Sonographic Elastography of Mastitis

Chronic mastitis manifest as complex breast cyst in ultrasound and the role of elastography: A case series

This case series aims to describe the clinical presentation of mastitis, the conventional sonography and elastography findings, and histopathological features in the diagnosis of chronic mastitis. We present 3 cases of breast swelling in young ladies with one of the cases is related to breastfeeding with similar imaging appearance of complex breast cyst and the histopathology finding of chronic mastitis. We will describe the role of elastography in evaluating and differentiating the benign and malignant complex breast cyst.

The "Halo Appearance" of Shear Wave Elastography in the Setting of Fat Necrosis: A Potentially Useful Sonographic Discriminator

OBJECTIVE

To describe the morphologic sonographic appearances and frequency of the "halo sign" in the setting of fat necrosis on shear wave elastography (SWE).

METHODS

Patients with clinically suspected fat necrosis were prospectively scanned using SWE in addition to standard gray-scale and Doppler images. Cases were qualitatively grouped into one of three sonographic appearances: focal hypoechoic lesion with increased internal tissue stiffness ("focal stiffness"), focal hypoechoic lesion with isoechoic or hyperechoic periphery demonstrating increased tissue stiffness relative to the central hypoechoic lesion ("halo stiffness"), heterogeneously echogenic lesion with diffusely increased stiffness ("heterogeneous stiffness").

RESULTS

Exactly 19 patients met inclusion criteria (female n = 14; male n = 5). Shear wave velocities were recorded and retrospectively evaluated. The mean clinical follow-up was 11.4 months (range 3.0-25.5). Lesions demonstrated higher average tissue stiffness than background tissue (overall mass shear wave velocity 3.26 m/s, background 1.42 m/s, P < .001; lesion Young's modulus 40.85 kPa vs background 7.22 kPa, P < .001). The halo sign was identified in 10/19 (55%) patients.

CONCLUSION

The halo sign is a potentially useful sign in the setting of fat necrosis seen in the majority of clinically suspected cases.

Evaluation of ARFI elastography for detecting active mastitis in sheep with previous fibrous lesions: a study of mammary parenchyma and supramammary lymph nodes

The aim of the study was to evaluate the use of Acustic Radiation Force Impulse (ARFI) elastography in mammary parenchyma and supramammary lymph nodes, for detection of active mastitis in sheep with naturally infected chronic fibrous lesions. 27 female sheep were included and B-mode ultrasound and ARFI elastography images were obtained, acquiring qualitative (echogenicity and echotexture) and quantitative (shear rate, depth and short/long axis ratio) variables of 48 mammary glands. The glands were divided into three experimental groups: control group (CG) - healthy animals; LSCC- animals that presented fibrous lesions and SCC (somatic cell count) less than 500 x 103 cls/mL; HSCC: animals that presented fibrous lesions and SCC (somatic cell count) more than 500 x 103 cls/mL; The qualitative variables using B-mode ultrasonography, including echotexture and echogenicity, showed no significant differences between the evaluated groups and tissues (p = 0.9336 and p = 0.233, respectively) .In healthy areas of the gland, it was an increasing in shear wave velocity (SWV) in LSCC than in HSCC (p=0.04). When comparing the fibrosis in the LSCC and HSCC groups with their respective normal areas, the velocity increased in both groups: LSCC (p= 0,0007) and HSCC (p= 0,0001). When comparing the areas of fibrosis in LSCC and HSCC with the CG parenchyma, there was an increase in LSCC (p=0.001) and HSCC (p=0.0001). B-mode ultrasound indicate predominance of hypoechoic echogenicity in lymph nodes and reduced short/long axis ratio in cases of active subclinical mastitis. The supramammary lymph node showed increased SWV when comparing the CG with HSCC groups (p=0.02) and GC with LSCC (p=0.04). B-mode ultrasonography is useful for evaluating the mammary parenchyma, however, its application as a standalone diagnostic technique is not recommended. ARFI elastography indicates potential cutoff points for differentiating subclinical mastitis from healed mastitis, highlighting its importance as a tool for distinguishing normal areas from fibrous parenchymal areas. While this study did not establish specific cutoff points due to sample size limitations, further research with larger sample sizes could explore and define these critical thresholds.

