Contrast-Enhanced Color Doppler Ultrasonography for Preoperative Evaluation of Sentinel Lymph Node in Breast Cancer Patients

The Value of Contrast-Enhanced Ultrasound in the Detection of Sentinel Lymph Nodes in Malignant Melanoma

OBJECTIVE

To evaluate the location and characterization value of contrast-enhanced ultrasound (CEUS) in the detection of sentinel lymph nodes (SLNs) in malignant melanoma.

METHODS

SLNs and the lymph node network were tracked by subcutaneous injection of ultrasonic contrast agent around the tumor and preoperative localization, and qualitative analyses were performed. The SLNs were also detected by the intraoperative subcutaneous injection of carbon nanoparticles, and the findings were compared with lymph nodes located by CEUS. The accuracy of the preoperative lymph node identification was evaluated by the results of postoperative pathology, which served as the gold standard of detection.

RESULTS

In 47 patients with malignant melanoma, the mean number of SLNs detected by CEUS was 1.72 ± 0.10, while that by carbon nanoparticle administration it was 1.79 ± 1.07 (P = .371 > .05). Seven cases of lymph node metastasis were detected by CEUS, with a sensitivity of 70.0%, specificity of 97.3%, positive predictive value of 87.5%, negative predictive value of 92.3%, and accuracy of 91.5%. There was high consistency between the findings of CEUS and pathology in differentiating benign and malignant lymph nodes (kappa = 0.726, χ²  = 25.243, P < .001).

CONCLUSIONS

CEUS can localize and differentiate SLNs in malignant melanoma, and thus, may potentially guide clinical treatment in the future.

Study on Sentinel Lymph Node and Its Lymphatic Drainage Pattern of Breast Cancer by Contrast-Enhanced Ultrasound

OBJECTIVES

Sentinel lymph node (SLN) and its lymphatic drainage pattern (LDP) of breast cancer were studied by contrast-enhanced ultrasound (CEUS).

METHODS

From July 2017 to December 2019, patients with SLN localization of breast cancer in Sichuan Academy of Medical Sciences·Sichuan Provincial People's Hospital were selected. The sentinel lymph system of breast cancer was observed by CEUS before both operation and blue staining in the surgery. The location, number, and route of sentinel lymphatic channel (SLC) were recorded, along with the number, size, and the depth from skin of SLN. LDPs were summarized according to these basic characteristics of SLC and SLN.

RESULTS

A total of 368 cases were included; 465 SLCs and 423 SLNs were detected. Most of the SLCs were originated from the outer upper quadrant of areola. Eleven LDPs were found, including 31 subtypes of LDPs. There were 6 cases of type A (1.63%), 15 cases of type B (4.08%), 223 cases of type C (57.88%), 38 cases of type D (10.33%), 2 cases of type E (0.54%), 3 cases of type F (0.82%), 50 cases of type G (13.59%), 30 cases of type H (8.15%), 2 cases of type I (0.54%), 6 cases of type J (1.63%), and 3 cases of type K (0.82%).

CONCLUSIONS

The most common LDP of breast cancer was one SLC originated from the upper quadrant of areola with one SLN. CEUS can identify the LDP before surgery to reduce the false negative rate of SLN biopsy.

Trans-lymphatic contrast-enhanced ultrasound with sentinel lymph node biopsy for detecting cervical skip metastasis to lymph nodes in early-stage oral tongue squamous cell carcinoma

OBJECTIVES

The purpose of this study was to assess whether trans-lymphatic contrast-enhanced ultrasound (CEUS) combined with sentinel lymph node biopsy can be used to assess the status of cervical lymph nodes and skip metastasis in patients with early squamous cell carcinoma (SCC) of the oral tongue.

METHODS

This study included 21 subjects with early oral tongue SCC who received multiple intramucosal peritumoral injections of Sonazoid. CEUS examinations were performed immediately after Sonazoid injection to identify sentinel lymph nodes (SLNs). The SLNs were excised for histological examination to determine if the lymph nodes has metastases.

