SWE Improves the Specificity of Breast Ultrasound



Mục đích: Để xác định xem thêm SA đàn hồi sóng biến dạng (shear wave, SW) vào có thể tăng cường tính chính xác của đánh giá siêu âm (US) các khối u vú hay không.

Đối tượng và phương pháp: Từ tháng 9 năm 2008 đến tháng 9 năm 2010, 958 phụ nữ đồng ý để khám siêu âm vú tiêu chuẩn, được bổ sung thêm siêu âm đàn hồi định lượng trong một khảo sát tiền cứu đa trung tâm được phê chuẩn, theo giao thức HIPAA tương thích. Các đặc điểm BI-RADS và đánh giá được ghi nhận. Đánh giá siêu âm đàn hồi sóng biến dạng (độ đàn hồi của phần cứng nhất của u vú trung bình, tối đa và tối thiểu và mô xung quanh; tỉ lệ độ đàn hồi của tổn thương với mô mỡ; tỷ lệ đường kính hoặc tiết diện tổn thương của SA đàn hồi với B-mode; dạng và sự đồng nhất tổn thương của SA đàn hồi) đã được thực hiện. SA đàn hồi màu độ cứng định tính được đánh giá độc lập. 939 khối u vú được phân tích; 102 khối u BI-RADS 2 được giả định là lành tính; 837 tổn thương BI-RADS 3 hoặc cao hơn thuộc tiêu chuẩn tham khảo. BI-RADS 4a hoặc cao hơn được coi là ác tính dương tính, hiệu quả tính năng SA đàn hồi trong vùng AUC (area under the receiver operating characteristic curve), độ nhạy và độ chuyên biệt các u sau khi tái phân hạng loại 3 và 4a được xác định.

Kết quả: Số trung vị tuổi tham gia là 50 năm; 289 /939 khối (30,8%) là ác tính (kích thước trung bình= 12 mm). AUC của BI-RADS B-mode là 0,950; 8/ 303 khối (2,6%) BI-RADS 3, 18 / 193 tổn thương (9,3%) BIRADS 4a, 41 / 97 tổn thương BIRADS 4b (42%), 42 / 57 tổn thương loại 4 c (74%), và 180 /187 (96,3%) loại 5 là tổn thương ác tính. Bằng cách sử dụng độ cứng màu nâng cấp có chọn lọc loại 3 và để hạ khối u vú thiếu độ cứng xuống khỏi BIRADS 4a, độ chuyên biệt tăng từ 61,1% (397 u / 650) lên 78,5% (510 / 650) (P <. 001); AUC tăng lên 0,962 (P =.005). Hình dạng bầu dục trên SA đàn hồi và độ đàn hồi định lượng tối đa là 80 kPa (tương đương =5,2 m/s) hoặc ít hơn được cải tiến độ đặc hiệu (69,4% [451 / 650] và 77,4% [503 / 650], P <.001 cho cả hai), mà không có sự cải tiến quan trọng của độ nhạy hoặc AUC.

Kết luận: Thêm đặc điểm SA đàn hồi SW vào phân tích BI-RADS làm tăng cường độ chuyên biệt của đánh giá SA vú mà không làm mất độ nhạy.

VTQ Using ARFI Technology of Solid Breast Masses

Abstract

Objectives— The purpose of this study was to investigate the clinical usage of Virtual Touch tissue quantification (VTQ; Siemens Medical Solutions, Mountain View, CA) implementing sonographic acoustic radiation force impulse technology for differentiation between benign and malignant solid breast masses.

Methods— A total of 143 solid breast masses were examined with VTQ, and their shear wave velocities (SWVs) were measured. From all of the masses, 30 were examined by two independent operators to evaluate the reproducibility of the results of VTQ measurement. All masses were later surgically resected, and the histologic results were correlated with the SWV results. A receiver operating characteristic curve was calculated to assess the diagnostic performance of VTQ.

Results— A total of 102 benign lesions and 41 carcinomas were diagnosed on the basis of histologic examination. The VTQ measurements performed by the two independent operators yielded a correlation coefficient of 0.885. Applying a cutoff point of 3.065 m/s, a significant difference (P < .001) was found between the SWVs of the benign (mean ± SD, 2.25 ± 0.59 m/s) and malignant (5.96 ± 2.96 m/s) masses. The sensitivity, specificity, and area under the receiver operating characteristic curve for the differentiation were 75.6%, 95.1%, and 85.6%, respectively. When the repeated non-numeric result X.XX of the SWV measurements was designated as an indicator of malignancy, the sensitivity, specificity, and accuracy were 63.4%, 100%, and 89.5%.

Conclusions— Virtual Touch tissue quantification can yield reproducible and quantitative diagnostic information on solid breast masses and serve as an effective diagnostic tool for differentiation between benign and malignant solid masses.



Breast cancer is a serious health threat worldwide and also the number one killer of women in China. For successful management of breast cancer, early detection is the key. Sonography has a long-established role in the assessment of mammographic and palpable abnormalities in the breast. It has been proven useful to differentiate benign and malignant solid masses.
In addition to conventional sonography, elastography is presently used to aid the differential diagnosis because it can yield information not only on the morphologic characteristics but also on the tissue elasticity of the masses. However, this technique has its own limitations: it is a qualitative evaluation method in which the acquisition of strain images requires external compression.

Now, a new trend has arisen, which applies acoustic radiation force impulse (ARFI) imaging to elastography. This technique requires no external compression and exploits short-duration acoustic radiation forces to generate localized tissue displacements. Such displacements can be tracked by sonographic correlation-based means and are related to the viscoelastic properties of local soft tissue. As such, ARFI imaging can enable qualitative visual and quantitative value measurements, and it has so far been used to delineate deep tissue structures via its viscoelastic characteristics in numerous applications.
Recently, Virtual Touch tissue quantification (VTQ; Siemens Medical Solutions, Mountain View, CA), which uses ARFI technology, has become available for diagnosis of superficial tissue lesions. However, to our knowledge, the diagnostic performance of this approach in solid breast masses has not yet been evaluated. The purpose of this study was to investigate the clinical use of VTQ for differentiation between benign and malignant solid breast masses.

