Biopathologic Characterization and Grade Assessment of Breast Cancer With 3-D Multiparametric Ultrasound Combining Shear Wave Elastography and Backscatter Tensor Imaging

OBJECTIVE

Despite recent improvements in medical imaging, the final diagnosis and biopathologic characterization of breast cancers currently still requires biopsies. Ultrasound is commonly used for clinical examination of breast masses. B-Mode and shear wave elastography (SWE) are already widely used to detect suspicious masses and differentiate benign lesions from cancers. But additional ultrasound modalities such as backscatter tensor imaging (BTI) could provide relevant biomarkers related to tissue organization. Here we describe a 3-D multiparametric ultrasound approach applied to breast carcinomas in the aims of (i) validating the ability of BTI to reveal the underlying organization of collagen fibers and (ii) assessing the complementarity of SWE and BTI to reveal biopathologic features of diagnostic interest.

METHODS

Three-dimensional SWE and BTI were performed ex vivo on 64 human breast carcinoma samples using a linear ultrasound probe moved by a set of motors. Here we describe a 3-D multiparametric representation of the breast masses and quantitative measurements combining B-mode, SWE and BTI.

RESULTS

Our results reveal for the first time that BTI can capture the orientation of the collagen fibers around tumors. BTI was found to be a relevant marker for assessing cancer stages, revealing a more tangent tissue orientation for in situ carcinomas than for invasive cancers. In invasive cases, the combination of BTI and SWE parameters allowed for classification of invasive tumors with respect to their grade with an accuracy of 95.7%.

CONCLUSION

Our results highlight the potential of 3-D multiparametric ultrasound imaging for biopathologic characterization of breast tumors.

Ultrasonic imaging of delamination in thick CFRP laminates using an energy-compensation reverse time migration method

In ultrasonic reflection method, the precision of defect detection in thick carbon fiber reinforced plastics (CFRP) is compromised by acoustic energy attenuation. An energy-compensation reverse time migration (ECRTM) method is proposed to identify multiple defects accurately. Forward and backward wavefields are formed using the finite element method within an anisotropic acoustic model based on the Christoffel equation and Bond transformation. To enhance the imaging quality of CFRP laminates, a novel cross-correlation imaging condition is introduced to compensate for energy dissipation caused by geometric diffusion and variations of the far-field radiation intensity at the emitter with the propagation direction. Employing ultrasonic detection technology with a multi-element array, numerical and experimental research on defect imaging was conducted, considering delamination with various sizes and positions in a multidirectional CFRP laminate. In comparison to other ultrasonic imaging methods, the near-surface artifacts in RTM images are mitigated by the far-field radiation directivity factor, while the deep information is enhanced by the geometric diffusion compensation factor in the ECRTM images. As a result, the precise position of delamination in CFRP laminates is achievable, demonstrating superior imaging capabilities, especially for deep delamination.

Gross and ultrasonic morphology of the equine conceptus on days 10 to 40

The gross and ultrasonic equine embryo morphology are described with emphasis on specific days after ovulation. Included are labeled colored photographs and detailed descriptions of the embryo proper (future fetus and foal) and of the entire embryonic vesicle on Days 21, 24, 30, 35/36, and 40. A few related aspects are included for the early fetus on Days 45 and 50. Regression lines for growth in the length of the embryo proper and diameter of the embryonic vesicle along with the mean days of the morphological event are included. Ultrasonograms of the embryonic vesicle are shown and discussed from Days 10 to 45. Major morphological changes in the embryo proper include: (1) appearance of forelimb and hindlimb buds, (2) appearance of the pontine flexure, (3) appearance of the genital tubercle, (4) closure of the pontine flexure, and (5) tapering of limbs toward the midline with hoof-shaped tips. Major changes in the embryonic vesicle are: (1) vascularization of mesoderm, (2) appearance of sinus terminalis, (3) emergence of allantoic sac, (4) formation of embryonic circulatory system, (5) formation and maturation of chorionic girdle, and (6) transition from yolk sac to allantoic sac.

An improved Fourier Ptychography algorithm for ultrasonic array imaging

Inspired by the optical imaging algorithm, the Fourier Ptychography (FP) algorithm is adopted to improve the resolution of ultrasonic array imaging. In the FP algorithm, the steady-state spectrum is utilized to recover the high-resolution ultrasonic images. Meanwhile, the parameters of FP algorithm are empirical, which can affect the imaging quality of ultrasonic array. Then the particle swarm optimization (PSO) algorithm is used to optimize the parameters of FP algorithm to further improve the imaging quality of ultrasonic array. The tungsten imaging experiments and pig eye imaging experiments are conducted to demonstrate the feasibility and effectiveness of the developed algorithm. In addition, the proposed algorithm and the coherent wave superposition (CWS) algorithm are both based on single plane wave (SPW) algorithms and they are then compared. The results show that the CWS algorithm and FP algorithm have good longitudinal and lateral resolutions, respectively. The particle swarm optimization-based FP (PSOFP) imaging algorithm has both excellent lateral and longitudinal resolutions. The average lateral resolution of PSOFP imaging algorithm is improved by 34.47% compared with CWS imaging algorithm in the tungsten wires experiments, and the lateral boundary structure width of the lens is improved by 49.48% in the pig eye experiments. The proposed algorithm can effectively improve the ultrasonic imaging quality for medical application.

Ultrasonic defect detection of high-density polyethylene pipe materials using FIR filtering and block-wise singular value decomposition

Condition monitoring of high-density polyethylene (HDPE) pipes used for fluid and gas transfer is important for the safety of energy conservation and the environment. Ultrasonic phased array imaging methods provide a solution to detect and assess defects in HDPE pipes. However, ultrasonic bulk waves propagating in these viscoelastic media are strongly attenuated, resulting in reduced signal amplitude. In this study, a linear-phase Finite Impulse Response (FIR) filter is used to remove unwanted frequency components from the measured ultrasonic signals to improve the signal-to-noise ratio before applying the imaging algorithm of the total focusing method (TFM). Building upon this, a block-wise singular value decomposition (SVD) technique, which can adaptively determine the singular value cutoff threshold based on each block in the whole TFM image, is used to enhance the obtained TFM image quality. The performance of the combination of FIR filtering and block-wise SVD technique is validated by experimental data of HDPE pipe materials. Results demonstrate that the proposed approach generates good images to provide the detection and characterization of side-drilled holes in HDPE pipe materials.

