The feasibility of shear wave elastography for diagnosing superficial benign soft tissue masses

Surgical Excision of Lipomas in Bilateral Upper Limbs and Right Thigh: A Case Report

Lipomas are common benign soft tissue tumors composed primarily of mature adipose tissue. They are often encountered clinically due to their characteristic slow growth, typically as soft, painless, subcutaneous nodules. While lipomas are generally asymptomatic, surgical intervention is sought by patients when they lead to discomfort, cosmetic concerns, or functional impairment. In this case report, we present the successful surgical excision of 25 lipomas in the bilateral upper limbs and right thigh of a 43-year-old male. Pre-operative assessment, precise surgical technique, and post-operative care are highlighted as essential management components. The case emphasizes the importance of individualized treatment, ensuring symptomatic lipomas' diagnosis and effective management. This report serves as a valuable reference for healthcare professionals caring for patients with lipomatous lesions, contributing to understanding soft tissue tumor management.

Practical approach to ultrasound of soft tissue tumors and the added value of MRI: how I do it

This review outlines a practical approach to the everyday assessment of both non-neoplastic and neoplastic soft tissue tumors, focusing on ultrasound examination, though emphasizing the added benefit of magnetic resonance imaging in certain instances. Ultrasound approach and assessment, practical scenarios, reporting, biopsy, and follow-up are covered, as well as the criteria used to distinguish benign from malignant tumors. The potential benefits and current limitations of elastography and contrast-enhanced ultrasound in assessment are also addressed. Examples of commonly encountered soft tissue tumors are shown. Ultrasound can characterize most soft tissue masses based on their ultrasound appearance alone. Following ultrasound examination, three potential scenarios usually exist in clinical practice: (a) confident regarding diagnosis, (b) indeterminate mass with no evidence of malignancy, and (c) indeterminate mass with possibility of malignancy. A diagnostic pathway for each of these scenarios is provided. Magnetic resonance imaging is generally not helpful in further characterizing masses which are indeterminate on ultrasound assessment, though it is helpful in addressing other issues such as exact tumor location and neurovascular bundle involvement that may not be fully resolved on ultrasound examination. In these situations, magnetic resonance imaging examination can be tailored to address those specific questions that have not been adequately addressed on ultrasound examination. In this sense, both examinations are highly complementary. Tips for undertaking magnetic resonance imaging examinations are provided.

Ultrasonography of fibroma of the tendon sheath in the hand and wrist

BACKGROUND

The purpose of our study was to explore the sonographic characteristics of fibromas of the tendon sheath of the hand and wrist and to evaluate the value of high frequency ultrasound in the diagnosis of FTS.

METHODS

We retrospectively reviewed the sonography of 42 patients with surgically proven FTS, including one with a relapsing tumor (43 lesions in total). The location, size, distribution, relationship with the surrounding tissue, two-dimensional gray-scale sonographic appearance and internal color blood flow of all lesions were analysed.

RESULTS

The maximum diameter ranged from 0.4 to 2.8 cm, with an average of 1.5 ± 0.6 cm. Twenty-eight lesions (65%) were associated with an adjacent tendon, while the other 15 lesions (35%) were next to the joint. Spindle or oval lesions were common, followed by irregular shape. The nodules with clear boundaries were hypoechoic and had posterior echo enhancement. Thirty-seven lesions (86%) were homogeneous, while 6 lesions (14%) had cystic components with no echo inside. Seventeen lesions (40%) had a large amount of blood flow. Nine lesions (20%) had a small amount of blood flow. The other 17 lesions (40%) had no significant blood flow.

CONCLUSIONS

The diagnosis of fibroma of the tendon sheath can be considered when ultrasound examination reveals a focal nodular mass adjacent to a tendon sheath with homogeneous hypoechogenicity and no or small or large amounts of blood flow.

Comparison of diagnostic potential of shear wave elastography between breast mass lesions and non-mass-like lesions

BACKGROUND

Shear wave elastography (SWE) can improve the specificity of B-mode ultrasound (US) without reducing the sensitivity for breast cancer diagnosis. Existing research on SWE includes both mass lesions and non‑mass‑like (NML) lesions or only NML lesions; however, there are no studies comparing the diagnostic potential of SWE in the detection of mass and NML lesions in the same trial.

OBJECTIVE

This study aimed to compare the diagnostic performance of SWE in detecting mass lesions and NML lesions and determine the different individualised thresholds of the SWE parameters according to the lesion type.