RESULTS

Thirty-five SLNs were detected by CEUS after Sonazoid injection in the subjects. SLNs were identified in 20 of the total 21 subjects. Four participants had metastasis to lymph nodes, and one had skip metastasis in level Ⅲ. In one subject, SLNs were successfully detected in level Ⅳ without skip metastasis.

CONCLUSIONS

Trans-lymphatic CEUS combined with sentinel lymph node biopsy showed high accuracy for evaluating cervical lymph node status. This could be a reliable approach for detecting cervical skip metastases of lymph nodes in early-stage oral cancer patients.

Contrast-Enhanced Ultrasound in Locating Axillary Sentinel Lymph Nodes in Patients with Breast Cancer: A Prospective Study

The objective was to explore the clinical value of contrast-enhanced ultrasound (CEUS) in locating the sentinel lymph node (SLN) in patients with early breast cancer. We screened 143 consecutive patients with breast cancer between July 2017 and August 2019. The number of SLNs identified by CEUS and dual labeling (blue dye and radiolabeled colloid) were recorded. The accuracy of CEUS plus fine-needle aspiration cytology (FNAC) was assessed. The rate of identification of SLNs with CEUS was 84.0% (121/144), and that of dual labeling was 97.92% (141/144). There was no significant association between non-enhancement (p = 0.060) or inhomogeneous enhancement (p = 0.468) and lymph node metastasis. The sensitivity and specificity of CEUS-SLNs plus FNAC was 78.38% and 100%, respectively. The technique of CEUS is a promising method for locating the axillary SLN. But it is hard to identify lymph node metastasis with CEUS alone. CEUS-SLNs plus FNAC is a sound technique for diagnosis of the metastasis of SLN.

Comparative study of two contrast agents for intraoperative identification of sentinel lymph nodes in patients with early breast cancer

Background

The use of contrast-enhanced ultrasound (CEUS) to locate sentinel lymph nodes (SLNs) in breast cancer has been studied more and more in recent years. This prospective study aimed to compare periareolar injection of two different contrast agents, SonoVue^® (SNV) and Sonazoid^® (SNZ), followed by CEUS to identify SLNs in breast cancer patients with clinically negative nodes.

Methods

A total of 205 patients with T1-2N0M0 breast cancer were divided into the SNV group and SNZ group. All were administered a periareolar injection of SNV or SNZ and underwent US to identify contrast-enhanced SLNs. Each contrast-enhanced SLN underwent a biopsy with blue dye and examined again by CEUS in vitro.

Results

In all cases, contrast-enhanced lymphatic vessels were clearly visualized using US soon after the periareolar injection of SNZ, and the SLNs were easily identified. The SLN identification rates were 75.27% (210/279) for SNV and 93.58% (102/109) for SNZ. Although the accuracy of detecting SLN metastasis was slightly different between the two groups, there was no statistically significant difference between those groups (P=0.615). Moreover, it was possible to identify SLNs in vitro in the SNZ group, and these could be compared with the lymph nodes (LNs) located using SNZ during the preoperative stage and with blue dye during the procedure. This helped in determining the resection requirements.

Conclusions

When comparing the subdermal use of SNV and SNZ, no significant differences in the number of detected SLNs and the diagnosis of metastatic LNs were observed. Because SLNs can be detected for a longer time in living tissues with SNZ, this contrast agent may provide more intraoperative information for complete resection of all preoperative localization of SLN.

Establishment of a model for predicting sentinel lymph node metastasis in early breast cancer based on contrast-enhanced ultrasound and clinicopathological features

Background

Sentinel lymph node (SLN) biopsy (SLNB) is the standard procedure for axillary staging in clinically node-negative (cN0) breast cancer patients. However, the positive rate of SLNs among cN0 stage patients is 26-35%. The identification of appropriate candidates for SLNB is quite challenging. This study aimed to establish and verify a predictive model of SLN metastasis using contrast-enhanced ultrasound (CEUS) and other clinicopathological indicators.