Materials and Methods

Patients

The study was approved by the Institutional Review Board and Ethics Committee of Shanghai First People’s Hospital, and all participants signed informed consent forms before the study started. From January 2011 to May 2011, a total of 108 women (age range, 19–87 years; mean age, 44 years) participated in the study. All of the patients were recruited on the basis that they had been suspected to have solid breast masses based on conventional sonographic examinations. Among all of the patients, 83 had solitary masses, and 25 had multiple masses. When multiple masses were found, masses larger than 0.5 × 0.6 cm were evaluated. Hence, a total of 143 masses in the 108 patients constituted the sample.

Conventional Sonography and VTQ

All sonographic examinations were performed by one of two radiologists, each of whom had no less than 11 years of experience in breast sonography and were also well trained in VTQ. Examinations of 30 masses were performed by both radiologists independently to evaluate the reproducibility of the VTQ results. Both the conventional sonographic and VTQ measurements were performed with an Acuson S2000 ultrasound system (Siemens Medical Solutions) using a linear 9-MHz multifrequency transducer.

Virtual Touch tissue quantification tracks a shear wave in the region of interest that travels perpendicular to the direction of the acoustic push pulse and calculates the speed of the wave=10 m/s. The stiffer the tissue is, the greater the shear wave velocity (SWV) will be. In this way, VTQ can provide numeric values offering quantitative information on the tissue stiffness at a precise image-based anatomic location. At present, VTQ can be integrated into the Acuson S2000 system and performed with a conventional 9-MHz superficial transducer during a routine sonographic examination without any special preparations.

During the study, conventional sonography was performed to scan the patient’s breast thoroughly before VTQ measurement. The maximum diameters of individual masses were measured. Planes of the maximum diameters were selected for VTQ measurement.

For VTQ measurement, the patient needed to lie in a position identical to the one for the conventional sonography examination. The transducer was gently applied together with a sufficient amount of contact gel to avoid generation of artifactual areas of stiffness radiating from the skin surface. After activating VTQ, the transducer was kept still, and the patient was asked to hold her breath during acquisition of the SWV.

Figure 1.

Region of interest completely within the mass and without thick calcifications.

The VTQ region of interest was determined to be a rectangle with fixed dimensions of 0.5 × 0.6 cm. Three regions of interest were localized to 3 areas of the selected plane to evaluate the average rigidity of the whole mass. Each region of interest was placed completely within the mass and included no thick calcifications (Figure 1). The reference region of interest was placed in the normal breast tissue at the same depth and no less than 0.5 cm away from the mass. For each region of interest, the SWV was measured at least 3 times to acquire 3 valid values, and only consistently stable values were used in the analysis. Hence, 9 SWV values were obtained from an individual mass and 3 from the reference breast tissue. All of the SWV values for an individual mass or the reference breast tissue were averaged to produce a mean SWV.

Statistical Analysis

Data were expressed as mean ± standard deviation. A correlation coefficient was calculated by bivariate correlation analysis. The size of a mass, its SWV, and the SWV of the reference breast tissue were compared between the benign and malignant groups by the Mann–Whitney U test. The SWVs of the masses and reference breast tissue were compared by a paired samples t test. A receiver operating characteristic curve was calculated to assess the clinical usefulness of the SWVs. All analyses were performed with SPSS version 11.0 software for Windows (SPSS Inc, Chicago, IL), and 2-sided P < .05 was considered statistically significant.

Results

A total of 108 women with 143 solid breast masses constituted the study group. The maximum diameters of the masses ranged from 0.8 to 4.1 cm (mean ± SD, 1.84 ± 0.63 cm). After resection, all masses were proven to be solid. Histopathologic analysis revealed 102 benign breast lesions and 41 breast carcinomas. Benign lesions consisted of fibroadenomas (n = 85), intraductal papillomas (n = 5), and adenosis (n = 12), and malignant lesions included invasive ductal carcinomas (n = 34), ductal carcinomas in situ (n = 5), a neuroendocrine carcinoma (n = 1), and a basal-like carcinoma (n = 1).

Reproducibility

The correlation between the VTQ-measured SWV results acquired by the two independent operators is shown in Figure 2. Its correlation coefficient was 0.885, indicating that these SWV measurements were reproducible.

Benign Lesions

The maximum diameters of the benign masses ranged from 0.8 to 3.5 cm (mean, 1.77 ± 0.56 cm). Numeric SWV values could be measured for all 102 masses and the reference breast tissue. The SWVs of the benign masses ranged from 1.27 to 4.88 m/s (mean, 2.25 ± 0.59 m/s), whereas those of the reference breast tissue ranged from 0.87 to 2.62 m/s (mean, 1.54 ± 0.36 m/s). There was a significant difference in the SWVs between the benign masses and reference breast tissue (P < .001).

Malignant Lesions

The maximum diameters of the malignant masses ranged from 0.8 to 4.1 cm (mean, 2.01 ± 0.75 cm). For 15 breast carcinomas (36.6%; 4 ductal carcinomas in situ and 11 invasive ductal carcinomas), numeric SWV values could be measured whereas for the remaining 26 (63.4%; 1 ductal carcinoma in situ, 1 neuroendocrine carcinoma, 1 basal-like carcinoma, and 23 invasive ductal carcinomas), all or part of the SWV measurements produced non-numeric results, which were all expressed as X.XX. It was known that the SWV values set by the system, representing the solid biological tissue values of all measurements, should be within the range of 0 to 9.10 m/s. In our study, X.XX measured in the solid target using a rigorous method was replaced by a value of 9.10, and in this way, the SWVs of the malignant masses were represented by a range of values from 1.17 to 9.10 m/s (mean, 5.96 ± 2.96 m/s).

Contrarily, all SWVs of the reference breast tissue were numeric, ranging from 0.81 to 2.95 m/s (mean, 1.68 ± 0.54m/s). There was a significant difference in the SWVs between the malignant masses and reference breast tissue (P< .001).

Benign and Malignant Group Comparison

A comparison of the sizes and SWVs between the benign and malignant groups is shown in Table 1. The SWVs of the malignant masses were significantly faster than those of the benign masses (P< .001; Figure 3).

