Elastografia ultrasonică și valoarea ei în diferențierea benign/malign în patologia nodulară tiroidiană
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1 Elastografia ultrasonică și valoarea ei în diferențierea benign/malign în patologia nodulară tiroidiană Ass Prof. Cristina Ghervan MD, PhD Primul Congres Național al Societății de Endocrinologie cu participare internațională 9-11 octombrie 2014, Chișinău.
2 Introducere Deşi metoda imagistică cea mai sensibilă şi specifică în diferenţierea benign malign este PCA, aplicarea ei în cazul tuturor nodulilor este nerezonabilă. Costuri materiale şi de timp Lame adecvate în doar 64% din cazuri în nodulii < 8 mm versus 86% în nodulii > 10 mm [Lenhardt et al J Clin Endocrinol Metab, 1999;84:24-28]. Diagnosticarea citologică a MCPT nu este neapărat un avantaj, deoarece 70% nu au evoluat timp de 4 ani / 10,2% au crescut la > 1cm şi doar 1,2% au dezvoltat adenopatie satelită [Ito Y et all, Thyroid, 2003; ].
3 Modalităţi de investigare ultrasonică Ecografia în modul B Evaluarea cantitativă şi calitativă a vascularizaţiei prin Doppler color şi Power Doppler Elastografia ultrasonică nouă metodă de investigare a nodulilor
4 Deşi ecografia are o mare acurateţe în identificarea nodulilor tiroidieni, utilitatea ei în a diferenţia între nodulii maligni şi cei benigni este destul de mică si foarte dependentă de experienţa examinatorului. Aspecte ecografice corelate cu caracterul malign al unui nodul tiroidian sunt: Nodul unic Formă neregulată Ecogenitate scăzută Margini imprecis delimitate Prezenţa microcalcificărilor în masa nodulului. Vascularizaţie intranodulară intensă şi tortuoasă.
5 Elastografia ultrasonică este o tehnică nouă ce foloseşte ultrasunetele pentru a analiza rigiditatea unei leziuni prin codificarea distorsionării ce apare atunci când nodulul este supus unei presiuni externe [Frey H Radiologe 2003; 43(10):8850-5
6 Aplicarea unei presiuni externe (cu ajutorul transducerului) va determina răspunsuri diferite în funcţie de elasticitatea structurii. Softul comparaă deformarea nodulului cu cea a ţesutului adiacent (indice de presiune - strain index). Rigiditate relativă va fi afişată pe un display color suprapus imaginii în modul B.
7 1. ELASTOGRAFIA IN TIMP REAL Metode: Elastografia ultrasonică ce utilizează pulsaţiile arterelor carotide (Medison) Elastografia ultrasonoră prin vibraţia mâinii (Hitachi) Elastografia in care traductorul emite şi receptionează vibraţiile (Siemens)
8 Scorul elastografic al nodulilor (Tsukuba) Întregul nodul este moale şi elastic. Nodulul este în mare parte elastic cu câteva porţiuni mai rigide. Periferia nodulului este elastică dar centrul este rigid.
9 Întregul nodul este rigid. Întregul nodul este rigid şi o parte din ţesutul adiacent.
10 Primul articol cu privire la elastografia tiroidiană: 92 de pacienţi consecutivi cu nodul tiroidian solitar care au fost trataţi chirurgical. [Rago et all J Clin Endocrinol Metab 2007, 92: ] malignant benign score 1-2 score 3 score4-5 Sensibilitae 97% şi specificitate 100 % VPP 100% şi VPN 98%
11 Studiul nostru A înrolat 34 pacienţi consecutivi cu guşă nodulară 31 femei + 3 bărbaţi Vârsta ani, medie / Evaluaţi prin: Ecografie în modul B şi Doppler color Scintigrafie Elastografie Dozări hormonale şi imunologice specifice Chirurgie EHP Elastografia a fost efectuată de acelaşi examinator utilizand un echipament Hitachi EUB cu un transducer de 13 MHz. Nodulii tiroidieni au fost clasificaţi în 5 clase după scorul indicat anterior.