Methods

The clinicopathological data of 224 patients who had undergone SLNB at the Affiliated Cancer Hospital of Zhengzhou University from June 2018 to July 2019 were analyzed retrospectively. The risk prediction model of SLN metastasis was established by logistic regression analysis. According to the β value of each variable in the model, a risk score system of SLN metastasis was established and verified using the internal population. The predictive model was prospectively applied to 73 patients from July 2019 to September 2019 to evaluate the clinical value of the model in patients with early breast cancer.

Results

Multivariate analysis confirmed that body mass index (BMI), SLN aspect ratio of CEUS mode, SLN aspect ratio of mammography, lympho-vascular invasion, and cytokeratin (CK)5/6 were independent risk factors for SLN metastasis. A scoring system was established according to the above risk factors, and a receiver operating characteristic (ROC) curve was drawn. After internal- and external verification, a corrected ROC curve was drawn, respectively. The ROC curve of the modeling group, internal verification group, and external verification group was 0.9075 (95% CI: 0.8616-0.9534), 0.8766 (95% CI: 0.8192-0.9341), and 0.8505 (95% CI: 0.7333-0.9676), respectively.

Conclusions

We constructed and verified a prediction model of SLN metastasis in early breast cancer. The model has a specific predictive value for preoperative evaluation of SLN status.

Preoperative evaluation and influencing factors of sentinel lymph node detection for early breast cancer with contrast-enhanced ultrasonography: What matters

Sentinel lymph node (SLN) is important in the early diagnosis of breast cancer. We aimed to evaluate the role of contrast-enhanced ultrasonography (CEUS) in the preoperative evaluation for SLN and potentially influencing factors, to provide evidence to the management of breast cancer.Patients with breast cancer who treated in our hospital from May 2018 to May 2020 were selected. All patients underwent CEUS examination to find SLN and judged whether the lymph node had cancer metastasis. We evaluated the sensitivity, specificity, and accuracy of CEUS in predicting SLN, and its differences in pathological diagnosis results and related influencing factors were also analyzed.A total of 108 patients with breast cancer were included. And a total of 248 SLNs were detected. The sensitivity of CEUS to the preoperative evaluation of SLN was 84.67%, the specificity was 81.14%, the positive predictive value was 76.08%, and the negative predictive value was 89.27%, the positive likelihood ratio was 4.06, and the negative likelihood ratio was 0.14. The area under the curve of the preoperative evaluation of SLN in CEUS examination was 0.813 (95% confidence interval: 0.765-0.911), and there was significant difference in the size of SLNs between SLN-negative and SLN-positive groups (P = .043).Preoperative CEUS has good predictive value for the SLN detection in patients with breast cancer, and it is worthy of clinical application.

Percutaneous Sonazoid-enhanced ultrasonography combined with in vitro verification for detection and characterization of sentinel lymph nodes in early breast cancer

Objectives

To assess the efficacy of percutaneous Sonazoid-enhanced ultrasound and in vitro verification for identification sentinel lymph nodes (SLNs) and diagnosis of metastatic SLNs in patients with early breast cancer (BC).

Methods

Sixty-eight patients with early BC were enrolled finally. After the induction of general anesthesia, 0.4 ml of Sonazoid (SNZ), a new second-generation tissue-specific ultrasound contrast agent (UCA), mixed with 0.6 ml of methylene blue, was injected intradermally. The lymphatic vessels and connected SLNs were immediately observed and marked. After being resected, these SLNs were soaked in saline water and examined still in the mode of contrast-enhanced ultrasound (CEUS) in vitro. This procedure could ensure that all the enhanced nodes had been removed as much as possible. The numbers of SLNs detected by UCA and blue dye were recorded. The enhancement patterns of SLNs were compared with the final pathological results.