Figure 2.

Correlation between the shear wave velocity (SWV) results acquired by the two independent operators from the first 30 masses (r = 0.885).

Table 1.

Comparison of the Sizes and Shear Wave Velocities in the Benign and Malignant Groups

Diagnostic Performance

When the masses with all numeric SWV values were designated as benign lesions and those with non-numeric SWV values, totally or partially, expressed as X.XX, were designated as malignant lesions, the sensitivity of the differentiation between the benign and malignant lesions was 63.4%; specificity, 100%; positive predictive value, 100%; negative predictive value, 87.2%; and accuracy, 89.5%.

Receiver operating characteristic curve analysis of SWVs for differentiation between the malignant and benign solid breast masses gave a cutoff value of 3.065 m/s. When the masses whose SWVs were less than 3.065 m/s were designated as benign lesions and the masses with SWVs of greater than 3.065 m/s were designated as malignant lesions, the sensitivity of the differentiation reached 75.6%, and the specificity, positive predictive value, area under the receiver operating characteristic curve, negative predictive value, and accuracy were 95.1%, 85.6%, 86.1%, 90.7%, and 89.5%, respectively (Figures 4 and 5).

Figure 3.

Shear wave velocity (SWV) values for the benign and malignant masses. The boxes indicate the values from the lower to the upper quartiles (25th–75th percentiles); center lines, medians; whiskers, minimum to maximum values; and dot, extreme value. The square is an outlier.

Among the 5 benign lesions whose SWVs were above the 3.065-m/s threshold, 2 fibroadenomas, 2 intraductal papillomas, and 1 adenosis were found, and for the 10 malignant lesions with SWVs below the 3.065-m/s threshold, 4 ductal carcinomas in situ and 6 invasive ductal carcinomas were found.

Figure 4.

Receiver-operator characteristic curve of the shear wave velocity (SWV) that distinguishes malignant solid breast masses. The sensitivity, specificity, and area under the curve were 75.6%, 95.1%, and 85.6%, respectively, when a cutoff value of 3.065 m/s was applied.

Discussion

In recent years, there has been increasing interest in assessing tissue elastic properties by sonography. Elastography of soft tissue relies on the deformation generated by an imparted force on the target organ.This method is based on two major imaging techniques. The first is strain elasticity imaging, also called static elastography, including real-time tissue elastography (Hitachi Medical Systems, Tokyo, Japan), eSie Touch (Siemens Medical Solutions), and elasticity imaging, among others; its implementation requires continuous transducer compression or external mechanical compression through the respiratory movements and cardiac pulsations. Its main drawback is that the compression cannot be quantified, and the site of compression cannot be restricted to the specific areas under investigation, leading to movement of the target and distortion of the measured results. The second type is acoustic stress elasticity imaging or dynamic elastography, including supersonic shear imaging and ARFI imaging, which applies a short-duration acoustic radiation force to the region of interest without producing movement of the whole target. Moreover, the acoustic radiation force can be quantified and yield quantitative information. This technique makes measured results less reliant on operator maneuvers. The advantages of this technique have been documented in other studies as well as ours.
Breast static elastography has diagnostic performance similar to that of conventional sonography for differentiating benign and malignant breast masses, but its reliability can be hampered by interobserver variability.Because the observational indicators in our study were numeric values, such variability was unlikely to arise.

Distribution of shear wave velocity (SWV) values of benign and malignant masses. The dotted line represents the cutoff value of 3.065 m/s.

In our study, for 63.4% (26 of 41) of the breast carcinomas, all or part of the SWV measurements were nonnumeric values, expressed as X.XX. There could be two main reasons to account for the X.XX values: First, the method does not conform to the biomechanical testing standard, or shear waves cannot be generated and propagated in the target; ie, the signal does not meet the quality assurance setup in the system because of considerable movement of the target (eg, due to respiration) during sampling, rendering the results unreliable, or the target is simple fluid in which shear waves could not be generated and propagated. Second, the target is so hard that the results are beyond the solid biological tissue value of 9.10 m/s set by the system. Because of the fact that we adopted a rigorous method in our study (eg, during sampling, the probe was kept still, and the patients were required to hold their breath to attain reliable SWV measurements) and verified the solid masses by histologic examination, the first reason can well be excluded. The X.XX values were most likely due to the presence of abnormal tissue (eg, dense fibrous desmoplastic tissue); for this reason, our substitution of X.XX with a value of 9.10 m/s could be justified. This argument can be strengthened by the fact that the X.XX values did not appear in any benign masses (in the absence of any thick calcification) but were only shown in the malignant lesions, with specificity and a positive predictive value of 100% (26 of 26). Such results indicate the potential clinical value of VTQ in differentiating malignant masses.

The results of this study showed that the SWVs of the benign masses were significantly faster than those of the reference breast tissue but slower than those of the malignant masses, implying that benign masses tend to be harder than normal breast tissue but softer than malignant masses, a result consistent with all previous findings. The malignant masses usually were very firm because of dense fibrous desmoplastic tissue. Our results have illustrated the clinical feasibility of using VTQ to quantitatively assess the relative stiffness of breast tissue. Furthermore, we have shown that SWV is indeed useful for differentiation between benign and malignant breast masses; in our study, an SWV value of greater than 3.065 m/s was indicative of malignancy. This finding not with standing, there was overlap. Five benign masses were recognized as malignant because their SWVs were above the 3.065-m/s threshold. Histopathologic examination showed that these 5 masses contained plentiful fibrous tissue, which might have contributed to the higher SWVs. On the other hand, 10 malignant masses were misdiagnosed as benign because their SWVs were below the 3.065-m/s threshold. Histopathologic examination revealed that these 10 masses were rich in epithelial cells and short of fibrous tissue, which might have accounted for the lower SWVs. It is also worthy of note that 80% (4 of 5) of the ductal carcinomas in situ had SWVs of less than 3.065 m/s, indicating that for detection of this specific type of malignancy, VTQ may be a less optimal approach.

The major limitations of applying VTQ in our study were the fixed box dimension of the target region of interest and its sensitivity to movement artifacts. In addition, our study was based on a relatively small number of malignant cases and types; to further confirm the benefits of VTQ, a larger sample size may be needed.