METHODS

This Study included 623 breast lesions of 562 consecutive women, who were scheduled for conventional US and SWE between January 2021 and December 2021. The diagnostic performances of conventional US and each quantitative SWE parameter (maximum elastic modulus [Emax], mean elastic modulus [Emean], and elastic modulus standard deviation [Esd]) were assessed. Histological diagnosis for all Breast Imaging Reporting and Database System (BI-RADS) category 4/5 patients and some BI-RADS category 3 patients and the follow-up results of other BI-RADS category 3 patients were used as the reference standard.

RESULTS

In this study, 281 benign lesions and 342 malignant lesions were identified. The diagnostic performance of conventional US and SWE was better in the mass lesion group than in the NML lesion group. Every SWE parameter had a different threshold in each group, and the thresholds of the SWE parameters were higher in the mass lesion group than in the NML lesion group. In the mass lesion group, Esd had the highest Az value, whereas in the NML lesion group, Emax had the highest Az value. In both the mass and NML lesion groups, the diagnostic specificity of the combination of conventional US and SWE was significantly higher than that of conventional US alone (P < 0.05), without a significantly decrease in the diagnosticsensitivity.

CONCLUSIONS

SWE could increase the confidence of breast ultrasound diagnosis, especially for NML lesions. NML lesions had lower thresholds of SWE parameters than did the mass lesions.

Performance of Sonoelastography for predicting malignancy in soft tissue

BACKGROUND

Separating benign from malignant soft-tissue masses often requires a biopsy. The objective of this study was to assess whether shear-wave elastography (SWE) helped to separate benign from malignant soft-tissue masses.

METHODS

In 2015-2016, we prospectively included patients with soft-tissue masses deemed by our multidisciplinary sarcoma board to require a diagnostic biopsy. All patients underwent ultrasonography (US) followed by SWE to measure elasticity. We compared benign and malignant tumors, overall and after separating tumors with vs. without a fatty component. The biopsy findings, and surgical-specimen histology when available, served as the reference standard.

RESULTS

We included 136 patients, 99 with non-fatty and 37 with fatty soft-tissue masses. Mean elasticity and tumor-to-fat elasticity ratio (T/F) values were significantly lower for the benign than the malignant soft-tissue masses in the overall cohort (30.9 vs. 50.0 kilopascals (kPa), P = 0.03; and 2.55 vs. 4.30, P = 0.046) and in the non-fatty subgroup (37.8 ± 31.9 vs. 58.9 ± 39.1 kPa, P = 0.049 and 2.89 ± 5.25 vs. 5.07 ± 5.41, P = 0.046). Data for fatty tumors were non relevant due to lack of conclusive results. By receiver operating characteristics curve analysis, a T/F cutoff of 3.5 had 46% sensitivity and 84% specificity for separating benign and malignant soft-tissue masses.

CONCLUSIONS

SWE had good specificity and poor sensitivity for separating benign from malignant soft-tissue masses.

Ultrasonographic and strain elastographic features of epidermal cyst according to body location

BACKGROUND

There are not many studies on the differences of ultrasound (US) findings between epidermal cysts (ECs) located in the trunk and those in the extremities.

PURPOSE

To compare the sonographic findings of ECs according to location in the body (trunk vs. extremity) and evaluated the feasibility of strain elastography (SE).

MATERIAL AND METHODS

This is a retrospective study of 76 patients with surgically confirmed non-ruptured EC who underwent US including SE. The US analyses included size, shape, ratio of depth to length (DLR), involvement of more than half the dermis, "submarine sign," and SE characters of each lesion. SE findings were assigned into four grades based on elasticity.

RESULTS

The submarine sign was more significantly observed in ECs located in the trunk versus extremities (P value = 0.004 and 0.035, respectively). Truncal lesions were significantly more likely to possess an ovoid shape (P < 0.05) and exhibited higher DLR (P < 0.05). There were more cases with low elasticity according to SE (grade 3 or 4) compared to high elasticity (grade 1 or 2). However, we did not observe significant differences between the two locations (P > 0.05). More-than-half signs also did not exhibit a significant difference (P > 0.05).

CONCLUSION

The submarine sign, ovoid shape, and tall lesions (higher DLR) are common in the trunk. However, the degree of elasticity and number of more-than-half signs did not differ between the two groups.

Epidermoid cyst in ureter: A case report

RATIONALE

Uro-originated epidermoid cysts, especially located in the upper urinary tract are rare and only 4 cases of epidermoid cyst occurring in the upper urinary tract have been reported worldwide so far. In the previous cases, the cysts were diagnosed as tumors and organs were removed.