Results

SLNs detection rate by SNZ-CEUS was 100%, which was higher than that by blue dye (95.59%). CEUS identified a median of 1.5 nodes, while blue dye identified a median of 1.9 nodes per case (p = 0.0012). When homogeneous high perfusion and complete annular high perfusion were regarded as negative nodes, the sensitivity and negative predictive value were 92.31% and 96.79% respectively, while the specificity was 84.21%.

Conclusions

Percutaneous SNZ-enhanced ultrasonography combined with in vitro verification is a feasible and reliable method for SLNs identification intraoperatively. Enhancement patterns can be helpful in determining the status of SLNs.

Key Points

• CEUS with percutaneous injection of Sonazoid can successfully identify SLNs with the rate of 100% in early breast cancer patients, higher than 95.59% of blue dye.

• Sonazoid, with high affinity with reticuloendothelial cells, increases the imaging time of SLNs and facilitates biopsy intraoperatively better than Sonovue as a lymphatic tracer.

• Homogenous high and complete annular high perfusions have a sensitivity of 92.31% and a negative predictive value of 96.79% in the prediction of uninvolved SLNs.

Clinical Utility of Contrast-enhanced Ultrasound for the Diagnosis of Lymphadenopathy

This meta-analysis aimed to evaluate the diagnostic accuracy of contrast-enhanced ultrasonography (CEUS) in identifying lymphazdenopathy. PubMed, Web of Science, Embase and the Cochrane Library were searched for relevant articles through September 2020. A total of 16 articles, which included 1787 participants, were analyzed. The summary sensitivity, specificity, positive likelihood ratio (LR), negative LR and diagnostic odds ratio of CEUS for diagnosing lymphadenopathy were 0.88 (0.86-0.90), 0.90 (0.88-0.92), 6.04 (3.67-9.95), 0.15 (0.10-0.21) and 47.38 (23.45-95.66), respectively. The summary receiver operating characteristic (SROC) area under the curve (AUC) was 0.9405. After omitting outliers identified in a bivariate box plot and forest plot, heterogeneity was decreased, and the pooled sensitivity and specificity were 0.87 (0.84-0.90) and 0.87 (0.84-0.90), respectively. Furthermore, the SROC AUC was 0.9327. In conclusion, CEUS has the potential to be a valuable tool for characterizing lymphadenopathy and could provide clinical decision support.

Correlation between the contrast-enhanced ultrasound image features and axillary lymph node metastasis of primary breast cancer and its diagnostic value

PURPOSE

To analyze the correlation between contrast-enhanced ultrasound image features and axillary lymph node metastasis of primary breast cancer and its diagnostic value.

METHODS

In this study, 64 patients with axillary lymph node metastasis of primary breast cancer diagnosed and treated in our hospital from February 2011 to March 2013 were collected as an observation group, and 54 patients without axillary lymph node metastasis were collected as a control group. All patients underwent a contrast-enhanced ultrasound examination, and the correlation between the contrast-enhanced ultrasound image features and axillary lymph node metastasis and its diagnostic value were analyzed. They were divided into two groups according to their survival conditions: the group with good efficacy and group with poor efficacy, and the prognostic factors of breast cancer in the two groups were analyzed.

RESULTS

There were statistical differences in the peripheral acoustic halo, blood flow classification, ratio of length to diameter (L/D), maximum cortical thickness, and enhancement mode of lymph nodes between the two groups (p < 0.05). The area under ROC curve for diagnosis of axillary lymph node metastasis by contrast-enhanced ultrasound was 0.854, sensitivity was 83.33%, and specificity was 87.5%; L/D and enhancement mode were independent prognostic factors for breast cancer.

CONCLUSIONS

Contrast-enhanced ultrasound image features have diagnostic and prognostic value for axillary lymph node metastasis of breast cancer.