Improving the quality of ultrasound images acquired using a therapeutic transducer

To enhance the effectiveness and safety of focused ultrasound (FUS) therapy, ultrasound image-based guidance and treatment monitoring are crucial. However, the use of FUS transducers for both therapy and imaging is impractical due to their low spatial resolution, signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR). To address this issue, we propose a new method that significantly improve the quality of images obtained by a FUS transducer. The proposed method employs coded excitation to enhance SNR and Wiener deconvolution to solve the problem of low axial resolution resulting from the narrow spectral bandwidth of FUS transducers. Specifically, the method eliminates the impulse response of a FUS transducer from received ultrasound signals using Wiener deconvolution, and pulse compression is performed using a mismatched filter. Simulation and commercial phantom experiments confirmed that the proposed method significantly improves the quality of images acquired by the FUS transducer. The -6 dB axial resolution was improved 1.27 mm to 0.37 mm that was similar to the resolution achieved by the imaging transducer, i.e., 0.33 mm. SNR and CNR also increased from 16.5 dB and 0.69 to 29.1 dB and 3.03, respectively, that were also similar to those by the imaging transducer (27.8 dB and 3.16). Based on the results, we believe that the proposed method has great potential to enhance the clinical utility of FUS transducers in ultrasound image-guided therapy.

Suppressing artifacts in the total focusing method using the directivity of laser ultrasound

Based on a synthesized laser ultrasonic array, full matrix capture can be used to acquire data, which can then be post-processed using the total focusing method. However, this noncontact ultrasonic imaging technique has not been widely used because of the numerous artifacts in ultrasonic images and time-consuming data acquisition. To address these issues, this study proposes a post-processing algorithm, which uses the laser ultrasound directivity information to suppress the artifacts in the total focusing method's images. In particular, a weight factor is defined using the directivity information. By multiplying the image intensity of the total focusing method with this factor, the algorithm uses not only the amplitude and phase information of laser ultrasound but also its directivity information. The experimental results indicate that four types of artifacts are suppressed. Because the grating lobe artifacts can be suppressed, a larger element spacing can be used to reduce the data acquisition time.

Detection of defects in highly attenuating materials using ultrasonic least-squares reverse time migration with preconditioned stochastic gradient descent

Accurate detection and characterization of defects in high-density polyethylene (HDPE) pipe materials are very important in assessing the structural integrity of critical structures in the nuclear industry. One specific challenge here is the presence of the viscoelastic attenuation of this material, which can lead to resolution degradation and loss of detail in ultrasound imaging. In this work, an effective ultrasonic imaging technique using the least-squares reverse time migration with preconditioned stochastic gradient descent (LSRTM-PSGD) is developed to improve image quality. Compared with standard ultrasonic imaging methods which only consider the direct ray path of ultrasound, least-squares reverse time migration (LSRTM) is a powerful wave-equation-based approach and it has the ability to account for rapid spatial velocity variations and to utilize all wavefield information. The LSRTM is an inversion method, which iteratively updates the reflectivity model by minimizing the modeled data and measured data. The proposed LSRTM-PSGD combines the advantages of stochastic gradient descent (SGD) and adaptive learning rate. The SGD updates the parameter on each transmitter and the fluctuation of SGD can enable it to reach a better minimum, thus improving the imaging quality. Compared with the conventional LSRTM algorithm using a fixed step size, the proposed LSRTM-PSGD algorithm can use the adaptive moment estimation to calculate the adaptive learning rate for the parameter, thereby updating the parameter appropriately. The performance of the LSRTM-PSGD algorithm is tested with experimental data. The results show high-quality reconstructed images with good resolution for defect identification in HDPE pipe materials, especially for deep defects.

Ultrasonic imaging using conditional generative adversarial networks

The Full Matrix Capture (FMC) and Total Focusing Method (TFM) combination is often considered the gold standard in ultrasonic nondestructive testing, however it may be impractical due to the amount of time required to gather and process the FMC, particularly for high cadence inspections. This study proposes replacing conventional FMC acquisition and TFM processing with a single zero-degree plane wave (PW) insonification and a conditional Generative Adversarial Network (cGAN) trained to produce TFM-like images. Three models with different cGAN architectures and loss formulations were tested in different scenarios. Their performances were compared with conventional TFM computed from FMC. The proposed cGANs were able to recreate TFM-like images with the same resolution while improving the contrast in more than 94% of the reconstructions in comparison with conventional TFM reconstructions. Indeed, thanks to the use of a bias in the cGANs' training, the contrast was systematically increased through a reduction of the background noise level and the elimination of some artifacts. Finally, the proposed method led to a reduction of the computation time and file size by a factor of 120 and 75, respectively.

Photoacoustic/ultrasonic dual-mode imaging for monitoring angiogenesis and synovial erosion in rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by the formation of new vessels, synovial proliferation and destruction of articular cartilage. However, characteristic early diagnostic and therapeutic monitoring methods are still lacking. We report a study using a photoacoustic/ultrasound (PA/US) dual-mode imaging for RA disease. By establishing a collagen-induced (CIA) RA mouse model to classify disease states based on a subjective grading system, PA/US imaging allows real-time assessment of synovial erosion and vascular opacification within the knee joint in different disease states at high spatial resolution. The system also quantitatively monitors subcutaneous vascular physiology and morphology in the hind paw of mice, measuring the area and photoacoustic signal intensity of vascular proliferation and showing a positive correlation with disease grading. Compared to traditional subjective scoring of arthritis severity, the PA/US imaging is more sensitive i.e., vascular signals and synovial erosion can be observed early in the course of arthritis.

Quantitative ultrasonographic diagnostics for midface and mandible fractures

The aim of this study was to examine whether ultrasonography and three-dimensional radiological procedures produce significantly different measurement results with respect to fracture dislocation. This was a retrospective study of patients who were admitted to the department for oral and maxillofacial surgery of the Medical Highschool Hannover with facial skull fracture and underwent high-resolution computed tomography and ultrasonography imaging during a period from 1 January 2019 to 31 August 2019. A 10 mHz transducer was used for fracture imaging, and the largest dislocation of each fracture was measured. A paired t-test for dependent samples was used for statistical evaluation of the measured differences, and the p-value was set at 0.05. A total of 16 patients with 29 fractures were included. The fractures were characterized as follows: zygomatic arch (n = 7), lateroorbital region (n = 4), maxilla/zygomatic bone (n = 15), mandible (n = 2), and frontal sinus (n = 1). Regardless of the fracture location, we found no statistical difference in fracture measurements between the ultrasonography and the computed tomography (p = 0.17 (fractures of the zygomatic arch) to p = 0.85 (all fractures)). The study findings suggest that ultrasonography not only allows basic detection but also a quantification of the dislocation in facial skull fractures. The ultrasonography results are not significantly different from those of the computed tomography. In everyday clinical practice, ultrasonography of facial fractures can be considered an adequate imaging procedure. If used correctly, additional radiation exposure to the patient can be avoided, thus representing a diagnostic alternative to computed tomography.