PATIENT CONCERNS AND DIAGNOSIS

We report a case of epidermoid cyst in ureter in a 48-year-old female patient admitted to the local hospital suffering from paroxysmal pain in the right hypochondriac for 8 years.

INTERVENTIONS AND OUTCOMES

She underwent right ureteroscopy in order to rule out the possibility of urinary epithelial carcinoma. The tumor was pathological diagnosed as a benign ureterocyst epidermoid. Postoperatively, the patient showed good recovery. During the 24-month follow-up period, the patient remained well and free of complications.

CONCLUSION

This case illustrates that benign epidermoid cysts can appear in the ureter, although it is extremely rare. It also indicates that perioperative examinations must be exhaustive to avoid the further injury to the patients.

The reproducibility of shear wave and strain elastography in epidermal cyst

Purpose

This study evaluated epidermal cyst elasticity using multiple parameters of strain elastography (SE) and shear wave elastography (SWE) and assessed the reproducibility of each parameter.

Methods

This retrospective study included 73 patients with epidermal cysts who underwent SE and SWE. SE scores were classified as 1-4 according to elasticity. The strain ratio was evaluated using the elasticity ratio of lesions and adjacent subcutaneous fat tissue. For SWE, the shear wave velocity (m/s), elasticity (kPa) according to the Young modulus, velocity ratio, and elasticity ratio were evaluated. All values were measured twice. The reproducibility of SE and SWE measurements was assessed. The relationships among SE and SWE measurements were evaluated.

Results

The strain ratio on SE images showed good reproducibility (intra-class correlation coefficient [ICC]=0.789), and SE scores showed substantial reproducibility (kappa=0.753 and kappa=0.758 for readers 1 and 2, respectively). Moderate reproducibility was found for shear wave velocity and elasticity (ICC=0.750 and ICC=0.648, respectively), as well as for the shear wave velocity of the reference tissue and velocity ratio (ICC=0.747 and ICC=0.713, respectively). All SE scores were positively correlated with the strain ratio (P<0.001). The strain ratio in the second SE session was significantly correlated with the elasticity ratio and velocity ratio in the first SWE session (r=0.245, P=0.037; r=0.243, P=0.038, respectively). Other variables were not correlated.

Conclusion

SE and SWE parameters of epidermal cysts showed moderate to good reproducibility. The strain ratio on SE showed good reproducibility and could provide relatively objective and consistent measurements of epidermal cyst elasticity.

Differentiation of benign and malignant superficial soft tissue lesions using real-time strain elastography

Background/aim

To evaluate benign and malignant cutaneous-subcutaneous lesions using real-time strain elastography (RTSE) and to compare the findings with histopathologic results.

Materials and methods

Over a period of 10 months, 72 patients (38 with benign and 34 with malignant cutaneous and subcutaneous lesions) were prospectively included in this study. Elasticity patterns and strain ratios were examined for each lesion. Lesions were evaluated in 4 groups as yellow-red (soft; pattern-1), green-yellow (moderate; pattern-2), blue-green (hard; pattern-3) and blue (hardest; pattern-4). The stiffness of the lesions was displayed with strain ratios by comparing of a nearby reference tissue. The recorded images were compared with histopathologic findings.

Results

On sonoelastograms, considering patterns 1-2 as benign and patterns 3-4 as malignant, the sensitivity, specificity, and positive and negative predictive values for the differentiation of malignant from benign lesions were 100%, 68.5%, 74%, and 100%, respectively. Considering a cut-off value of the strain ratio as > 3.05, the sensitivity, specificity, and positive and negative predictive values were 91%, 89%, 88%, and 92%, respectively. The area under the curve (AUC: 0.972) showed the excellent ability of strain elastography to differentiate benign and malignant lesions.

Conclusion

RTSE is an important imaging tool to differentiate benign and malignant superficial soft tissue lesions. Our results suggest that RTSE can be used to predict malignancy since malignant lesions are more confidentially diagnosed than benign superficial soft tissue lesions on elastograms.

The diagnostic value of ultrasound and shear wave elastography in the differentiation of benign and malignant soft tissue tumors

AIM

To evaluate the diagnostic value of ultrasound (US) and shear wave elastography (SWE) in the differentiation of benign and malignant soft tissue tumors.