New technologies in breast cancer sentinel lymph node biopsy; from the current gold standard to artificial intelligence

Sentinel lymph node biopsy is an important diagnostic procedure performed in early breast cancer patients with clinically negative axillary lymph nodes. Detection and examination of sentinel lymph nodes determine further therapy decisions, therefore a choice of optimal technique minimising the risk of false-negative results is of great importance. Currently, the gold standard is the dual technique comprising the blue dye and radiotracer, however, this method creates a logistical problem for many medical units. The intrinsic constraints of the existing methods led to the development of a very wide range of alternatives with varying clinical efficiency and feasibility. While each method presents with its own advantages and disadvantages, many techniques have improved enough to become a non-inferior alternative in the sentinel lymph node biopsy. Along with the improvement of the existing technologies, there are evolving trends such as multimodality of the techniques maximising the diagnostic outcome or an emerging use of artificial intelligence (AI) improving the workflow of the procedure. This literature review aims to give an overview of the current status of the standard techniques and emerging cutting-edge technologies in the sentinel lymph node biopsy.

Color Doppler Ultrasound Improves Machine Learning Diagnosis of Breast Cancer

Color Doppler is used in the clinic for visually assessing the vascularity of breast masses on ultrasound, to aid in determining the likelihood of malignancy. In this study, quantitative color Doppler radiomics features were algorithmically extracted from breast sonograms for machine learning, producing a diagnostic model for breast cancer with higher performance than models based on grayscale and clinical category from the Breast Imaging Reporting and Data System for ultrasound (BI-RADS_US). Ultrasound images of 159 solid masses were analyzed. Algorithms extracted nine grayscale features and two color Doppler features. These features, along with patient age and BI-RADS_US category, were used to train an AdaBoost ensemble classifier. Though training on computer-extracted grayscale features and color Doppler features each significantly increased performance over that of models trained on clinical features, as measured by the area under the receiver operating characteristic (ROC) curve, training on both color Doppler and grayscale further increased the ROC area, from 0.925 ± 0.022 to 0.958 ± 0.013. Pruning low-confidence cases at 20% improved this to 0.986 ± 0.007 with 100% sensitivity, whereas 64% of the cases had to be pruned to reach this performance without color Doppler. Fewer borderline diagnoses and higher ROC performance were both achieved for diagnostic models of breast cancer on ultrasound by machine learning on color Doppler features.

Role of gamma probe-assisted intraoperative sentinel lymph node evaluation in predicting axillary breast cancer metastasis after neoadjuvant chemotherapy

OBJECTIVE

Intraoperative sentinel lymph node biopsy is a universally accepted technique to identify patients who are candidates for axillary lymph node dissection during breast cancer surgery. However, there is controversy over its use in patients who underwent preoperative neoadjuvant chemotherapy. This study aimed to examine the diagnostic value of gamma probe-assisted intraoperative sentinel lymph node examination with frozen section in breast cancer patients who had undergone preoperative neoadjuvant chemotherapy.

METHODS

This retrospective study included 94 tumors diagnosed with stage IIA, IIB or IIIA invasive breast cancer with locoregional lymph node metastasis who underwent surgical treatment after neoadjuvant chemotherapy. Intraoperatively, axillary sentinel lymph node sampling was done using radioactive colloid and gamma probe and materials were examined with frozen section method. Patients with positive sentinel nodes underwent axillary resection. Histopathological examination of all surgical samples was done postoperatively.

RESULTS

In 87 of 94 tumors (92.6%), a sentinel lymph node could be identified using the method. The sensitivity, specificity and accuracy of the method for predicting axillary macro metastasis were 85.7, 86.5 and 86.2%, respectively, with 5.7% false negative rate.

CONCLUSIONS

Sentinel lymph node identification using preoperative scintigraphy and intraoperative use of gamma probe seems to be a feasible and efficient method in terms of differentiating patients that require axillary lymph node dissection during breast cancer surgery, even when they have received neoadjuvant chemotherapy. Further large prospective studies allowing subgroup analyses are warranted.