12 Rezultate 34 pacienţi / 99 noduli elastografic 65 elastici sau moi (scor 1-3) EHP results related to elastographic score 34 duri (scor 4 5) EHP 17 noduli maligni (15 carcinom papillar şi 2 carcinom folicular). La 4 pacienţi au fost găsite leziuni maligne multiple ,2,3, 4,5 malignant benign 82 noduli benigni
13 Sensibilitatea 100% = un nodul malign este întotdeauna dur Specificitatea 79 % = un nodul benign este moale in 79 % din cazuri. VPP 50 % = un nodul dur este malign în 50 % din cazuri VPN 100 % = un nodul moale este benign în 100 % din cazuri Rezultate diferite de cele pulicate de Rago şi col, dar similare cu cele obţinute de alţi autori: Tranquart and all: 13 noduli duri / 6 maligni [Tranquart et all J Radiol, 2008, 89:35-9] Asteria and all: sens 94.1%, spec 81%, VPP 55.2%, VPN 98.2% [Asteria et all thyroid 2008, 18(5):523-31] Hong Y and all: sens 88%, spec 90%, VPP 81%, VPN 93%. [Hong Y et all J ultrasound Med (7):861-7]
14 Limitări ale elastografiei în timp real Interpretarea unei game de culori păstrează o doză de subiectivism, Există variaţii ale rigidităţii în funcţie de intensitatea şi ritmul comprimării, Profunzimea la care este situat nodulul influenţează rigiditatea obţinută, Uneori (în cazul nodulilor foarte mari) nu există ţesut tiroidian normal faţă de care să se facă comparaţia, Elasticitatea parenchimului tiroidian adiacent (faţă de care se face raportarea) are elasticitate diferită.
15 2. ELASTOGRAFIA CANTITATIVA (QUANTITATIVE STRAIN ELASTOGRAPHY) Pentru a depăşi aceste limitări au fost dezvoltate softuri care permit exprimarea numerică a raportului dintre rigiditatea nodulului şi cea a parenchimului adiacent: Comparaţia se realizează ulterior examinării, prin post procesarea imaginilor înregistrate. Deşi rezultatele studiilor publicate sunt uneori discordante [1,2,3,4] majoritatea indică faptul că un SR mai mare de 4 este înalt predictiv pentru malignitatea nodulului; cea mai bună sensibilitate fiind de 82% iar specificitate de 96%. Şi această metodă este grevată de limitarea produsă de elasticitatea diferită a ţesutului tiroidian (normal sau afectat de o patologie difuză) faţă de care se face raportarea. 1. Luo S et Al Thyroid nodule classification using ultrasound elastography via linear discriminant analysis. Ultrasonics May;51(4): Xing P et Al Differentiation of benign from malignant thyroid lesions: calculation of the strain ratio on thyroid sonoelastography. J Ultrasound Med May;30(5): Ning CP et Al The value of strain ratio in differential diagnosis of thyroid solid nodules. Eur J Radiol Feb;81(2): Cantisani V et Al Prospective evaluation of multiparametric ultrasound and quantitative elastosonography in the differential diagnosis of benign and malignant thyroid nodules: preliminary experience. Eur J Radiol Oct;81(10):
16 3. SHEAR WAVE ELASTOGRAPHY O altă modalitate de a determina elasticitatea unui ţesut este prin măsurarea undei de forfecare (shear wave). Viteza de propagare a undei de forfecare este direct proporţională cu rigiditatea ţesutului care în acest fel poate fi măsurată direct în kilopascali (KPa). Un prim studiu [1] măsoară un indice de elasticitate (IE) de 150 KPa în nodulii maligni faţă de 36,3 KPa în nodulii benigni şi stabileşte un cutt-of de 65KPa pentru diferenţierea benign/malign pentru care sensibilitatea este de 85,2% iar specificitatea de 93,9%. 1. Sebag F et Al Shear wave elastography: a new ultrasound imaging mode for the differential diagnosis of benign and malignant thyroid nodules. J Clin Endocrinol Metab Dec;95(12):