Proof of Concept of 3-D Backscatter Tensor Imaging Tomography for Non-invasive Assessment of Human Breast Cancer Collagen Organization

Tumor growth, similarly to several other pathologies, tends to change the structural orientation of soft tissue fibers, which can become relevant markers for diagnosis. Current diagnosis protocols may require a biopsy for histological analysis, which is an invasive, painful and stressful procedure with a minimum turnaround time of 2 d. Otherwise, diagnosis may involve the use of complex methods with limited availability such as diffusion tensor imaging (magnetic resonance diffusion tensor imaging), which is not widely used in medical practice. Conversely, advanced methodologies in ultrasound imaging such as backscatter tensor imaging (BTI) might become a routine procedure in clinical practice at a limited cost. This method evaluates the local organization of soft tissues based on the spatial coherence of their backscattered ultrasonic echoes. Previous work has proven that BTI applied with matrix probes enables measurement of the orientation of soft tissue fibers, especially in the myocardium. The aims of the study described here were (i) to present for the first time a methodology for performing BTI in a volume on ex vivo human breast tumors using a linear probe and (ii) to display a first proof of concept of the link between BTI measurements and the orientation of collagen fibers.

[Comparison of wall filter algorithms for ultrasonic microvascular imaging]

The design of wall filter in ultrasonic microvascular imaging directly affects the resolution of blood flow imaging. We compared the traditional polynomial regression wall filter algorithm and two algorithms based on singular value decomposition (SVD), Full-SVD algorithm and RS-RSVD algorithm (random sampling based on random singular value decomposition) through experiments with simulated data and human renal entity data imaging experiments. The experimental results showed that the filtering effect of the traditional polynomial regression wall filter algorithm was limited, however, Full-SVD algorithm and RS-RSVD algorithm could better extract the micro blood flow signal from the tissue or noise signal. When RS-RSVD algorithm was randomly divided into 16 blocks, the signal-to-noise ratio was the same as that of Full-SVD algorithm, reduces the contrast-to-noise ratio by 2.05 dB, and reduces the execution time by 90.41%. RS-RSVD algorithm can improve the operation efficiency and is more conducive to the real-time imaging of high frame rate ultrasound microvessels.

Imaging a defect in layered media with different shaped interfaces using reverse time migration without velocity model known a priori

In this work, the highly accurate image of a defect in the layered media using a reverse time migration (RTM) is obtained without priori information of the interface geometry and acoustic velocity of the lower medium. The interface of layered media is reconstructed by RTM, and its profile is determined using the reconstructed image within the range of -6 to 0 dB. At the assumed acoustic velocity of the lower medium, the minimum variance of the possible position distribution of a defect is evaluated to be an acoustic velocity of the lower medium by processing the travel times of the defect scattered echoes. The velocity model of the layered media is reconstructed by the mapped interface and the calibrated acoustic velocity of the lower medium, and a defect in the layered media is imaged by RTM. The proposed method is verified by utilizing the silicone rubber-water layered media with horizontal, titled, and circular arc interfaces. The obtained results for the interface geometry, acoustic velocity of the lower medium, and location of defect are consistent with the actual values. Therefore, a defect in the layered media can be accurately located and imaged without the velocity model of layered media known a priori via the RTM method.

Deep learning inversion with supervision: A rapid and cascaded imaging technique

Machine learning has been demonstrated to be extremely promising in solving inverse problems, but deep learning algorithms require enormous training samples to obtain reliable results. In this article, we propose a new solution, the deep learning inversion with supervision (DLIS) and applied it for corrosion mapping in guided wave tomography. The inversion results show that when dealing with multiple defects of complex shape on a plate-like structure, DLIS methods can reduce the scale of training set effectively compared with other deep learning algorithms in experiment because a good starting model is provided and the nonlinearity between the global minimum and observed wave field is greatly reduced. In terms of reconstruction accuracy using experimental data, the thickness maps produced by DLIS are reliable with high accuracy. With few modifications, this method can be conveniently extended to 3D cases. These results imply that DLIS is one of the promising methods to be applied in fields with similar physics like non-destructive evaluation (NDE), biomedical imaging and geophysical prospecting.

Ultrasonic autofocus imaging of internal voids in multilayer polymer composite structures

Multilayer polymer composite structures have been playing important roles in various fields, but the voids inside are not allowed in most scenarios. Ultrasonic technology has been widely used to inspect voids in concrete and metal structures. However, the application of ultrasonic imaging in polymer composite structures is severely blocked by the coating and lamination structures and unstable manufacturing induced sound speed variations. In this paper, a method to autofocus imaging of internal voids in multilayer polymer composite structures with ultrasonic phased array is firstly proposed. The method processes the full matrix capture (FMC) and focuses all voids in the multilayer structure automatically without the prior information of the speed of sound (SOS). The method utilizes the focus criterions to evaluate the focusing quality and then estimates the SOS with differential evolution layer by layer from surface to deep, which improves the robustness and computational efficiency. The method was examined with simulation data from three multilayer structures and well-focused all voids with position error less than 0.6 mm and SOS error less than 6 %. Moreover, the method was verified with the experimental data and focused voids with position error less than 1 mm.

Imaging damage in plate waveguides using frequency-domain multiple signal classification (F-MUSIC)

Earlier, an ameliorated MUSIC (Am-MUSIC) algorithm is developed by the authors [1], aimed at expanding conventional MUSIC algorithm from linear array-facilitated nondestructive evaluation to in situ health monitoring with a sparse sensor network. Yet, Am-MUSIC leaves a twofold issue to be improved: i) the signal representation equation is constructed at each pixel across the inspection region, incurring high computational cost; and ii) the algorithm is applicable to monochromatic excitation only, ignoring signal features scattered out of the excitation frequency band which also carry information on structural integrity. With this motivation, a multiple-damage-scattered wavefield model is developed, with which the signal representation equation is constructed in the frequency domain, avoiding computationally expensive pixel-based calculation - referred to as frequency-domain MUSIC (F-MUSIC). F-MUSIC quantifies the orthogonal attributes between the signal subspace and noise subspace inherent in signal representation equation, and generates a full spatial spectrum of the inspected sample to visualize damage. Modeling in the frequency domain endows F-MUSIC with the capacity to fuse rich information scattered in a broad band and therefore enhance imaging precision. Both simulation and experiment are performed to validate F-MUSIC when used for imaging single and multiple sites of damage in an isotropic plate waveguide with a sparse sensor network. Results accentuate that effectiveness of F-MUSIC is not limited by the quantity of damage, and imaging precision is not downgraded due to the use of a highly sparse sensor network - a challenging task for conventional MUSIC algorithm to fulfil.