In conclusion, VTQ can yield quantitative information on the tissue stiffness of solid breast masses in a reproducible way. With a cutoff SWV value of 3.065 m/s, we could accurately identify both benign and malignant solid masses. Moreover, all of the lesions with an SWV of X.XX were found to be malignant, suggesting that repeated X.XX values can serve as a malignancy indicator. Given these promising results, we propose the use of VTQ as an effective diagnostic tool for differentiating between benign and malignant solid breast masses.


© 2012 by the American Institute of Ultrasound in Medicine
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Trong nghiên cứu của chúng tôi, có 63.4% (26/41) carcinomas vú, tất cả hay một phần của đo SWV là các giá trị không số (nonnumeric), biểu hiện như X.XX. Có thể có hai lý do chính cho các giá trị X.XX: trước tiên, phương pháp thử nghiệm chuẩn biomechanical không phù hợp, hoặc sóng biến dạng không thể được tạo ra và truyền trong mục tiêu; tức là, các tín hiệu không đáp ứng các thiết lập bảo đảm chất lượng trong máy  vì mục tiêu không chuyển động đáng kể (ví dụ như, nhờ sự hô hấp) trong thời gian lấy mẫu, kết xuất các kết quả không đáng tin cậy, hoặc mục tiêu là dịch đơn thuần nên sóng biến dạng có thể không được tạo ra và lan truyền. Thứ hai, mục tiêu quá cứng nên kết quả vượt quá giá trị rắn sinh học mô 9,10 m/s của máy. Vì thực tế chúng tôi đã thông qua một phương pháp nghiêm ngặt trong nghiên cứu (ví dụ như, trong khi lấy mẫu, đầu dò được giữ yên, và bệnh nhân được yêu cầu nín thở để có kết quả đo đạc SWV đáng tin cậy) và xét nghiệm mô bệnh học khối cứng, nên nguyên nhân đầu tiên cũng có thể được loại trừ. Các giá trị X.XX rất có thể do có mô bất thường (ví dụ như, nhiều mô sợi [desmoplastic]); vì lý do này, chúng tôi thay thế X.XX bằng giá trị 9,10 m/s có thể được chứng minh. Điều suy luận này được tăng cường bởi thực tế là giá trị X.XX đã không xuất hiện trong bất kỳ khối u lành tính nào (không có vôi hoá dày) mà chỉ xuất lộ trong các tổn thương ác tính, với độ đặc hiệu và giá trị tiên đoán dương là 100% (26 / 26 ca). Kết quả như vậy cho thấy giá trị tiềm năng lâm sàng của VTQ trong phân biệt các u ác tính.


Kết quả của nghiên cứu này cho thấy rằng SWVs của u lành tính nhanh đáng kể hơn mô vú tham chiếu nhưng chậm hơn so với u ác tính, ngụ ý rằng u lành tính có xu hướng cứng hơn mô vú bình thường nhưng mềm hơn u ác tính, phù hợp với tất cả phát hiện trước đây. Bởi u ác tính thường rất chắc vì dày đặc mô xơ hoá. Kết quả của chúng tôi đã minh họa tính khả thi lâm sàng của sử dụng VTQ để đánh giá định lượng độ cứng tương đối của mô vú. Hơn nữa, chúng tôi đã chứng tỏ SWV thực sự giúp ích phân biệt giữa u vú lành tính và ác tính; trong nghiên cứu của chúng tôi, giá trị SWV lớn hơn 3.065 m/s được coi là ác tính. Dấu hiệu này chưa vững vì đã có trùng lặp (overlapping). Năm khối lành tính được nhận là ác tính bởi vì SWVs đã ở trên ngưỡng 3,065m/s. Kết quả mô bệnh học cho thấy 5 u này có nhiều mô xơ, có thể đã góp phần làm cho SWVs cao hơn. Mặt khác, 10 khối ác tính đã lầm là lành tính bởi vì SWVs dưới ngưỡng 3,065m/s. Kết quả mô bệnh học cho thấy 10 khối này có nhiều tế bào biểu mô và ít mô xơ, làm cho SWVs thấp hơn. Đáng lưu ý rằng 80% (4 / 5) của ductal carcinomas in situ có SWVs thấp hơn 3,065 m/s, chỉ ra rằng với đặc trưng của loại bệnh lý ác tính này, VTQ là cách tiếp cận ít tối ưu.

Những hạn chế chủ yếu của việc áp dụng VTQ trong nghiên cứu của chúng tôi là kích thước cố định của ROI box và độ nhạy với artifact do chuyển động. Ngoài ra, nghiên cứu của chúng tôi chỉ có một số trường hợp ác tính tương đối ít và vài loại; nên để xác định lợi thế của VTQ, cần một kích thước mẫu lớn hơn.

Tóm lại, VTQ cho thông tin định lượng về độ cứng khối vú đặc có tính lập lại. Với một giá trị SWV =3,065 m/s, chúng tôi có thể xác định chính xác các u đặc cả lành tính và ác tính. Hơn nữa, với tất cả tổn thương ác tính có SWV =X.XXm/s, cho thấy rằng các giá trị X.XX lặp đi lặp lại có thể được xem như là chỉ báo ác tính. Với kết quả đầy hứa hẹn, chúng tôi đề xuất việc sử dụng VTQ như một phương tiện chẩn đoán hiệu quả cho việc phân biệt u vú đặc lành tính và ác tính.

XÂM LẤN NHĨ P DO U GAN P Ở BỆNH NHI NAM 8 TUỔI

NHÂN CA XÂM LẤN NHĨ P DO U GAN P Ở BÉ TRAI 8  TUỔI TẠI MEDIC, BS NGUYỄN THIỆN HÙNG, BS PHAN THANH HẢI



Ngày 29/01/2012, khoa siêu âm Medic tiếp nhận 1 bé trai 8 tuổi từ miền trung với chẩn đoán u gan P. Siêu âm xác nhận chẩn đoán u gan P =7x9 cm của tuyến trước và ghi nhận thêm xâm lấn tĩnh mạch chủ bụng gần tim. Xét nghiệm Medic cho thấy bé nhiễm siêu vi viêm gan B với alpha-fetoprotein = 48.800IU/mL. MDCT bụng ngực sau đó phát hiện khối choán chỗ gần trọn tâm nhĩ P.

