Role of sonographic elastography in the differential diagnosis of axillary lymph nodes

Transcription

1 Role of sonographic elastography in the differential diagnosis of axillary lymph nodes Poster No.: C-0438 Congress: ECR 2010 Type: Scientific Exhibit Topic: Breast Authors: J. J. Choi, B. J. Kang, S. H. Kim, J. H. Lee, S. K. Jeh; Seoul/KR Keywords: elastography, axillary lymph node, breast cancer DOI: /ecr2010/C-0438 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 18

2 Purpose # Axillary lymph node status is the most important prognostic factor in breast cancer. # Sonography, a non-invasive method, has been used to predict the preoperative axillary lymph node status. The sonographic criteria for metastasis have been focused on size, shape, hilum, and cortical thickening of lymph nodes. The detection of metastatic LN is of help for selecting patients who are in need of ALND. # Sonographic elastography is a method that visualize the elasticity characteristics of a lesion. Malignant breast lesions are less prone to deformation by pressure than normal breast tissue. # The purpose of this study was to evaluate the diagnostic utility of B-mode USG and elastography in differentiating benign from malignant axillary lymph nodes. Methods and Materials 1. Patients and Axillary LNs # 64 axillary LNs (33 reactive, 31 metastatic) from 62 breast cancer patients - examined by both B-mode USG and elastography - from April to July one ipsilateral LN (62 pts), two ipsilateral LNs (1pt), bilateral LNs (1pt) # Patients Page 2 of 18

3 - age range years (mean 53 years) - initial diagnosis for breast cancer (47 pts), FU after breast surgery (15 pts) 2. Pathologic Examination # Biopsy only (31 LNs) - 18G core needle biopsy (26), fine needle aspiration (5) Surgery only (13 LNs) - ALND (6), SNB (7) Both core biopsy and surgery (20 LNs) # Pathology of breast cancer - invasive ductal carcinoma (51 pts) - invasive lobular carcinoma (3) - medullary carcinoma (1) - metaplastic carcinoma (1) - ductal carcinoma (2) - DCIS (1) - unknown (3) 3. Imaging Acquisition and Analysis - Digital elastography scanner (EUB 8500, Hitachi Medical, Tokyo, Japan) MHz linear probe (EUP-L53; Hitachi Medical) - Four experienced radiologists examined both B-mode USG and elastography - Real-time free-hand light compression, perpendicular to skin Page 3 of 18

4 - Two experienced radiologists reviewed retrospectively B-mode USG and elastographic findings (motion image) 1) B-mode USG # 4 criteria - Short axis diameter - Long/short axis diameter ratio - Fatty hilum (present, absent) - Cortical thickening (no, concentric, eccentric, not available due to absent hilum) # B-mode USG score (sum of scores for 4 criteria) - Short axis diameter (<=7.0mm, score of 0 ; > 7.0mm, score of 1) - L/S axis ratio (> 2.0, 0 ; <= 2.0, 1) - Fatty hilum (present, 0 ; absent, 1) - Cortical thickening (no and concentric, 0 ; eccentric and NA, 1) 2) Elastography # Elasticity score Elasticity score Description 1 Absent of very small blue area 2 Small scattered blue areas, total blue area<45% 3 Large blue area, total blue area>=45% 4 Blue area with or without a green rim Page 4 of 18

5 Fig.: Elasticity scores References: B. J. Kang; Radiology, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, KOREA, Republic of # Strain Ratio - Ratio of Strain (B) / Strain (A) - ROI (region of interest) ROI (A) axillary LN on coupled gray scale image in prominent cortex ROI (B) subcutaneous fat on coupled elastographic image in green area or including cortex and fatty hilum 3) Combination of B-mode USG and elastography - Best cutoff calculation by ROC curve analysis - Suspicious finding of combined B-mode USG and elastography : B-mode score > best cutoff or Elasticity score > best cutoff Page 5 of 18

6 Images for this section: Fig. 1: Elasticity scores Page 6 of 18

7 Results 1. B-mode USG criteria # Diagnostic value of B-mode USG findings for metastatic axillary LN Score Reactive LN (n=33) MetastaticSN SP PPV NPV Acc LN (n=31) Short diameter 0 30(90.9%) 8(25.8%) <=7.0 mm 1 3(9.1%) 23(74.2%) >7.0 mm L/S axis ratio > 2.0 <=2.0 Hilum present absent Cortical (39.4%) 11(35.5%) (60.6%) 20(64.5%) 28(84.8%) 16(51.6%) (15.2%) 15(48.4%) thickening 0 thin, 1 concentric 1 eccentric 27(81.8%) 8(25.8%) (3.0%) 8(25.8%) 5(15.2%) 15(48.4%) NA Page 7 of 18