17 Rezultatele au fost confirmate ulterior şi de alte studii [1-5] cut-off de 65 KPa De asemenea, reproductibilitatea intra şi inter observator este mult superioară celorlalte metode elastografice, crescând acurateţea şi gradul de încredere [6]. 1. Magri F et Al Shear wave elastography in the diagnosis of thyroid nodules: feasibility in the case of coexistent chronic autoimmune Hashimoto's thyroiditis. Clin Endocrinol (Oxf) Jan;76(1): Monpeyssen H et Al Elastography of the thyroid. Diagn Interv Imaging Apr 24. doi:pii: S (13) Kim H et Al Quantitative assessment of shear-wave ultrasound elastography in thyroid nodules: diagnostic performance for predicting malignancy. Eur Radiol Apr Park YJ et Al Quantitative Shear Wave Elastography as a Prognostic Implication of Papillary Thyroid Carcinoma (PTC): Elasticity Index Can Predict Extrathyroidal Extension (ETE). Ann Surg Oncol Mar Veyrieres JB et Al A threshold value in Shear Wave elastography to rule out malignant thyroid nodules: a reality? Eur J Radiol Dec;81(12): Bhatia K et Al Reliability of shear wave ultrasound elastography for neck lesions identified in routine clinical practice. Ultraschall Med Oct;33(5):
18 4. ARFI (Acoustic Radiation Force Impulse) Este o tehnică bazată pe acelaşi principiu dar cu o rată de achiziţie mai lentă şi limitată la un cadru. Permite măsurarea vitezei cu care se propagă unda de forfecare (SWV) şi prin aceasta, cuantificarea elasticităţii tisulare [1]. Deşi metoda este încă în curs de evaluare, un studiu publicat recent [2] indică o viteză de 2,34 m/s în nodulii benigni, semnificativ mai mică faţă de cea din nodulii maligni 4,82 m/s, cu un cut-off de 2,87 m/s. Limitarea ar fi legată de dimensiunile nodulilor: metoda are sensibilitate şi specificitate net mai bună în cazul nodulilor mai mari de 2 cm. Sensibilitatea este cuprinsă între 75 şi 86% iar specificitatea între 89 şi 93% [2-5]. 1. Sporea I et Al Thyroid stiffness assessment by acoustic radiation force impulse elastography (ARFI). Ultraschall Med Jun;32(3): Zhang YF et Al Virtual touch tissue quantification of acoustic radiation force impulse: a new ultrasound elastic imaging in the diagnosis of thyroid nodules. PLoS One. 2012;7(11):e Gu J et Al Preliminary study on the diagnostic value of acoustic radiation force impulse technology for differentiating between benign and malignant thyroid nodules. J Ultrasound Med May;31(5): Bojunga J et Al Acoustic radiation force impulse imaging for differentiation of thyroid nodules. PLoS One. 2012;7(8):e Hou XJ et Al The application of Virtual Touch tissue quantification (VTQ) in diagnosis of thyroid lesions: a preliminary study. Eur J Radiol May;82(5):
19 Concluzii Explorarea elastografică ultrasonică este cea mai importantă dezvoltare tehnologică în ultrasonografie de la imagistica Doppler încoace. Metoda este încă în curs de dezvoltare, existând mai multe variante tehnice, dintre care, deocamdată, nici una nu s-a validat ca fiind cea mai bună şi singura de folosit. Caracterizarea elastografică a nodulilor tiroidieni trebuie făcută doar după o atentă examinare în modul B, Doppler color şi Power Doppler, iar informaţia elastografică trebuie integrată în scorul ecografic. Indiferent de metoda de elastografie folosită parametrul care are constant cea mai mare valoare este valoarea predictivă negativă (VPN) 90% - 100% elastografia este foarte performantă în a exclude caracterul malign al unui nodul, ceea ce pentru practică este foarte important, permiţând o triere substanţială a nodulilor care necesită evaluare PCA!
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