U gan P 7x9cm ở HPT 8, nhiều múi, ít mạch máu, độ đàn hồi ARFI của u =1,97m/s (cứng) so với nền gan.

U gan P lồi vào tĩnh mạch chủ dưới trên mặt cắt ngang=2x1,2cm. ARFI elastography với Virtual Touch Imaging (VTI) cho dạng nốt cứng (black), trong khi u gan còn lại cứng (black) so với nền gan.

MDCT bụng ngực sau đó phát hiện khối choán chỗ gần trọn tâm nhĩ P.

Sẽ phải làm gì cho em bé 8 tuổi này?


Bài báo (2009) sau đây từ một ca hepatoblastoma ở trẻ 18 tháng xâm lấn nhĩ P.
Sau 6 tuần hóa trị với cisplatin và doxorubicin (PLADO, SIOPEL protocol), khối u tim P biến mất, bé được cắt u nguyên phát ở gan mà không phải phẫu thuật tim, AFP sau mổ giảm còn 4IU/mL (trước mổ, AFP= 175.000IU/mL).

HEPATOBLASTOMA METASTATIC TO THE RIGHT ATRIUM RESPONDING TO CHEMOTHERAPY ALONE, November 2009, Vol. 26, No. 8 , Pages 583-588

Vural Kesik, MD Yilmaz Yozgat, MD Erkan Sari, MD Murat Kocaoğlu, MD Erol Kismet, MD and Vedat Koseoglu, MD,
Ankara, Turkey

Department of Radiology, Gulhane Military Medical Academy, School of Medicine, Etlik, Ankara, Turkey

An 18-month-old boy presented with abdominal pain and distension. On physical examination there was a 10 × 7 cm mass in the right upper abdominal quadrant. His alpha-fetoprotein level was 175,000 IU/mL. Abdominal magnetic resonance findings revealed hepatomegaly with multiple tumor masses involving nearly all the segments of the liver. The tumor extended through the inferior vena cava and filled 2/3 of the right atrium. Echocardiography revealed normal cardiac function. Histopathologic findings after liver biopsy were consistent with hepatoblastoma. After 6 courses of chemotherapy including cisplatin and doxorubicin (PLADO, SIOPEL protocol), the cardiac tumor regressed completely. The patient's primary tumor was then fully resected; no cardiac surgery was performed. After surgery the AFP level was 4 IU/mL and echocardiography revealed normal cardiac function with no residual tumor. The patient has been in remission for 31 months postdiagnosis.

Keywords

cardiac invasion, children, hepatoblastoma

NHÂN 5 CA U CARCINOID Ở TRUNG TÂM MEDIC

Siêu âm có thể phát hiện di căn gan, lách của u carcinoid ruột khi khám kiểm tra.
Qua 5 trường hợp, siêu âm phát hiện di căn gan 2/5 ca, 1/5 ca di căn lách. Đó là những tổn thương echo kém, đường viền rõ, có ít  mạch máu tân sinh. Di căn gan của u carcinoid do siêu âm phát hiện đã được y văn công bố, nhưng chưa có thông tin nào về u carcinoid di căn lách và hạch cổ như trong case series này.
Ngoài ca thứ 5, 4 ca đầu do bs Nguyễn Trung Kiên (khoa Nội soi tiêu hoá Medic) chọn.

LAO VÚ và VIÊM VÚ DO LAO

Introduction

Tuberculosis (TB) of the breast is a rare disease despite the fact that TB affects one to two billion people worldwide.TB is a chronic granulomatous disease caused by Mycobacterium, predominantly Mycobacterium tuberculosis. In 1829, TB of the breast was first described by Sir Ashley Cooper as ‘scrofulous swellings in the bosom’ of young women suffering from enlargement of the cervical lymph nodes.
TB remains a major problem in many parts of the world. It is more common in undeveloped countries but is re-emerging in the West. The globalisation of TB is related to the prevalence of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), the emergence of multi-medication-resistant strains of TB and the increased movement of people (travel and immigration). Until recently, most cases of TB of the breast have been reported in South Africa and India. However, even in endemic areas, TB of the breast has not been commonly reported. It has, in fact, been described as ‘rare’.


Results

From 2002 to 2008, 21 patients were identified that met the criteria for the study. The age range was from 27 to 74 years, with a mean age of 40 years. Ninety-five percent were female. All the cases except one had unilateral disease. The right breast was involved in 57% of the patients. Seventy-one percent complained of palpable axillary nodes. Fifty-two percent of the patients complained of diffuse breast swelling. Only one patient presented with a discharging sinus. Upon clinical examination, 80% had palpable axillary lymph nodes. Thirty-eight percent had a palpable breast mass, including the male patient who had a chest mass that extended to involve the breast.

Ultrasound was performed in all the patients. Enlarged axillary lymph nodes and an oedematous breast were the most common findings on ultrasound. Eighty percent of the patients had enlarged axillary lymph nodes on ultrasound. The axillary lymph nodes that were positive for TB or ‘suspicious for TB’ varied in size in short axis diameter from 10 to 41 mm. Absence of the normal fatty hilum or cortical thickening was present. The shape of the nodes ranged from oval to round. Sixty-two percent of the patients had an oedematous breast on ultrasound. The ultrasound features of an oedematous breast include increased echogenicity of the parenchyma and dilated lymphatics. Skin thickening could be appreciated in these patients on ultrasound.

The intramammary masses varied in appearance on ultrasound. Unilocular abscess formation was noted in three (14%) patients. Two (10%) patients had well-defined, smoothly marginated nodules that were hypoechoic to isoechoic on ultrasound. Both of these patients also had enlarged ipsilateral axillary lymph nodes. In these two patients, both the axilla and the breast were subject to FNA and both results were ‘suspicious for TB’. In the two patients (10%), multiple, complex intercommunicating collections were present in the breast.