MATERIALS AND METHODS

A hundred and nine patients (mean age 43.3 ± 20.5, range 0-85; 64 men and 45 women) diagnosed with soft tissue tumors between August 2016 and January 2020 were evaluated with US and SWE. The stiffness of the lesions was measured as mean and maximum shear wave velocity (SWV_mean and SWV_max) in meters/second (m/s). Two radiologists evaluated the US images independently and then reached a final consensus. Final diagnosis was obtained either by histopathological examination (core needle biopsy or surgery) or by follow-up. The diagnostic value of US and SWE in the differentiation of malignant and benign lesions was assessed.

RESULTS

Pathology results revealed 37 malignant and 43 benign lesions. Twenty-nine lesions were benign based on follow-up criteria. Consensus US reading revealed 91.9% sensitivity and 72.2% specificity with almost perfect inter-observer agreement (κ = 0.802). Larger lesion size, male gender, advanced patient age, deep location, hypoechoic and hypervascular appearance, ill-defined margins, and presence of cystic area were associated with malignant diagnosis (p < 0.001, p = 0.010, p = 0.001, p = 0.001, p = 0.003, p < 0.001, p = 0.001, and p = 0.011, respectively). Median SWV_mean and median SWV_max of malignant lesions (2.87 and 2.68) were not significantly different than those of the benign lesions (3.30 and 3.05; p = 0.271 and p = 0.402, respectively).

CONCLUSION

US features can differentiate malignant and benign soft tissue tumors, whereas SWE did not contribute to the differentiation of soft tissue tumors.

Evaluation of the ulnar nerve with shear-wave elastography: a potential sonographic method for the diagnosis of ulnar neuropathy

PURPOSE

This study was designed to verify whether shear-wave elastography (SWE) can be used to differentiate ulnar neuropathy at the cubital tunnel from asymptomatic ulnar nerve or medial epicondylitis. An additional aim was to determine a cut-off value to identify patients with ulnar neuropathy.

METHODS

This study included 10 patients with ulnar neuropathy at the cubital tunnel as confirmed with electromyography (three women and seven men; mean age, 51.9 years), 10 patients with medial epicondylitis (nine women and one man; mean age, 56.1 years), and 37 patients with asymptomatic ulnar nerve and lateral epicondylitis (21 women and 16 men; mean age, 54.0 years). Each patient underwent SWE of the ulnar nerve at the cubital tunnel, distal upper arm, and proximal forearm.

RESULTS

Patients with ulnar neuropathy at the cubital tunnel exhibited significantly greater mean ulnar nerve stiffness at the cubital tunnel (66.8 kPa) than controls with medial epicondylitis (21.2 kPa, P=0.015) or lateral epicondylitis (33.9 kPa, P=0.040). No significant differences were observed between patients and controls with regard to ulnar nerve stiffness at the distal upper arm or the proximal forearm. A stiffness of 31.0 kPa provided 100% specificity, 80.0% sensitivity, 100% positive predictive value, and 83.3% negative predictive value for the differentiation between ulnar neuropathy and medial epicondylitis.

CONCLUSION

Cubital tunnel syndrome is associated with a stiffer ulnar nerve than lateral or medial epicondylitis. SWE seems to be a new, reliable, and simple quantitative diagnostic technique to aid in the precise diagnosis of ulnar neuropathy at the cubital tunnel.

What shear wave elastography parameter best differentiates breast cancer and predicts its histologic aggressiveness?

Purpose

This study aimed to identify useful shear wave elastography (SWE) parameters for differentiating breast cancer and predicting associated immunohistochemical factors and subtypes.

Methods

From November 2018 to February 2019, a total of 211 breast lesions from 190 patients who underwent conventional breast ultrasonography and SWE were included. The Breast Imaging Reporting and Data System categories and qualitative and quantitative SWE parameters for each lesion were obtained. Pathologic results including immunohistochemical factors were evaluated. The diagnostic performance of each parameter and its correlation with histological characteristics, immunohistochemical factors, and subtypes of breast cancer were analyzed using analysis of variance, the independent t test, the Fisher exact test, logistic regression analysis, and the DeLong method.

Results

Among 211 breast lesions, 82 were malignant, and 129 were benign. Of the SWE parameters, Emax showed the highest area under the curve (AUC) for differentiating malignant from benign lesions (AUC, 0.891; cut-off>50.85). Poor tumor differentiation and progesterone receptor-negativity were correlated with higher SDmean and Emax (P<0.05). Ki-67-positive breast cancer showed higher SDmean and a heterogeneous color distribution (P<0.05). Ki-67 and cytokeratin 5/6-positive breast cancers showed higher Emax/Efat ratios (P<0.05). Luminal B, human epidermal growth factor receptor 2-enriched, and triple-negative (non-basal) subtypes showed somewhat higher SDmean values than the luminal A and triple-negative (basal) subtypes (P=0.028).

