B-mode and color Doppler images
Sensitivity	96.8%	97.1%
Specificity	75.5%	88.7%
Accuracy	85.3%	92.6%
Area under the curve (AUC)	0.956	0.982

The researchers noted that the addition of color Doppler information improved the algorithm's specificity and accuracy on a statistically significant basis (p < 0.001). The small increase in sensitivity was not statistically significant, however.

"Overall, Doppler information should be incorporated into breast [ultrasound] examination protocols for breast masses, and the use of such a dual-modal system may improve cancer diagnostics," the authors wrote.

The researchers also had 10 radiologists with three to 20 years of breast imaging experience assess the 605 masses in the test set. Nine of the 10 radiologists had a sensitivity that ranged from 87.8% to 94.6%, while the last radiologist had 64.7% sensitivity. That same radiologist had the highest specificity (98.5%), with the remaining participants producing sensitivity ranging from 84.1% to 91.7%. Overall, the 10 readers produced an AUC of 0.948.

"These results indicate that the performance of model 2 reached the levels of the human experts," the authors concluded.

 

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