Patients above 35 years of age were selected for mammography and this was performed in 10 patients (48%). One 38-year-old patient was incorrectly not assessed mammographically. Forty percent of the mammograms had a diffuse increase in density in the affected breast when compared with the normal breast. A focal increase in density was seen in 40% of the mammograms. Coarsened trabecular markings were noted to be diffuse in 40% and focal in 20%. Forty percent of the mammograms revealed diffuse skin thickening. Seventy percent of the patients had enlarged axillary lymph nodes visible on mammography. An intramammary mass was present in 40% of the mammograms.

All the patients in the study were subjected to ultrasound-guided FNA of the breast mass and/or an axillary lymph node. The male patient with the chest wall mass had a single-core biopsy in addition to the FNA. The number of passes for the FNA ranged from one to three per lesion.

Fifteen patients underwent FNA of axillary lymph nodes. Of these 15 patients, nine were confirmed for TB (60%) and six (40%) were suspicious for TB. The seven intramammary FNA results showed five (71%) to be positive for TB and two (29%) to be suspicious for TB. The one chest wall mass was positive for acid fast bacilli.

The results were obtained with TB BACTEC culture or Ziehl–Neelsen staining. Thirteen were positive on TB BACTEC culture and two were positive on Ziehl–Nielsen staining only for acid fast bacilli. Three were positive on both BACTEC culture and Ziehl–Neelsen staining. Five were ‘morphologically highly suspicious for TB’. The mean number of days to diagnosis with BACTEC culture was 27 ± 12.5 days.

Discussions

TB accounts for less than 0.1% of all breast lesions in Western countries and approximately 4% of all breast lesions in TB endemic countries. Mammary tissue appears to provide a relatively infertile environment for the survival and multiplication of the TB bacilli.  The relative lack of lymphoid tissue within the breast may be in part responsible for this. The significance of TB of the breast lies in recognising the disease entity as it can mimic breast cancer or pyogenic breast abscess.

The disease is very rare in males (4% of cases), which was confirmed in our study where only one patient (5%) was male. Females tend to present in the reproductive years (20–40 years) of age. In our study, there was a mean age of 40 years. The frequent changes the breast undergoes in this period may make the breast more liable to trauma and infection. In pregnant and lactating females, the ducts are dilated and there is increased vascularity of the breast. The breast is also more predisposed to trauma and infection.
The disease is reported to be bilateral in only 3% of cases. Similarly in our study, only one case (5%) was bilateral. Different series demonstrate predominance of the left breast  or of the right breast. Fifty-seven percent of our series involved the right breast.

The risk factors for TB of the breast appear to be related to AIDS, multiparity, lactation, previous suppurative mastitis and trauma. In the setting of our study, HIV is a major risk factor. A study at this hospital in 2006 found the level of concurrent TB and HIV co-infection to be 95%. The incidence of HIV in this series is not known and can only be inferred from the data of the 2006 study.

Tuberculous mastitis (TBM) is classified as primary or secondary. Primary TBM is extremely uncommon and is confined only to the breast. Secondary TBM is seen when there is coexisting TB elsewhere in the body. However, an extramammary source is identified in less than 15% of cases.

The routes of infection include the following: lymphatic, haematogenous, spread from contiguous structures, direct inoculation and ductal infection.

Centripetal lymphatic spread is the most accepted view for spread of infection. Here, the spread of disease from the lungs to the breast can be traced via tracheobronchial, paratrachael, mediastinal and internal mammary nodes. According to Cooper's theory, communication between the axillary glands and the breast results in secondary involvement of the breast by retrograde lymphatic extension. In 50–75% of cases of TBM, axillary lymph node involvement was present, lending support to this hypothesis.Our series would support this view with the most common presentation being that of enlarged axillary lymph nodes in 71% of the patients ( Figs 2,3).

Figure 2. Right mediolateral oblique mammogram. The axillary lymph nodes are infiltrated with TB. The skin is thickened and the breast is oedematous secondary to the axillary adenopathy.
Figure 3. Normal left mediolateral oblique mammogram for comparison.

Breast tissue appears to be resistant to haematogenous spread of TB.  In an autopsy series of 34 patients who had died of miliary TB, TB was demonstrated in almost all organs except the breast.
Direct extension of TB from contiguous structures such as infected rib, costochondral cartilage, sternum, shoulder joint, pleura or skin can occur occasionally. The one male patient in our series presented in this manner with extension of TB from the chest wall into the breast.

TB of the faucial tonsils of suckling infants may spread to the lactiferous sinus of the breast resulting in primary TBM. This is not an important mode of spread in developed countries.
Clinical presentation is commonly a painless lump, which is usually ill-defined and irregular. It may be a hard mass, clinically indistinguishable from a cancerous mass. The upper outer quadrant is the most common site. There may be oedema of the breast with extensive involvement of the axillary lymph nodes. Fistulous tracts and breast abscesses may occur. In our series, the incidence of fistulous tracts was only 5%.

TB of the breast has been classified into three main types:

1. Nodular: 

The nodular form is slow growing. If immunity is good and there is low virulence of the organism, the inflammatory process is limited to the formation of a non-caseating granuloma producing a well-defined, smoothly marginated nodule. Macrocalcification may be associated with this nodule. Thickening of the surrounding breast parenchyma and Cooper's ligaments is minimal. Ultrasound features of this type of TBM resemble a fibroadenoma in that they are well-defined hypoechoic masses with posterior acoustic enhancement (see Fig. 4).

Figure 4. Ultrasound breast demonstrating an isoechoic nodule. This is the nodular form of TB of the breast.

If there is abscess formation, perilesional oedema or scarring, the nodule is irregular in outline mimicking a cancer. In our series, 14% of the patients presented with intramammary collections in keeping with unilocular abscess formation (see Figs 5,6).

Figure 5. Ultrasound of a TB of the breast abscess.

Figure 6. Ultrasound of a hypoechoic TB collection of the breast.

In this study, five patients were classified as nodular TB of the breast. This is 24% of the patients studied. Two of the five patients presented with well-defined, smoothly marginated nodules within the breast, accounting for 10% of the study group. The remaining three (14% of the study) had unilocular abscess formation.