A Prospective Validation Cohort Study of a Prediction Model on Non-sentinel Lymph Node Involvement in Early Breast Cancer

BACKGROUND

Early breast cancer with one or two sentinel lymph nodes (SLNs) may omit axillary lymph node dissection (ALND) if followed by radiotherapy. However, only less than one-third of the patients have positive non-SLNs and can truly benefit from radiotherapy. Before any regional treatment decision, the risk of non-SLN metastasis must be identified. The authors previously developed a predictive model for non-SLN involvement using CK19 mRNA and contrast-enhanced ultrasound (CEUS) score in a training set. They designed a further study to evaluate the predictive effect using the model prospectively in a validation set of one or two involved SLNs.

METHODS

This study identified early breast cancer patients at Zhejiang Cancer Hospital from July 2017 to June 2018. The CK19 mRNA tested by quantitative real-time polymerase chain reaction and CEUS scores were collected before surgery. Patients with one or two involved SLNs were enrolled and underwent ALND. The estimated percentage of non-SLN involvement was calculated by the authors' model formula and the Memorial Sloan Kettering Cancer Center (MSKCC) nomogram. The false-negative rates, predictive accuracy, and area under curve (AUC) were compared between two predictive models.

RESULTS

The study enrolled 235 patients, and 35.36% (83/235) of them had non-SLN involvement. The authors' model had a false-negative rate of 6% and an accuracy of 94.9%. The AUC was 0.952 (95% confidence interval [CI] 0.922-0.982), which was significantly higher than that of the MSKCC model at all three cutoff value levels.

CONCLUSION

The authors' model, using CK19 mRNA and the CEUS score, showed the potential predictive value of non-SLNs before surgery for early breast cancer patients.

CLINICALTRIALS REGISTRY

NCT02992067, NCT03280134.

Percutaneous contrast-enhanced ultrasound for localization and diagnosis of sentinel lymph node in early breast cancer

This study assessed the efficacy of percutaneous contrast-enhanced ultrasound (CEUS) in localization sentinel lymph node (SLNs) for biopsy and diagnosis of metastatic SLNs in patients with early breast cancer. From January to November 2017, seventy-five patients with early breast cancer confirmed by pathology were enrolled in this study. CEUS was performed after subdermal injection of ultrasound contrast agent (SonoVue, 2.0 ml in total dose) around the areola on the ipsilateral side of the breast. The contrast-enhanced lymphatic vessels and associated SLNs were observed and traced in real time. The lymphatic vessels and SLN were mapped and labeled on the skin surface. Sentinel lymph node biopsy (SLNB) was performed after injection of 2.0 ml methylene blue at same injection site of SonoVue. The accuracy of percutaneous CEUS localization of SLNs was determined compared to blue dye injection technique. The pathological results under blue dye guided biopsy were used as the reference standard to calculate the sensitivity and specificity of CEUS for the diagnosis of SLNs. A total of 163 SLNs obtained through SLNB following methylene blue tracing in 75 patients. There were 116 SLNs identified by percutaneous CEUS. The difference of detection rates between blue dye and CEUS was statistically significant (Z = -2.651, P = 0.008). The identification rate of SLNs by CEUS was 71.17% (116/163). The accuracy of percutaneous CEUS localization of axillary SLNs was 94.67% (71/75) compared to blue dye-guided biopsy. Among the 116 SLNs detected by percutaneous CEUS, pathologic results showed 51 positive SLNs and 65 negative SLNs whiles CEUS findings indicated 83 positive SLNs and 33 negative SLNs. Only 50 of 83 SLNs had metastasis on pathology, while 33 were detected as false positive. The sensitivity and specificity of CEUS for the diagnosis of metastatic SLN was 98.04%(50/51) and 49.23%(32/65), respectively. Percutaneous CEUS can be used as an effective method to localize the SLNs for guiding SLNB. This method has excellent sensitivity for identifying the SLNs but lower specificity for detecting metastatic SLNs in patients with early stage breast cancer.