Differential diagnosis of B-mode ultrasound Breast Imaging Reporting and Data System category 3-4a lesions in conjunction with shear-wave elastography using conservative and aggressive approaches

BACKGROUND

The high false-positive rates of US Breast Imaging Reporting and Data System (BI-RADS) category 3-4a breast lesions leads to excessive biopsies of many benign lesions, and our aim was to investigate the diagnostic performance achieved by adding a maximum elasticity (Emax) of shear-wave elastography (SWE) to ultrasound (US) to evaluate US BI-RADS category 3-4a breast lesions using conservative and aggressive approaches. We explored the capacity of using this method to avoid unnecessary biopsies without increasing the probability of missing breast cancers.

METHODS

A total of 123 breast lesions of 120 patients classified as BI-RADS category 3 or 4a were enrolled from January 2019 to December 2019. The US features were evaluated according to the US BI-RADS lexicon. The maximum diameter measured on the US was defined as the size of the lesion. The Emax was assessed by SWE, and the average Emax of breast lesions on two images were calculated and recorded as the final maximum Young's modulus. The diagnostic performance of the combined B-mode US and SWE approach for BI-RADS category 3-4a breast lesions was tested using a conservative approach and an aggressive approach. In the conservative approach, the lesions were downgraded with Emax of 30 kPa or less and upgraded with Emax of 160 kPa or more. In the aggressive approach, the lesions were downgraded with Emax of 80 kPa or less and upgraded with Emax of 160 kPa or more. Pathologic results were defined as the reference standard.

RESULTS

Among all 123 breast lesions, there were 60 lesions classified as BI-RADS category 3 and 63 lesions classified as BI-RADS category 4a. Compared to the B-mode US, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, and area under the receiver operating characteristic (ROC) curve (AUC) of the combined B-mode US and SWE with a conservative approach changed from 88.9% to 94.4%, 55.2% to 60.0%, 25.4% to 28.8%, 96.7% to 98.4%, 60.2% to 65.0%, and 0.721 to 0.772, respectively. The specificity, PPV, and accuracy of combined B-mode US and SWE with an aggressive approach increased from 55.2% to 72.4%, 25.4% to 29.3%, and 60.2% to 71.5%, respectively, but this was accompanied with decreases in the sensitivity from 88.9% to 66.7%, the NPV from 96.7% to 92.7%, and the AUC from 0.721 to 0.695.

CONCLUSIONS

The addition of SWE improves the diagnostic performance of breast US. Adding the diagnostic criteria of SWE to the BI-RADS assessment of B-mode US, downgrading the lesions with Emax 30 kPa or less, and upgrading the lesions with Emax 160 kPa or more helped discriminate low suspicion lesions from benign lesions in order to decrease false-positive findings and avoid missing cancer diagnosis.

Evaluation of Different Types of Breast Lesions With Apparent Diffusion Coefficient and Shear Wave Elastography Values: Comparison of Shear Wave Elastography and Apparent Diffusion Coefficient in Breast Lesions

Objective:

The aim of this study was to compare the stiffness of different histological types of breast lesions by obtaining shear wave elastography (SWE) and apparent diffusion coefficient (ADC) values, and to determine the contribution of these two methods to the diagnosis.

Materials and Methods:

In total, 70 patients with biopsy-proven breast lesions were included in the study. The mean SWE values of breast lesions were recorded and ADC values of these lesions were calculated. Receiver operating characteristic (ROC) curve analyses and the diagnostic accuracies of SWE-ADC values were determined.

Results:

The mean SWE values were 45.47 ± 25.11 kPa and 3.51 ± 1.04 m/s in benign group, and 161.11 ± 219.34 kPa and 5.96 ± 1.06 m/s in malignant group, respectively. The mean ADC values were 1.38 ± 0.32 (×10–3 mm2/s) in benign group and 0.96 ± 0.22 (×10–3 mm2/s) in malignant group, respectively. When the diagnostic performances of both imaging modalities on mass stiffness are evaluated, statistically significant negative correlations were found between SWE lesion values and ADC lesion values.

Conclusion:

Evaluation of tissue elasticity has recently been used frequently in the diagnosis of breast diseases. SWE-ADC values, which are negatively correlated in the diagnosis of breast masses, may prove to be a powerful alternative diagnostic tool that can be used interchangeably, as appropriate.