2. Disseminated: 

The diffuse form is seen with more virulent infection and poor immune response. In this form, multiple foci of TB intercommunicate and develop into abscesses. Irregular margins with skin thickening are noted in the diffuse form. On mammography, the centre of the lesion is less dense than the periphery due to fluid breakdown centrally. The imaging findings may mimic an inflammatory cancer with skin thickening. On ultrasound, the abscess is characterised by a heterogeneous, hypoechoic mass with irregular margins and posterior acoustic enhancement. The presence of mobile internal echoes is highly suggestive of abscess formation.
Two of our patients (10%) had multiple intercommunicating abscesses. These were seen as multiple complicated interconnecting collections with surrounding oedema, which was demonstrated both mammographically and with ultrasound.

3. Sclerosing: 

Fibrosis is the dominant feature of the sclerosing form. Mammographic features vary according to the degree of fibrosis present producing two main features on mammography. The breast becomes denser as fibrosis develops and is more localised to the involved quadrant. In addition, as the Cooper's ligaments become involved by the fibrotic process, there is retraction and atrophy of the breast. The atrophy of the breast is a distinguishing feature from malignancy.
The reticular scarring and interlobular oedema may obscure an underlying mass mammographically and for this reason ultrasound is important to assess the breast further.

No patients in this study were classified as sclerosing.

Further imaging findings, not falling into the above classification, have been described. These include ductal involvement occurring secondary to direct inoculation of the organism into their ostia. Retroareolar linear densities are seen mammographically, and on ultrasound there are dilated debris filled ducts.
Healed granuloma appears as calcifications on mammography. The calcifications are predominantly microcalcifications.
Skin changes may be evident mammographically. The skin may be oedematous and thickened. A sinus tract may be evident as a localised area of skin thickening and a bulge in the contour of the skin.
Intramammary or extramammary lymph node enlargement may also be visible on imaging. In previous reports, the lymph nodes maintain benign features, i.e. are 1 cm long in the short axis, retain the sinus fat lucency and have oval shape. In contrast, our series reveals the lymph nodes to have a pathological appearance with loss of the normal fatty hilum and enlargement up to 41 mm in short axis. Ultrasound is sensitive in detecting and characterising axillary lymph nodes (see Fig. 7).

Figure 7. Ultrasound of an axillary lymph node that is infiltrated by TB. The node is enlarged, rounded and has lost the fatty hilum.

In this study, the predominant presenting feature was that of enlarged axillary lymph nodes with associated skin thickening and diffused oedema of the breast. In this group, this is the most common presentation and distinguishes this study from other studies of TB of the breast (see Table 4).

The role of ultrasound is that of a complimentary modality to the mammogram. In suspected TB of the breast, ultrasound should be performed. The value of ultrasound is in its ability to differentiate solid from cystic lesions, identifying nodules masked by the coarse stroma and assessing the lymph node status. Ultrasound is also the means for biopsy and percutaneous abscess drainage and may add information when excluding malignancy.

A four-limb strategy of clinical assessment, mammography (patients in this study over the age of 35 years were selected for mammography), ultrasound and FNA is required to make the diagnosis.
Imaging with MRI has not been extensively used in TBM. A breast abscess will demonstrate a ring-like bright signal intensity on T2-weighted images. In post-gadolinium, there is a non-specific enhancement seen in abscesses and cancers. The value of MRI is in determining the extramammary extent of the disease.
Treatment of TB associated breast disease at this institute follows the 2009 South African National TB guidelines. The recommendation is the same regimen for extra-pulmonary TB (TB of the breast) as for pulmonary TB.

The standard treatment regimen for patients who have never had TB is a 2-month intensive phase with four medications (isoniazid, rifampicin, pyrazinamide and ethambutol), which results in rapid killing of bacilli. The subsequent 4-month continuation phase with two medications (isoniazid and rifampicin) eliminates the remaining bacilli.

Patients who received previous TB treatment for at least 4 weeks have a higher risk of medication resistance and receive an extended regimen. The intensive phase lasts 3 months with the addition of a fifth medication, the injectable streptomycin to the standard four medications for the first 2 months. The continuation phase with three medications (isoniazid, rifampicin and ethambutol) lasts 5 months.

In summary, TB patients receive fixed dose combinations of between two and five medications for 6–8 months depending on the stage of therapy and whether they have previously been treated for TB.

Conclusion

TB of the breast is an uncommon disease even in endemic countries; however, it should be considered in the differential diagnosis of breast pathology as it may mimic inflammatory breast cancer and pyogenic abscess. The most common presentation in this series is that of a swollen oedematous breast secondary to enlarged axillary lymph nodes. FNA of the enlarged axillary lymph nodes and/or breast mass with confirmation of TB on Ziehl–Neelsen staining or BACTEC culture is required for the diagnosis of this uncommon disease.


BÀN LUẬN VỀ CHẨN ĐOÁN LAO VÚ TẠI MEDIC:

1/ Chẩn đoán dựa vào siêu âm trước tiên (90%, do đó là chủ yếu), nhũ ảnh, sinh thiết (phần lớn lao vú chỉ được chẩn đoán chính xác bằng mô học với các tổn thương mô hạt (granulomatous), hoại tử bã đậu (caseum), đại bào Langhans) và nhuộm trực khuẩn kháng acid bằng phương pháp Ziehl-Neelsen (tỉ lệ dương tính thường thấp).

Các phương tiện hình ảnh học khác ngoài siêu âm chỉ giúp xác định bệnh lan rộng, có tính cách định hướng và phân biệt (hơn là để chẩn đóan). Tuy nhiên nhũ ảnh khó phân biệt giữa ác tính và lao vú.


2/ Thường gặp nhất là thể lan toả. Thể xơ teo (sclerosing) và carcinoma kết hợp với lao vú chưa gặp bao giờ.

Hình 3 thể lao vú: thể lan toả, thể nốt và thể xơ teo (Hình của bs Nguyễn Duy Thư, Lao vú và CĐHA) 




3/ Với siêu âm đàn hồi Shear Wave Elastography: Dùng elastography để bổ sung chẩn đoán phân biệt trong tạo hình siêu âm về lao vú (và ung thư vú).