Correlation-based ultrasound imaging of strong reflectors with phase coherence filtering

Two main metrics are usually employed to assess the quality of medical ultrasound (US) images, namely the contrast and the spatial resolution. A number of imaging algorithms have been proposed to improve one of those metrics, often at the expense of the other one. This paper presents the application of a correlation-based ultrasound imaging method, called Excitelet, to medical US imaging applications and the inclusion of a new Phase Coherence (PC) metric within its formalism. The main idea behind this algorithm, originally developed and validated for Non-Destructive Testing (NDT) applications, is to correlate a reference signal database with the measured signals acquired from a transducer array. In this paper, it is shown that improved lateral resolutions and a reduction of imaging artifacts are obtained over the Synthetic Aperture Focusing Technique (SAFT) when using Excitelet in conjunction with a PC filter. This novel method shows potential for the imaging of specular reflectors, such as invasive surgical tools. Numerical and experimental results presented in this paper demonstrate the benefit, in terms of contrast and resolution, of using the Excitelet method combined with PC for the imaging of strong reflectors.

Ultrasonic biomechanics method for vortex and wall motion of left ventricle: a phantom and in vivo study

Background

The non-invasive quantitative evaluation of left ventricle (LV) function plays a critical role in clinical cardiology. This study proposes a novel ultrasonic biomechanics method by integrating both LV vortex and wall motion to fully assess and understand the LV structure and function. The purpose of this study was to validate the ultrasonic biomechanics method as a quantifiable approach to evaluate LV function.

Methods

Firstly, B-mode ultrasound images were acquired and processed, which were utilized to implement parameters for quantifying the LV vortex and wall motion respectively. Next, the parameters were compared in polyvinyl alcohol cryogen (PVA) phantoms with different degree of stiffness corresponding to different freezing and thawing cycles in vitro. Finally, the parameters were computed in vivo during one cardiac cycle to assess the LV function in normal and abnormal subjects in vivo.

Results

In vitro study, the velocity field of PVA phantom differed with stiffness (varied elasticity modulus). The peak of strain for wall motion decreases with the increase of elasticity modulus, and periodically changed values. Statistical analysis for parameters of vortex dynamics (energy dissipation index, DI; kinetic energy fluctuations, KEF; relative strength, RS; and vorticity, W) based on different elasticity (E) of phantom depicted the good viability of this algorithm. In vivo study, the results confirmed that subjects with LV dysfunction had lower vorticity and strain (S) compared to the normal group.

Conclusion

Ultrasonic biomechanics method can obtain the vortex and wall motion of left ventricle. The method may have potential clinical value in evaluation of LV dysfunction.

Effectiveness of synthetic aperture focusing and coherence factor weighting for intravascular ultrasound imaging

Synthetic aperture focusing (SAF) and coherence factor weighting (CFW) have been used to improve the lateral resolution of ultrasound images. Although the two methods are effective for array-based ultrasound imaging, many researchers have also employed the methods for single-element-based imaging including intravascular ultrasound (IVUS) imaging. For single-element-based imaging, CFW is generally calculated from the scanlines obtained by SAF and applied to the scanline obtained after coherent summation of the SAF delayed scanlines, which is called a SAF-CFW method. In the paper, a theoretical model was derived to explore the effectiveness of SAF and CFW for single-element-based imaging, and the model was used to explain that SAF is not effective for IVUS imaging in terms of enhancing the spatial resolution, although it has the advantage of improving a contrast-to-noise ratio (CNR). This means that the SAF-CFW method is not optimal for improving the spatial resolution of IVUS imaging. In contrast, it was found in simulations and experiments that applying CFW to the target scanline itself is beneficial for the spatial resolution rather than a coherent summed scanline for IVUS SAF imaging, but CNR was not as good as SAF and SAF-CFW. As a result of both simulation and experimentation, it could be concluded that focused IVUS transducers without the application of those methods may be more advantageous to improve the spatial and contrast resolution simultaneously, considering the system complexity in the implementation of such imaging methods.

A reverse time migration-based multistep angular spectrum approach for ultrasonic imaging of specimens with irregular surfaces

We develop a new ultrasonic imaging framework for non-destructive testing of an immersed specimen featuring an irregular top surface and demonstrate its capability of accurately depicting the lower surfaces of multiple damages hidden in the specimen. Central to the framework is a multistep angular spectrum approach (ASA), via which the forward propagation wavefields of wave sources and backward propagation wavefields of the received wave signals are calculated. Upon applying a zero-lag cross-correlation imaging condition of reverse time migration (RTM) to the obtained forward and backward wavefields, the image of the specimen with an irregular surface can be reconstructed, in which hidden damages, if any and regardless of quantity, are visualized. The effectiveness and accuracy of the framework are examined using numerical simulation, followed with experiment, in both of which multiple side-drilled holes, at different locations in aluminum blocks with various irregular surfaces, are characterized. Results have proven that multiple damages in a specimen with an irregular surface can be individually localized, and the lower surface of each damage can further be imaged accurately, thanks to the RTM-based algorithm in which multiple wave reflections from the specimen bottom are taken into wavefield extrapolation. The proposed imaging approach presents higher computational efficiency, compared to conventional RTM, and enhanced imaging contrast over prevailing total focusing methods.

Real-time mapping of a whole heart chamber using a novel sparse ultrasonic catheter array

PURPOSE

Atrial fibrillation (AF), the most prevalent form of cardiac arrhythmia, afflicts millions worldwide. Here, we developed an imaging algorithm for the diagnosis and online guidance of radio-frequency ablation, which is currently the first line of treatment for AF and other arrhythmia. This requires the simultaneous mapping of the left atrium anatomy and the propagation of the electrical activation wave, and for some arrhythmia, within a single heartbeat.

METHODS

We constructed a multi-frequency ultrasonic system consisting of 64 elements mounted on a spherical basket, operated in a synthetic aperture mode, that allows instant localization of thousands of points on the endocardial surface and yields a MRI-like geometric reconstruction.

RESULTS

The system and surface localization algorithm were extensively tested and validated in a series of in silico and in vitro experiments. We report considerable improvement over traditional methods along with theoretical results that help refine the extracted shape. The results in left atrium-shaped silicon phantom were accurate to within 4 mm.

CONCLUSIONS

A novel catheter system consisting of a basket of splines with multiple multi-frequency ultrasonic elements allows 3D anatomical mapping and real-time tracking of the entire heart chamber within a single heartbeat. These design parameters achieve highly acceptable reconstruction accuracy.

Combining high-intensity focused ultrasound (HIFU) ablation with percutaneous ethanol injection (PEI) in the treatment of benign thyroid nodules

OBJECTIVE

Assessing the 6-month efficacy of combined high-intensity focused ultrasound (HIFU) ablation with percutaneous ethanol injection (PEI) in benign thyroid nodules by comparing it with HIFU ablation alone.