How Pre-operative Sentinel Lymph Node Contrast-Enhanced Ultrasound Helps Intra-operative Sentinel Lymph Node Biopsy in Breast Cancer: Initial Experience

We aimed to evaluate the value of sentinel lymph node contrast-enhanced ultrasound (SLN-CEUS) and surface tracing for the biopsy of intra-operative sentinel lymph nodes (SLNs). Between June 2015 and December 2017, a total of 453 patients with early invasive breast cancer were recruited. Patients received an intradermal injection of microbubble contrast agent around the areola on the day before surgery. The locations and sizes of lymphatic channels (LCs) and SLNs were marked on the body surface using gentian violet. Then, injection of double blue dye was performed half an hour before surgery. We compared the pathway of LCs and the location of SLNs obtained from SLN-CEUS and blue dye during surgery. Among the 453 patients, the mean numbers of LCs and SLNs detected by SLN-CEUS were 1.42 and 1.72, respectively, and the coincidence rate was 98.2% compared with blue dye during surgery. The median distance from the SLN to skin measured by pre-operative CEUS and blue dye was 1.95 ± 0.69 and 2.03 ± 0.87 cm (p = 0.35). There were three SLN enhancement in our research, including homogeneous enhancement, inhomogeneous enhancement and no enhancement, with the sensitivity, specificity, positive predictive value and negative predictive value of SLN-CEUS for the diagnosis of SLNs being 96.82%, 91.91%, 87.54% and 98.01%, respectively. SLN-CEUS with skin marking can identify the pathway of LCs and the location of the SLN before surgery, measure the distance from the SLN to skin and determine if the SLN is metastatic. SLN-CEUS can be used as an effective complement to the blue dye method.

ACR Appropriateness Criteria® Monitoring Response to Neoadjuvant Systemic Therapy for Breast Cancer

Patients with locally advanced invasive breast cancers are often treated with neoadjuvant chemotherapy prior to definitive surgical intervention. The primary aims of this approach are to: 1) reduce tumor burden thereby permitting breast conservation rather than mastectomy; 2) promptly treat possible metastatic disease, whether or not it is detectable on preoperative staging; and 3) potentially tailor future chemotherapeutic decisions by monitoring in-vivo tumor response. Accurate radiological assessment permits optimal management and planning in this population. However, assessment of tumor size and response to treatment can vary depending on the modality used, the measurement technique (such as single longest diameter, 3-D measurements, or calculated tumor volume), and varied response of different tumor subtypes to neoadjuvant chemotherapy (such as concentric shrinkage or tumor fragmentation). As discussed in further detail, digital mammography, digital breast tomosynthesis, US and MRI represent the key modalities with potential to help guide patient management. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Risk factors associated with the progression and metastases of hindgut neuroendocrine tumors: a retrospective study

BACKGROUND

The worldwide incidence of neuroendocrine tumors (NETs) has increased remarkably, with the hindgut being the second most common site for such tumors. However, the mechanisms underlying progression and metastasis of hindgut NETs are unclear. A retrospective study was conducted to elucidate these mechanisms.

METHODS

Clinicopathological data of cases of hindgut NET between April 1996 and September 2015 were analyzed, retrospectively. Patients with neuroendocrine carcinoma were excluded. Formalin-fixed paraffin-embedded tissues of hindgut NET cases were subjected to detailed morphometric and immunohistochemical analyses. Statistical analyses were performed using the non-parametric Mann-Whitney U test, Spearman's correlation coefficient, and chi-squared test. Multivariate logistic regression analysis was conducted as appropriate for the data set.

RESULTS

Fifty-six hindgut NET cases were considered. Microvessel density and lymphatic microvessel density were identified as significant risk factors for venous and lymphatic invasion. There was a positive correlation between microvessel density and the maximum tumor diameter. Multivariate logistic regression analysis revealed that the maximum tumor diameter alone was an independent predictor of lymph node metastasis, whereas lymphovascular invasion and MVD was not the predictor of lymph node metastasis. There were no significant correlations between the Ki-67 labeling index and any of the parameters evaluated including age, sex, the maximum tumor diameter, venous invasion, lymphatic invasion, microvessel density, lymphatic microvessel density, and lymph node metastasis.