Khối lao vú có đặc điểm rất cứng ở viền ngoại biên, độ đàn hồi E= >120kPa (đỏ), vùng trung tâm mềm, không đồng nhất, có vùng có độ đàn hồi E= 60kPa (xanh hoặc không có tín hiệu). Còn trong ung thư mô mềm có vùng hoại tử thì ngược lại: bản đồ màu thiên về màu đỏ (cứng) và dàn đều từ ngoài vào trong.

Đặc điểm elastogram trên giúp chọn vị trí sinh thiết, nên chọn những vị trí màu đỏ (cứng), vì nếu sinh thiết nhầm vào chỗ màu xanh (mềm) hoặc mất tín hiệu (vì hoại tử) thì sẽ có kết quả âm tính giả.

SEVERITY of CARPAL TUNNEL SYNDROME and COLOR DOPPLER FINDINGS

TÓM TẮT:

MỤC TIÊU. Hội chứng ống cổ tay (carpal tunnel syndrome, CTS) là một trong những bệnh l‎í bẫy thần kinh (entrapment mononeuropathies) ngoại biên phổ biến nhất. Mục đích nghiên cứu là để đánh giá tương quan tiềm tàng giữa tăng tưới máu trong dây thần kinh, siết mạc giữ gân gấp (flexor retinaculum bowing), và tiết diện dây thần kinh giữa và mức độ nghiêm trọng của CTS trong các trường hợp được khảo sát dẫn truyền thần kinh xác nhận.



ĐỐI TƯỢNG VÀ PHƯƠNG PHÁP. Gồm 60 bệnh nhân với triệu chứng kinh điển hay có thể xảy ra các triệu chứng của CTS trong nghiên cứu. Một nhóm chứng gồm 27 tình nguyện viên lành mạnh chưa bao giờ được chẩn đoán CTS hoặc có bất kỳ triệu chứng của CTS được chọn trong số nhân viên của viện. Tất cả bệnh nhân có triệu chứng được kiểm tra ban đầu bởi một bác sĩ phẫu thuật bàn tay và sau đó khám siêu âm và điện sinh l‎í.

KẾT QUẢ. Gồm 90 cổ tay (ở 60 bệnh nhân) trong nghiên cứu. Hai mươi tám ca (31,1%) có CTS nhẹ, ca 33 bệnh trung bình và 29 ca có bệnh nặng. Chúng tôi phát hiện thấy tương quan đáng kể giữa tăng tưới máu thần kinh giữa và mức độ nặng của CTS (p = 0,01, hồi quy logistic) cho CTS trung bình và (p = 0,04) ở bệnh nặng. Chúng tôi cũng tìm thấy tương quan đáng kể trong flexor retinaculum bowing và tiết diện dây thần kinh giữa với sự gia tăng mức độ nặng của CTS (p <0,001 và < 0,008; test chi-bình phương và phân tích đa biến).



KẾT LUẬN. Nghiên cứu của chúng tôi cho thấy độ nặng của CTS tương quan mạnh với những phát hiện siêu âm Doppler màu, và kỹ thuật này có thể là một công cụ bổ sung đáng tin cậy trong khám hội chứng ống cổ tay (CTS) .



PAPILLARY LESIONS of the BREAST

Abstract


• OBJECTIVE. The purpose of this article is to describe the different imaging appearances of benign and malignant papillary lesions of the breast as well as to point out potential errors of interpretation that can lead to misdiagnosis.

• CONCLUSION. There is a wide spectrum of appearances of papillary lesions of the breast on MRI, ultrasound, and mammography. This variable appearance of papillary lesions makes differentiation of benign from malignant pathologies difficult on imaging, and tissue sampling is usually warranted.

COMPRESSIBILITY of THYROID MASSES

Tóm tắt


MỤC TIÊU : Nhằm đánh giá ấn khối tuyến giáp với đầu dò siêu âm bằng tay và để xác định liệu tính năng siêu âm này có thể được sử dụng để phân biệt tổn thương tuyến giáp lành tính với ác tính không.

ĐỐI TƯỢNG VÀ PHƯƠNG PHÁP. Chúng tôi so sánh tiền cứu hình ảnh thu được khi ấn với đầu dò siêu âm và hình ảnh siêu âm không ấn của 180 khối tuyến giáp bệnh l‎‎‎‎í (51 ác tính, 129 lành tính) nhỏ hơn 2 cm ở 169 bệnh nhân (127 nữ, 42 nam; tuổi bình quân 51,2 năm). Kích thước (chiều trước sau và chiều ngang) và dạng (tỷ lệ kích thước trước sau - ngang) của các tổn thương đã được đo bằng cả hai tạo hình siêu âm không ấn và có ấn tại một máy tính trạm, và tính độ ấn (tỷ lệ trước sau-ngang của tạo hình không ấn trừ đi tỷ lệ trước sau-ngang trên hình có ấn). Độ ấn được phân tích để xác định mức kết hợp với kết quả mô bệnh học (lành tính so với ác tính) và các đặc tính của các khối tuyến giáp (thùy nào, vị trí thùy, halo, và thành phần). Khu vực dưới đường cong đặc trưng hoạt động nhận (AUROC) được sử dụng như là một chỉ báo về hiệu suất.

KẾT QUẢ. Tỷ lệ bình quân trước sau-ngang của khối tuyến giáp trên hình siêu âm có ấn thấp hơn có ý nghĩa đáng kể so với hình không ấn (0,78 ± 0,28 vs 0,92 ± 0,30; p < 0,001). Độ ấn của khối lành tính lớn hơn tổn thương ác tính (0,19 ± 0,16 vs 0,05 ± 0,12; p < 0,001). Không có ý nghĩa thống kê giữa các kết hợp được xác định giữa độ ấn với các đặc tính khác của tổn thương. AUROC cho ấn khối tuyến giáp là 0,78. Với giá trị ngưỡng độ ấn nhỏ hơn 0,10 cho bệnh l‎í ác tính, độ nhạy, độ đặc hiệu và độ chính xác lần lượt là 72,5%, 72,9% và 72,8%.

KẾT LUẬN. Ấn với đầu dò siêu âm là một tiêu chí hữu ích giúp phân biệt tổn thương tuyến giáp lành tính với ác tính.