METHODS

One hundred and eighty-one (55.2%) patients underwent HIFU alone (group I) while 147 (44.8%) underwent concomitant HIFU and PEI treatment for solid or predominantly solid nodules (group II). Intravenous sedation and analgesia were given before the start of treatment. Extent of nodule shrinkage (by volume reduction ratio (VRR)), pain scores (by 0-10 visual analogue scale) during and after ablation, and rate of vocal cord palsy (VCP), skin burn, and nausea/vomiting were compared between the two groups.

RESULTS

The mean amount of ethanol injected in group II was 1.3 ± 0.7 ml. The 3- and 6-month VRR were significantly greater in group II (60.41 ± 20.49% vs. 50.13 ± 21.06%, p = 0.001; and 71.08 ± 21.25% vs. 61.37 ± 22.76%, p = 0.001, respectively), and "on-beam" treatment time was significantly shorter in group II (26.55 min vs. 30.26 min, p = 0.001). Group II patients reported significantly lower pain score during treatment (2.24 ± 3.07 vs. 4.97 ± 3.21, p < 0.001) and 2 h after treatment (2.23 ± 2.50 vs. 2.97 ± 4.39, p = 0.044). Rates of VCP, skin burn, and nausea or vomiting were not significantly different (p > 0.05).

CONCLUSIONS

The combined HIFU and PEI approach with improved administration of intravenous sedation and analgesia was associated with a significantly better 6-month efficacy than HIFU alone in benign thyroid nodules without compromising the safety and comfort of patients.

KEY POINTS

• Concomitant HIFU and PEI have a better treatment efficacy than HIFU alone. • Concomitant HIFU and PEI have a comparable safety profile as HIFU alone.

Primary renal synovial sarcoma: A case report

BACKGROUND

Synovial sarcoma, a rare mesenchymal tumor type with unclear histological origin and direction of differentiation, accounts for 6%–10% of soft tissue tumors. It is mainly located near the joints and tendons of the limbs, and occurs primarily in children or young adults. Primary renal synovial sarcoma (PRSS) is very rare, accounting for approximately 1% of synovial sarcomas. It is a spindle cell tumor type affecting mesenchymal tissue, and has morphological, genetic, and clinical characteristics, and a certain degree of epithelial differentiation. It is highly malignant and has the fourth highest incidence among soft tissue sarcomas. Here, we report a case of PRSS and share some valuable information about the disease.

CASE SUMMARY

A 54-year-old male patient was admitted to the hospital for a space-occupying lesion in the right kidney for 2 d upon ultrasound examination. The patient had no cold or fever; no frequency, urgency or pain of urination; and no other discomfort. The results of a hemogram, blood biochemistry, and tumor markers were in the normal range. The patient was examined by computed tomography (CT), which indicated the presence of a soft tissue density shadow with a diameter of approximately 6.8 cm in the right renal pelvis area, showing uneven enhancement. Ultrasound indicated a cystic solid mass of approximately 6.8 cm × 6.5 cm in the right kidney, with an unclear boundary and irregular shape. Meanwhile, color Doppler flow imaging showed dotted blood flow signals in the periphery and interior. Contrast-enhanced ultrasound (CEUS) showed "slow in and fast out" hyperenhancement of the right renal mass after contrast agent injection. The postoperative pathological diagnosis was (right kidney) synovial sarcoma. Despite postoperative adjuvant chemotherapy, tumor recurrence was detected two years later.

CONCLUSION

PRSS is a rare malignant tumor. To date, no characteristic imaging findings have been observed. The diagnosis is confirmed primarily through postoperative pathological immunohistochemistry and SS18 (SYT) gene detection. In this case, CEUS was used preoperatively. We found that PRSS has the characteristic of "slow in and fast out" hyperenhancement, and its particular characteristics have diagnostic value. Postoperative adjuvant chemotherapy is not very effective.

Fundamental wave amplitude difference imaging for detection and characterization of embedded cracks

An ultrasonic technique for imaging nonlinear scatterers, such as partially-closed cracks, buried in a medium has been recently proposed. The method called fundamental wave amplitude difference (FAD) consists of a sequence of acquisitions with different subsets of elements for each line of the image. An image revealing nonlinear scatterers in the medium is reconstructed line by line by subtracting the responses measured with the subsets of elements from the response obtained with all elements transmitting. In order to get a better insight of the capabilities of FAD, two metallic samples having a fatigue or thermal crack are inspected by translating the probe with ultrasonic beam perpendicular (i.e. parallel) to the crack direction which is the most (i.e. less) favorable case. Each time, the responses of the linear scatterers (i.e. conventional image) and nonlinear scatterers (i.e. FAD image) are compared in term of intensity and spatial repartition. FAD exhibits higher detection specificity of the crack with a better contrast than conventional ultrasound imaging. Moreover, we observe that both methods give complementary results as nonlinear and linear scatterers are mostly not co-localized. In addition, we show experimentally that FAD resolution in elevation and lateral follows the same rule as the theoretical resolution of conventional ultrasonic technique. Finally, we report that FAD gives the possibility to perform parametric studies which let the opportunity to address the physical mechanisms causing the distortion of the signal. FAD is a promising and reliable tool which can be directly implemented on a conventional open scanner ultrasound device for real-time imaging. This might contribute to its fast and wide spread in the industry.

A universal ultrasound diagnostic system developed to support urology and coloproctological applications

In this study, we sought to describe a novel imaging apparatus that is lightweight, inexpensive, and highly effective for use in colorectal diagnostic and treatment settings. Typical probes for use in colorectal ultrasonic imaging applications are developed for surgeons to diagnose and stage rectal tumors and image the rectum and anus. Here we outline a new technique and use it for colorectal imaging in an animal. This technique involves use of an ultrasound array module positioned along the axis of rotation such that improved rotation is possible. This module is in the shape of a linear rod with a rotary linear component that allows for emission of focused ultrasonic echo signals from a linear section of the probe. The usability of the transducer and rectal image quality are satisfactory in a porcine model with the technique proposed here, axial/lateral resolution as 0.96/2.24 mm with 6 dB applied through the contour map using the point spread function. When compared to currently available methods, this technique provides superior diagnostic 3D volumetric image quality with reduced acquisition time. Given this, the ultrasound device proposed here may prove a viable and preferable method to those currently available for urology and colorectal imaging applications.

Sizing of flaws using ultrasonic bulk wave testing: A review

Ultrasonic testing is a non-destructive method that can be used to detect, locate and size flaws. The purpose of this paper is to review techniques that utilise ultrasonic bulk waves to size flaws. Flaws that are embedded within a component (i.e. remote from any surface) as well as flaws growing from inaccessible surfaces are considered. The different available techniques are grouped into the following categories: amplitude, temporal, imaging and inversion. The principles, applications and limitations of the different techniques are covered, as well as approaches to assessing the performance of the techniques. Finally, remaining gaps and challenges in sizing flaws, particularly in an industrial setting, are discussed.