Conclusion

Emax is a reliable parameter for differentiating malignancies from benign breast lesions. In addition, high stiffness and SDmean values in tumors measured on SWE could be used to predict poorly differentiated, progesterone receptor-negative, or Ki-67-positive breast cancer.

Characterization of soft tissue tumours with ultrasound, shear wave elastography and MRI

OBJECTIVE

To predict accurately whether a soft tissue mass was benign or malignant and to characterize its type using ultrasound, shear wave elastography and MRI. We hypothesized that with the addition of shear wave elastography, it would be possible to determine a threshold velocity value to classify a lesion as benign or malignant.

MATERIALS AND METHODS

A total of 151 consecutive, consenting adult patients were prospectively recruited to this study in a tertiary referral musculoskeletal oncology centre. All lesions were assessed with ultrasound, including B mode, Doppler and shear wave elastography measurements. One hundred thirty-eight patients also underwent MRI of the lesion. A histological diagnosis was obtained for all lesions.

RESULTS

Malignant lesions were larger than benign lesions and had a greater Doppler activity. There was no useful threshold shear wave velocity to differentiate between benign and malignant lesions. Longitudinal and transverse shear wave velocities were strongly positively correlated with each other. An inverse correlation was shown with lesion size and depth, regardless of whether it was benign or malignant. A logistic regression model combining the ultrasound and MRI characteristics did not confidently classify a lesion as benign or malignant and was inferior to expert opinion.

CONCLUSION

The strongest predictors of malignancy are large lesion size and high vascularity. The combination of all ultrasound characteristics (including shear wave elastography) and MRI features does not confidently classify a lesion as benign or malignant, and histological diagnosis remains the gold standard.

High resolution ultrasound for imaging complications of muscle injury: Is there an additional role for elastography?

Muscle healing after injury occurs within a period of weeks following a three-phase physiological process. Disruption of the normal healing process may lead to a number of complications, including excessive scar formation, myositis ossificans, muscle atrophy, muscle cysts and hernias. Complications of muscle injury are important because they may be symptomatic, are associated with high risk of re-injury and compromise muscle performance, thus delaying return to sporting activity and requiring special treatment. High-resolution ultrasound imaging equipped with high-frequency probes and advanced B-mode and Doppler technology has emerged as a promising modality for the diagnosis, grading and follow-up of muscle injury. Ultrasound allows imaging of minimal scar formation, early detection of myositis ossificans and cysts, and dynamic evaluation of small muscle hernias. Ultrasound imaging combined with strain and shear wave elastography can also provide information on the mechanical properties of intact and diseased muscle tissue, thus allowing assessment of muscle biomechanics in the clinical setting. This article reviews the histology and ultrasound appearance of normal and abnormal muscle healing with an emphasis on the sonographic appearances of muscle injury complications. It also discusses pitfalls, provides tips for an less experienced sonographer and presents the possible role of strain elastography in the diagnosis of complications, such as scar tissue.

Sonographic appearance of sebaceous cysts. Our experience and a review of the literature

Sebaceous cysts are benign enveloped nodules resulting from an obstruction of a hair follicle. Although they are very common, differential diagnosis is not obvious and may include many diseases. Ultrasound examination with high frequency probes, in the hands of a skilled operator, is the gold standard for noninvasive evaluation of these diseases. The aim of our study was to describe sonographic patterns found in our experience with high frequency probes. We decided to reevaluate the sonographic appearance of the last 100 patients with sebaceous cysts that were under our observation through conducting a retrospective study. All lesions were examined by a skilled radiologist with an Esaote MyLab 70 XVG ultrasound unit and a dedicated 18 MHz linear probe, sometimes supplemented by 20 MHz. In these skin lesions, we evaluated morphology, size, vascularity, and especially the visibility of skin pores, a characteristic of sebaceous cysts. We found 118 lesions that were mostly located on the trunk. In the majority of cases, the skin lesions had an oval-shaped morphology - 114 (96.6%) - and were hypoechoic in appearance -108 (91.5%). In 60 (50.8%) cases, the skin lesions showed a homogeneous appearance, known as "pseudotestis". The average ultrasound examines with very high frequency probes allowed to evidence skin pores. Our retrospective study on higher frequency probes confirms the data in literature regarding the diagnosis of sebaceous cysts, demonstrating the high incidence and clinical significance of evidence of the so-called epidermal punctum.