Does ARFI elastography complement B-mode ultrasonography in the radiological diagnosis of idiopathic granulomatous mastitis and invasive ductal carcinoma?

BACKGROUND

Idiopathic granulomatous mastitis (IGM) is a chronic, unpleasant autoimmune inflammatory condition and is clinically and radiologically often confused with breast malignancy.

PURPOSE

To investigate the contributions of qualitative and quantitative aspects of acoustic radiation force impulse (ARFI) elastography to the differential diagnosis between IGM and invasive ductal carcinoma (IDC) in the breast.

MATERIAL AND METHODS

Ninety-four women with IDC and 39 with IGM were included in the study. Shear wave velocity (SWV) was calculated for all lesions using quantitative elastography. Next, each lesion's correspondence on qualitative elastographic images to those on the B-mode images was evaluated: pattern 1, no findings on elastography images; pattern 2, lesions that were bright inside; pattern 3, lesions that contained both bright and dark areas; and pattern 4, lesions that were dark inside. Pattern 4 was subdivided into 4a (dark area same size as lesion) and 4b (dark area larger than lesion size). Sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy were calculated.

RESULTS

The mean SWV based on ARFI elastography was 3.78 ± 1.26 m/s for IGM and 5.34 ± 1.43 m/s for IDC lesions (P < 0.05). Based on qualitative ARFI elastography, IDC lesions were mostly classified as pattern 4b, while IGM lesions were mostly classified as pattern 1 or 2 (P = 0.01). Evaluation of both the qualitative and quantitative aspects of ARFI elastography yielded a sensitivity of 89% and specificity of 84%.

CONCLUSION

ARFI elastography may facilitate the differential diagnosis between IGM and IDC.

Evaluation of ulcerative colitis activity using transabdominal ultrasound shear wave elastography

BACKGROUND

Transabdominal ultrasound (US) has been reported to be effective in the evaluation of ulcerative colitis (UC). US can measure shear wave elastography (SWE) and shear wave dispersion (SWD), which may be correlated with inflammation and necrosis. We aimed to investigate the relationship between UC activity and SWE and SWD.

METHODS

Patients with UC who underwent US within 2 days before or after a colonoscopy between April 2019 and March 2020 were included. SWE and SWD were measured in the sigmoid colon; the correlations of SWE and SWD with the Lichtiger index and the Ulcerative Colitis Endoscopic Index of Severity (UCEIS) were investigated. We also compared SWE and SWD between patients with mucosal healing and those in the active phase according to the UCEIS.

RESULTS

Twenty-six UC patients were enrolled. The median Lichtiger index, UCEIS, SWE values, and SWD values were 8 [interquartile range (IQR), 5.3-10.8], 4 (IQR, 3.3-5), 1.69 (IQR, 1.49-2.16) m/s, and 11.9 (IQR, 10.9-13.3) (m/s)/kHz, respectively. The Lichtiger index and UCEIS were negatively correlated with the SWE values (rs=-0.404 and rs=-0.506) but not with the SWD values (rs=0.004 and rs=0.002). The SWE values differed significantly between the mucosal healing and active phase groups [2.40 (IQR, 2.18-3.38) vs. 1.62 (IQR, 1.44-1.95) m/s, P=0.007], whereas the SWD values did not [13.1 (IQR, 7.05-21.6) vs. 11.9 (IQR, 11.1-13.2) (m/s)/kHz, P=0.918].

CONCLUSIONS

SWE may be useful for the evaluation of UC activity and could be a noninvasive method of assessing disease severity.

Breast Elastography: How to Perform and Integrate Into a "Best-Practice" Patient Treatment Algorithm

Breast elastography has been available for more than 15 years but is not widely incorporated into clinical practice. Many publications report extremely high accuracy for various breast elastographic techniques. However, results in the literature are extremely variable. This variability is most likely due to variations in technique, a relatively steep learning curve, and variability in methods between vendors. This article describes our protocol for performing breast elastography using both strain elastography and shear wave elastography, which produces high sensitivity and specificity. Additionally, we will describe the most commonly known false-positive and false-negative lesions as well as how to detect them.

Breast Ultrasound during Lactation: Benign and Malignant Lesions

Background

Structural changes during lactation make breast physical examination difficult. When breast problems occur, patients are often referred for an ultrasound (US) scan. Most breast lesions diagnosed in these patients are benign, but the diagnosis of breast cancer is a challenge. We aim to demonstrate the spectrum of US imaging findings in lactating women.