Motion Estimation in Echocardiography Using Sparse Representation and Dictionary Learning

This paper introduces a new method for cardiac motion estimation in 2-D ultrasound images. The motion estimation problem is formulated as an energy minimization, whose data fidelity term is built using the assumption that the images are corrupted by multiplicative Rayleigh noise. In addition to a classical spatial smoothness constraint, the proposed method exploits the sparse properties of the cardiac motion to regularize the solution via an appropriate dictionary learning step. The proposed method is evaluated on one data set with available ground-truth, including four sequences of highly realistic simulations. The approach is also validated on both healthy and pathological sequences of in vivo data. We evaluate the method in terms of motion estimation accuracy and strain errors and compare the performance with state-of-the-art algorithms. The results show that the proposed method gives competitive results for the considered data. Furthermore, the in vivo strain analysis demonstrates that meaningful clinical interpretation can be obtained from the estimated motion vectors.This paper introduces a new method for cardiac motion estimation in 2-D ultrasound images. The motion estimation problem is formulated as an energy minimization, whose data fidelity term is built using the assumption that the images are corrupted by multiplicative Rayleigh noise. In addition to a classical spatial smoothness constraint, the proposed method exploits the sparse properties of the cardiac motion to regularize the solution via an appropriate dictionary learning step. The proposed method is evaluated on one data set with available ground-truth, including four sequences of highly realistic simulations. The approach is also validated on both healthy and pathological sequences of in vivo data. We evaluate the method in terms of motion estimation accuracy and strain errors and compare the performance with state-of-the-art algorithms. The results show that the proposed method gives competitive results for the considered data. Furthermore, the in vivo strain analysis demonstrates that meaningful clinical interpretation can be obtained from the estimated motion vectors.

Assessment of Curve Flexibility on Scoliotic Surgical Candidates Using Ultrasound Imaging Method

The ultrasound imaging method was implemented to assess the spinal curve flexibility of scoliotic surgical candidates, or how much correction it can achieve while patients are bending or lying down. Fifteen participants were recruited. Pre-operative radiographs and ultrasound images in both standing and bending positions were acquired. The post-operative standing radiographs were obtained 1 wk after surgery. Two raters (RZ, EL) measured the ultrasound images twice, 1 wk apart. A curve correction index (C_I) was developed to estimate the curve flexibility. The C_I from the pre-operative bending radiograph, ultrasound and post-operative radiograph were 0.51 ± 0.18; R1: 0.74 ± 0.08 vs R2: 0.72 ± 0.09 and 0.60 ± 0.10, respectively. The correlation of C_I between ultrasound and post-operative radiography was slightly higher than the pre-operative bending and post-operative radiography. This pilot study demonstrated the bending ultrasound method is a promising supplemental tool to assess curve flexibility before surgical intervention for scoliotic surgical candidates.

Linear and nonlinear characterization of microbubbles and tissue using the Nakagami statistical model

The goal of this work is to exploit the statistical signatures for discrimination between biological tissues and contrast microbubbles in order to develop new strategies for contrast imaging and tissue characterization. For this purpose, the efficiency of the Nakagami statistical model, for describing the ultrasonic echoes of both contrast microbubbles and tissues, was investigated. Experimental measurements have been performed using a linear array probe connected to an open research platform. A commercially available in vitro phantom was used to mimic biological tissue in which SonoVue contrast microbubbles were flowing. Experimental ultrasound echoes have been filtered around the transmitted frequency (fundamental at 2.5MHz) and around twice the transmitted frequency (at 5MHz) for 2nd harmonic analysis, and a logarithmic compression was applied. The signals have been analyzed in order to evaluate the Nakagami parameter m, the scaling parameter Ω and the probability density function at both frequencies. Parametric images based on the Nakagami parameters map (Nakagami-mode images) were reconstructed and compared to B-mode images. Contrary to the B-mode image which is influenced by the system settings and user operations, the Nakagami parametric image is only based on the backscattered statistics of the ultrasonic signals in a local phantom. Such an imaging principle allows the Nakagami image to quantify the local scatterer concentrations in the phantom and to extract the backscattering information from the regions of the weakest echoes that may be lost in the conventional B-mode image. Results show that the tissue and microbubbles characterization is more sensitive in the 2nd harmonic mode when a logarithmic transform is used. These results would be useful for improving the ultrasound image quality and contrast detection in nonlinear mode.

Topological imaging in bounded elastic media

Detecting, imaging and sizing defects in a bounded elastic medium is still a difficult task, especially when access is complex. Adjoint methods simplify the task as they take advantage of prior information such as the geometry and material properties. However, they still reveal a number of important limitations. Artifacts observed on the conventional topological energy image result from wave interactions with the boundaries of the inspected medium. The paper describes a method for addressing these artifacts, which involves forward and adjoint fields specified in terms of the boundary conditions. Modified topological energies are then defined according to the type of analyzed flaw (open slit or inclusion). Comparison of the numerical results with the experimental data confirms the relevance of the approach.

Acoustic window planning for ultrasound acquisition

Autonomous robotic ultrasound has recently gained considerable interest, especially for collaborative applications. Existing methods for acquisition trajectory planning are solely based on geometrical considerations, such as the pose of the transducer with respect to the patient surface.

PURPOSE

This work aims at establishing acoustic window planning to enable autonomous ultrasound acquisitions of anatomies with restricted acoustic windows, such as the liver or the heart.

METHODS

We propose a fully automatic approach for the planning of acquisition trajectories, which only requires information about the target region as well as existing tomographic imaging data, such as X-ray computed tomography. The framework integrates both geometrical and physics-based constraints to estimate the best ultrasound acquisition trajectories with respect to the available acoustic windows. We evaluate the developed method using virtual planning scenarios based on real patient data as well as for real robotic ultrasound acquisitions on a tissue-mimicking phantom.

RESULTS

The proposed method yields superior image quality in comparison with a naive planning approach, while maintaining the necessary coverage of the target.

CONCLUSION

We demonstrate that by taking image formation properties into account acquisition planning methods can outperform naive plannings. Furthermore, we show the need for such planning techniques, since naive approaches are not sufficient as they do not take the expected image quality into account.

Superharmonic Imaging for Medical Ultrasound: a Review

Ultrasound with harmonics has emerged as an exceptional alternative to competitively low resolution fundamental ultrasound imaging. The use of second harmonic is already a trend now but higher harmonics are also being seen as even better option due to its improved resolution. The resolution improved with frequency but achieves penetration of reduced energy. The cumulative addition of higher harmonics during propagation yields higher harmonics giving better resolution with adequate penetration. This paper summarizes the progress of such similar decade old harmonic ultrasound imaging technique i.e., superharmonic imaging (SHI) geared towards medical field. It comprises of harmonics higher than second harmonic preferably up to 5th harmonic. We conclude that SHI can be an advanced ultrasound imaging with comprehensive high resolution and adequate penetration depth on sole and coded modes.