8 SN:sensitivity, SP:specificity, PPV:positive predictive value, NPV:negative predictive value, Acc:accuracy, NA:not available - Short axis diameter for metastatic LNs (mean 11.3mm) was larger than that of reactive LNs (mean 5.1mm) - L/S axis ratio for metastatic LNs (mean 1.9) was smaller than that of reactive LNs (mean 2.1) - Short axis diameter : mostly sensitive - Cortical thickening : mostly specific 2. Elasticity score and B-mode score # Histologic outcomes according to Elasticity and B-mode scores Methods Score Reactive Metastatic P value (n=33) (n=31) Elasticity score (12.1%) 18(54.6%) 10(30.3%) - 6(19.4%) 16(51.6%) < (3%) 9(29%) B-mode score (30.3%) 16(48.5%) 3(9.1%) 3(9.7%) 5(16.1%) 4(12.9%) (12.1%) 8(25.8%) 4-11(35.5%) Page 8 of 18

9 - Elasticity score for metastatic LNs was significantly higher than that of reactive LNs - B-mode score for metastatic LNs was significantly higher than that of reactive LNs 3. Strain ratio - Best strain ratio cutoff was 2.3 # Diagnostic value of strain ratio at various cut-off points Cutoff point SN SP PPV NPV Acc AUC-ROC > > > > > > > Combined B-mode USG and Elastography - Best B-mode score cutoff : beween 1 and 2 - Best elasticity score cutoff : beween 2 and 3 # Diagnostic performance of B-mode USG, Elastography and Combined USG Methods SN SP PPV NPV Acc AUC- ROC Standard error B-mode Page 9 of 18

10 score Elasticity score Combined USG AUC-ROC:area under the receiver operating characteristic curve - Sensitivity of combined USG was higher than that of B-mode USG or elastography alone (Fig. 1A and 1B) Page 10 of 18

11 Fig.: (1A) Metastatic LN with B-mode score 1 and Elasticity score 3. USG shows concentric cortical thickening and preserved fatty hilum of the LN with short diameter of 8mm and L/S axis ratio of 2.4. References: B. J. Kang; Radiology, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, KOREA, Republic of Page 11 of 18

12 Fig.: (1B) Metastatic LN with B-mode score 1 and Elasticity score 3. Elastography shows large blue area in the cortex of the LN. References: B. J. Kang; Radiology, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, KOREA, Republic of Images for this section: Page 12 of 18

13 Fig. 1: (1A) Metastatic LN with B-mode score 1 and Elasticity score 3. USG shows concentric cortical thickening and preserved fatty hilum of the LN with short diameter of 8mm and L/S axis ratio of 2.4. Page 13 of 18

14 Fig. 2: (1B) Metastatic LN with B-mode score 1 and Elasticity score 3. Elastography shows large blue area in the cortex of the LN. Page 14 of 18

15 Conclusion # Limitations of our study - in vivo imaging however, evaluation of the representative LN and node-by-node correlation with size, location, skin marking - not consider underestimation of biopsy result # Elastography (elasticity score and strain ratio) showed diagnostic performance comparable with that of B-mode USG for differentiation of reactive and metastatic axillary LNs. # Combination of B-mode USG and elastography increased the sensitivity in detecting metastatic axillary LN in breast cancer. References 1. Fisher B, Bauer M, Wickerham DL, et al. Relation of number of positive axillary nodes to the prognosis of patients with primary breast cancer. An NSABP update. Cancer 1983;52: Carter CL, Allen C, Henson DE. Relation of tumor size, lymph node status, and survival in 24,740 breast cancer cases. Cancer 1989;63: Reintgen D, Giuliano R, Cox CE. Sentinel Node Biopsy in Breast Cancer: An Overview. Breast J 2000;6: Fisher B, Jeong JH, Anderson S, Bryant J, Fisher ER, Wolmark N. Twenty-five-year follow-up of a randomized trial comparing radical mastectomy, total mastectomy, and total mastectomy followed by irradiation. N Engl J Med 2002;347: Fraile M, Rull M, Julian FJ, et al. Sentinel node biopsy as a practical alternative to axillary lymph node dissection in breast cancer patients: an approach to its validity. Ann Oncol 2000;11: Page 15 of 18

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18 31. Chung SY, Moon WK, Choi JW, Cho N, Jang M, Kim KG. Differentiation of benign from malignant nonpalpable breast masses: A comparison of computer-assisted quantification and visual assessment of lesion stiffness with the use of sonographic elastography. Acta Radiol 2009 Personal Information Page 18 of 18