Methods

77 breastfeeding patients who underwent breast US in our department between February 2012 and March 2017 were evaluated. Patients' electronic medical records were reviewed for the presenting complaint, US reports, pathology results if available, and clinical/radiologic follow-up. All examinations were performed by 2 radiologists.

Results

28 of the 77 patients had normal US findings. Cysts were seen in 16 patients. 4 patients had stable fibroadenomas. 6 patients had US imaging findings suggestive of mastitis, 5 patients had galactoceles, 1 patient had an abscess, and 1 patient had unilateral hypertrophy without any accompanying lesion. In 13 patients, BI-RADS 3 solid masses were diagnosed. Invasive breast cancer was diagnosed in 3 patients.

Conclusion

US can demonstrate or exclude a true mass against the background of a nodular breast parenchyma. Radiologists must be aware of malignant US features to avoid delays in the diagnosis of pregnancy-associated breast cancer.

Future of breast elastography

Both strain elastography and shear wave elastography have been shown to have high sensitivity and specificity for characterizing breast lesions as benign or malignant. Training is important for both strain and shear wave elastography. The unique feature of benign lesions measuring smaller on elastography than B-mode imaging and malignant lesions appearing larger on elastography is an important feature for characterization of breast masses. There are several artifacts which can contain diagnostic information or alert to technique problems. Both strain and shear wave elastography continue to have improvements and new techniques will soon be available for clinical use that may provide additional diagnostic information. This paper reviews the present state of breast elastography and discusses future techniques that are not yet in clinical practice.

Farrerol Relieve Lipopolysaccharide (LPS)-Induced Mastitis by Inhibiting AKT/NF-κB p65, ERK1/2 and P38 Signaling Pathway

Farrerol has been proved to have an anti-inflammatory effect. However, the effects of farrerol on mastitis have not been investigated. This study was aimed to investigate the effect and mechanism of farrerol in lipopolysaccharide (LPS)-induced mouse mastitis and LPS-induced inflammatory response of mouse mammary epithelial cells (mMECs). In vivo, LPS were injected to the tetrad pair of nipples for establishing mouse mastitis, and then tested the effect of farrerol on histopathological changes, inflammatory response and activation degree of protein kinase B (AKT), nuclear factor-kappa B p65 (NF-κB p65), p38, extracellular regulated protein kinase (ERK1/2). In vitro, the mMECs were incubated by farrerol for 1 h following by stimulating with LPS, and then the inflammatory response and the related signaling pathways were detected. The in vivo results found that farrerol could improve pathological injury of mammary gland, attenuate the activity of myeloperoxidase (MPO), inhibit the production of pro-inflammatory mediators and the phosphorylation of AKT, NF-κB p65, p38 and ERK1/2. The in vitro results also found farrerol inhibited inflammatory response and the related signaling pathways. Collectively, this study revealed that farrerol inhibits the further development of LPS-induced mastitis by inhibiting inflammatory response via down regulating phosphorylation of AKT, NF-κB p65, p38, and ERK1/2. These findings suggest that farrerol may be used as an anti-inflammatory drug for mastitis.

Resveratrol inhibits LPS-induced mice mastitis through attenuating the MAPK and NF-κB signaling pathway

Resveratrol is a natural polyphenol extracted from mangy plants. It has been reported that resveratrol show multitudinous positive role in biology such as anti-oxidant, anti-nociception and anti-inflammatory effects. Therefore, the present study devotes to test the effect of resveratrol on LPS-induced mastitis in mice. Resveratrol was administered intraperitoneally 1 h before LPS treatment. And the anti-inflammatory effect of resveratrol was measured by histopathological examination, MPO assay, real-time PCR and western blotting analysis. The results showed that resveratrol significantly reduced the LPS-induced mammary histopathological changes. Meanwhile, it sharply attenuated the activity of MPO. The result also indicated that the resveratrol can decrease the expression of pro-inflammatory cytokines TNF-α and IL-1β. From the results of western blotting, resveratrol suppressed the expression of phosphorylation of p65 and IκB from NF-κB signal pathway and phosphorylation of p38 and ERK from MAPK signal pathway. These findings suggested that resveratrol may inhibit the inflammatory response in the mastitis.