A pictorial review of signature patterns living in musculoskeletal ultrasonography

The musculoskeletal system is mainly composed of the bones, muscles, tendons, and ligaments, in addition to nerves and blood vessels. The greatest difficulty in an ultrasonographic freeze-frame created by the examiner is recognition of the targeted structures without indicators, since an elephant's trunk may not be easily distinguished from its leg. It is not difficult to find descriptive ultrasonographic terms used for educational purposes, which help in distinguishing features of these structures either in a normal or abnormal anatomic condition. However, the terms sometimes create confusion when describing common objects, for example, in Western countries, pears have a triangular shape, but in Asia they are round. Skilled experts in musculoskeletal ultrasound have tried to express certain distinguishing features of anatomic landmarks using terms taken from everyday objects which may be reminiscent of that particular feature. This pictorial review introduces known signature patterns of distinguishing features in musculoskeletal ultrasound in a normal or abnormal condition, and may stir the beginners' interest to play a treasure-hunt game among unfamiliar images within a boundless ocean.

Full-matrix capture with phased shift migration for flaw detection in layered objects with complex geometry

This paper introduces a method for an ultrasonic imaging with a phased array based on a wave migration algorithm. The method allows for imaging layered objects with lateral velocity variations such as objects with a complex geometry or layers that are not perpendicular to the array's axis. The full-matrix capture ensures that there is enough information to reconstruct an image even when the wave indication angle is large. The method is implemented in a omega-k domain. The proposed algorithm is first tested in a single simulation of a concave object with side drilled holes under the concave surface. For evaluating the algorithm's performance three experiments are presented: one with a tilted object (surface not perpendicular with respect to the array axis) with side drilled holes and two experiments of an object with concave surface and two artificial defects under it. The results presented in the paper verify that the proposed method reconstructs images from the data gathered with the phased array.

Computer-Aided Diagnosis for Breast Ultrasound Using Computerized BI-RADS Features and Machine Learning Methods

This work identifies effective computable features from the Breast Imaging Reporting and Data System (BI-RADS), to develop a computer-aided diagnosis (CAD) system for breast ultrasound. Computerized features corresponding to ultrasound BI-RADs categories were designed and tested using a database of 283 pathology-proven benign and malignant lesions. Features were selected based on classification performance using a "bottom-up" approach for different machine learning methods, including decision tree, artificial neural network, random forest and support vector machine. Using 10-fold cross-validation on the database of 283 cases, the highest area under the receiver operating characteristic (ROC) curve (AUC) was 0.84 from a support vector machine with 77.7% overall accuracy; the highest overall accuracy, 78.5%, was from a random forest with the AUC 0.83. Lesion margin and orientation were optimum features common to all of the different machine learning methods. These features can be used in CAD systems to help distinguish benign from worrisome lesions.

Plane Wave Imaging for ultrasonic non-destructive testing: Generalization to multimodal imaging

This paper describes a new ultrasonic array imaging method for Non-Destructive Testing (NDT) which is derived from the medical Plane Wave Imaging (PWI) technique. The objective is to perform fast ultrasound imaging with high image quality. The approach is to transmit plane waves at several angles and to record the back-scattered signals with all the array elements. Focusing in receive is then achieved by coherent summations of the signals in every point of a region of interest. The medical PWI is generalized to immersion setups where water acts as a coupling medium and to multimodal (direct, half-skip modes) imaging in order to detect different types of defects (inclusions, porosities, cracks). This method is compared to the Total Focusing Method (TFM) which is the reference imaging technique in NDT. First, the two post-processing algorithms are described. Then experimental results with the array probe either in contact or in immersion are presented. A good agreement between the TFM and the PWI is observed, with three to ten times less transmissions required for the PWI.

Intra-rater and inter-rater reliability of ultrasonographic measurements of acromion-greater tuberosity distance in patients with post-stroke hemiplegia

BACKGROUND

Glenohumeral subluxation (GHS) is reported in up to 81% of patients with stroke. Ultrasonographic measurements of GHS by measuring the acromion-greater tuberosity (AGT) have been found to be reliable for experienced raters.

OBJECTIVES

The primary aim was to assess the intra-rater reliability of measurements of AGT distance in people with stroke following a short course of rater training. A secondary aim was to compare the inter-rater reliability of these measurements between novice and experienced raters.

METHODS

Patients with stroke (n = 16; 5 men, 11 women; 74 ± 10 years) with 1-sided weakness who gave informed consent were recruited. Ultrasonographic measurements were recorded at the bedside by two physiotherapists with patients seated upright in a hospital chair. Reliability was assessed by intra-class correlation coefficients (ICCs) and the standard error of measurements (SEM). Minimum detectable change (MDC90) scores were used to estimate the magnitude of change that is likely to exceed measurement error.

RESULTS

Mean ± SD AGT distances on the affected and unaffected sides for rater 1 were 2.2 ± 0.7 and 1.7 ± 0.4 cm, respectively. Corresponding values for rater 2 were 2.5 ± 0.6 and 2.0 ± 0.4 cm. Intra-class correlation coefficient values for the affected and unaffected shoulders for rater 1 were 0.96 and 0.91, respectively. Corresponding values for rater 2 were 0.95 and 0.90.SEM and MDC90 for both affected and unaffected shoulders were ≤ 0.2 cm. Inter-rater reliability coefficients were 0.86 (affected) and 0.76 (unaffected) shoulders.

CONCLUSION

Ultrasonographic measurement of AGT distance demonstrates excellent intra-rater reliability for a novice rater. Inter-rater reliability of ultrasonographic measurement of AGT also demonstrates good reliability between novice and experienced raters.

Relationship between the phases of the menstrual cycle and the transversus abdominis muscle

[Purpose] This study investigated changes in the thickness of the transversus abdominis muscle at various stages of the menstrual cycle. [Subjects] The subjects were 15 young healthy females with regular menstrual cycles. [Methods] A regular menstrual cycle was defined as a 28-day cycle comprising 3 phases: the menstrual phase, the follicular phase, and the luteal phase. For the purpose of the study, measurements were taken at day 3 (menstrual phase), day 12 (follicular phase), and day 21 (luteal phase) of the cycle. An ultrasonic imaging diagnostic device (MyLab 25) and a linear expression probe were used for measurement of the transversus abdominis muscle. [Results] There were no significant differences in the variation rate of the thickness of the muscle at any phase of the menstrual cycle. [Conclusion] The results suggested that the sex hormones associated with the menstrual cycle do not affect the contractility or changes in the thickness of the transversus abdominis muscle. For the reasons stated above, there is little need to consider the menstrual cycle when measuring muscle thickness in physical therapy scenarios because the transversus abdominis muscle does not depend on the menstrual cycle.