CONCLUSIONS

Angiogenic mechanisms may play important roles in the progression of hindgut NET. Otherwise, the maximum tumor diameter alone was an independent predictor of lymph node metastasis in hindgut NETs. Moreover, our study raises the question of whether the presence of lymphovascular invasion, in endoscopically obtained hindgut NET tissues, is an absolute indication for additional surgery or not.

Correlation analysis between the parameters of contrast-enhanced ultrasonography in evaluating cervical cancer metastasis and expression of E-cadherin

The study aims to investigate the correlation between the parameters of contrast-enhanced ultrasonography in evaluating cervical cancer metastasis and expression of E-cadherin. All 120 patients with cervical cancer underwent contrast-enhanced ultrasonography. According to the results of postoperative pathological examination, patients were divided into distant metastasis group (group A), lymph node metastasis without distant metastasis group (group B) and no metastasis group (group C). Expression of E-cadherin in cervical cancer tissues was detected by enzyme-linked immunosorbent assay (ELISA). Correlations between the parameters of contrast-enhanced ultrasonography in evaluating cervical cancer metastasis and expression of E-cadherin were analyzed by Pearsons correlation analysis. Comparison of parameters of contrast-enhanced ultrasonography showed that, the baseline intensity of group A was 11.9±2.2 dB, which was significantly lower than that of group B and C. Baseline intensity of group B was significantly lower than that of group C (13.0±2.4 vs. 15.3±3.6 dB), significant differences were found among three groups (P<0.05). The sensitivity and specificity of the use of enhanced intensity ~83.7 dB in evaluating tumor metastasis of patients with cervical cancer were 82.42 and 79.32%, respectively. Expression level of E-cadherin protein in group A was 0.030±0.003 ng/ml, which was significantly lower than that in group B and C (P<0.05), expression level of E-cadherin protein in group A was significantly lower than that in group C (0.037±0.007 vs. 0.045±0.012 ng/ml), significant differences in the expression level of E-cadherin protein were found among the three groups of cervical cancer patients (P<0.05). Pearsons correlation analysis showed that there was a positive correlation between the baseline intensity of contrast-enhanced ultrasonography and the expression level of E-cadherin (P<0.05), while there was a negative correlation between the enhanced intensity of contrast-enhanced ultrasonography and the expression level of E-cadherin (P<0.05). Contrast-enhanced ultrasonography can be used to determine the tumor metastasis of cervical cancer patients, in addition, the combined use of contrast-enhanced ultrasonography and E-cadherin protein expression can significantly improve the diagnosis and treatment of cervical cancer.

The role of ultrasound and lymphoscintigraphy in the assessment of axillary lymph nodes in patients with breast cancer

Breast cancer is the most common malignancy and the leading cause of death due to cancer in European women. Mammography screening programs aimed to increase the detection of early cancer stages were implemented in numerous European countries. Recent data show a decrease in mortality due to breast cancer in many countries, particularly among young women. At the same time, the number of sentinel node biopsy procedures and breast-conserving surgeries has increased. Intraoperative sentinel lymph node biopsy preceded by lymphoscintigraphy is used in breast cancer patients with no clinical signs of lymph node metastasis. Due to the limited sensitivity and specificity of physical examination in detecting metastatic lesions, developing an appropriate diagnostic algorithm for the preoperative assessment of axillary lymph nodes seems to be a challenge. The importance of ultrasound in patient qualification for sentinel lymph-node biopsy has been discussed in a number of works. Furthermore, different lymphoscintigraphy protocols have been compared in the literature. The usefulness of novel radiopharmaceuticals as well as the methods of image acquisition in sentinel lymph node diagnostics have also been assessed. The aim of this article is to present, basing on current guidelines, literature data as well as our own experience, the diagnostic possibilities of axillary lymph node ultrasound in patient qualification for an appropriate treatment as well as the role of lymphoscintigraphy in sentinel lymph node biopsy.