Reverberation clutter from subcutaneous tissue layers: simulation and in vivo demonstrations

The degradation of ultrasonic image quality is typically attributed to aberration and reverberation. Although the sources and impact of aberration are well understood, very little is known about the source and impact of image degradation caused by reverberation. Reverberation is typically associated with multiple reflections at two interfaces along the same propagation path, as with the arterial wall or a metal sphere. However, the reverberation that results in image degradation includes more complex interaction between the propagating wave and the tissue. Simulations of wave propagation in realistic and simplified models of the abdominal wall are used to illustrate the characteristics of coherent and diffuse clutter generated by reverberation. In the realistic models, diffuse reverberation clutter is divided into that originating from the tissue interfaces and that originating from sub-resolution diffuse scatterers. In the simplified models, the magnitude of the reverberation clutter is observed as angle and density of the connective tissue are altered. The results suggest that multi-path scattering from the connective tissue/fat interfaces is a dominant component of reverberation clutter. Diffuse reverberation clutter is maximal when the connective tissue is near normal to the beam direction and increases with the density of connective tissue layers at these large angles. The presence of a thick fascial or fibrous layer at the distal boundary of the abdominal wall magnifies the amount of reverberation clutter. The simulations also illustrate that compression of the abdominal layer, a technique often used to mitigate clutter in overweight and obese patients, increases the decay of reverberation clutter with depth. In addition, rotation of the transducer or steering of the beam with respect to highly reflecting boundaries can reduce coherent clutter and transform it to diffuse clutter, which can be further reduced using coherence-based beamforming techniques. In vivo images of the human bladder illustrate some of the reverberation effects observed in simulation.

Ultrasound thermal mapping based on a hybrid method combining physical and statistical models

Non-invasive temperature measurement of tissues deep inside the body has great potential for clinical applications, such as temperature monitoring during thermal therapy and early diagnosis of diseases. We developed a novel method for both temperature estimation and thermal mapping that uses ultrasound B-mode radiofrequency data. The proposed method is a hybrid that combines elements of physical and statistical models to achieve higher precision and resolution of temperature variations and distribution. We propose a dimensionless combined index (CI) that combines the echo shift differential and signal intensity difference with a weighting factor relative to the distance from the heat source. In vitro experiments verified that the combined index has a strong linear relationship with temperature variation and can be used to effectively estimate temperature with an average relative error <5%. This algorithm provides an alternative for imaging guidance-based techniques during thermal therapy and could easily be integrated into existing ultrasound systems.

Lesion edge preserved direct average strain estimation for ultrasound elasticity imaging

Elasticity imaging techniques with built-in or regularization-based smoothing feature for ensuring strain continuity are not intelligent enough to prevent distortion or lesion edge blurring while smoothing. This paper proposes a novel approach with built-in lesion edge preservation technique for high quality direct average strain imaging. An edge detection scheme, typically used in diffusion filtering is modified here for lesion edge detection. Based on the extracted edge information, lesion edges are preserved by modifying the strain determining cost function in the direct-average-strain-estimation (DASE) method. The proposed algorithm demonstrates approximately 3.42-4.25 dB improvement in terms of edge-mean-square-error (EMSE) than the other reported regularized or average strain estimation techniques in finite-element-modeling (FEM) simulation with almost no sacrifice in elastographic-signal-to-noise-ratio (SNRe) and elastographic-contrast-to-noise-ratio (CNRe) metrics. The efficacy of the proposed algorithm is also tested for the experimental phantom data and in vivo breast data. The results reveal that the proposed method can generate a high quality strain image delineating the lesion edge more clearly than the other reported strain estimation techniques that have been designed to ensure strain continuity. The computational cost, however, is little higher for the proposed method than the simpler DASE and considerably higher than that of the 2D analytic minimization (AM2D) method.

Contrast-enhanced ultrasonography assessment of gastric cancer response to neoadjuvant chemotherapy

AIM: To quantitatively assess the ability of double contrast-enhanced ultrasound (DCUS) to detect tumor early response to pre-operative chemotherapy.

METHODS: Forty-three patients with gastric cancer treated with neoadjuvant chemotherapy followed by curative resection between September 2011 and February 2012 were analyzed. Pre-operative chemotherapy regimens of fluorouracil + oxaliplatin or S-1 + oxaliplatin were administered in 2-4 cycles over 6-12 wk periods. All patients underwent contrast-enhanced computed tomography (CT) scan and DCUS before and after two courses of pre-operative chemotherapy. The therapeutic response was assessed by CT using the response evaluation criteria in solid tumors (RECIST 1.1) criteria. Tumor area was assessed by DCUS as enhanced appearance of gastric carcinoma due to tumor vascularity during the contrast phase as compared to the normal gastric wall. Histopathologic analysis was carried out according to the Mandard tumor regression grade criteria and used as the reference standard. Receiver operating characteristic (ROC) analysis was used to evaluate the efficacy of DCUS parameters in differentiating histopathological responders from non-responders.

RESULTS: The study population consisted of 32 men and 11 women, with mean age of 59.7 ± 11.4 years. Neither age, sex, histologic type, tumor site, T stage, nor N stage was associated with pathological response. The responders had significantly smaller mean tumor size than the non-responders (15.7 ± 7.4 cm vs 33.3 ± 14.1 cm, P < 0.01). According to Mandard’s criteria, 27 patients were classified as responders, with 11 (40.7%) showing decreased tumor size by DCUS. In contrast, only three (18.8%) of the 16 non-responders showed decreased tumor size by DCUS (P < 0.01). The area under the ROC curve was 0.64, with a 95%CI of 0.46-0.81. The effects of several cut-off points on diagnostic parameters were calculated in the ROC curve analysis. By maximizing Youden’s index (sensitivity + specificity - 1), the best cut-off point for distinguishing responders from non-responders was determined, which had optimal sensitivity of 62.9% and specificity of 56.3%. Using this cut-off point, the positive and negative predictive values of DCUS for distinguishing responders from non-responders were 70.8% and 47.4%, respectively. The overall accuracy of DCUS for therapeutic response assessment was 60.5%, slightly higher than the 53.5% for CT response assessment with RECIST criteria (P = 0.663). Although the advantage was not statistically significant, likely due to the small number of cases assessed. DCUS was able to identify decreased perfusion in responders who showed no morphological change by CT imaging, which can be occluded by such treatment effects as fibrosis and edema.

CONCLUSION: DCUS may represent an innovative tool for more accurately predicting histopathological response to neoadjuvant chemotherapy before surgical resection in patients with locally-advanced gastric cancer.