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Ultrasound Elastography

Posted Jun 30, 2010 Updated Apr 7, 2023
By Rong Tan MM , Ying Xiao MD PhD , Qun He MD
8 min read

Rationale and Objectives

The aims of this study were to investigate the value of ultrasound elastography (UE) in the diagnosis of lymphadenopathy and to explore whether UE could improve the differentiation between benign and malignant cervical lymph nodes (LNs).

Materials and Methods

B-mode ultrasound, power Doppler imaging, and UE were performed in 107 consecutive patients with 128 cervical LNs. Only LNs that unequivocally matched between sonography and pathology were analyzed. The results of B-mode ultrasound, power Doppler imaging, and UE were interpreted separately to assess cervical LNs, using histopathologic analysis as the reference standard.

Results

A marked difference ( P = .000) was found in the strain ratio between 70 malignant LNs (median, 2.71; range, 1.36–36.09) and 58 benign LNs (median, 1.44; range, 0.62–3.90). Receiver-operating characteristic curves showed that a strain ratio > 1.5 had high utility in enlarged cervical LN classification, with 92.5% sensitivity, 53.4% specificity, and a Youden’s index of 0.463. These results were significantly better than those obtained using the best grayscale criterion, a ratio of long-axis to short-axis diameter > 2, which yielded 58.6% sensitivity, 70% specificity, and a Youden’s index of 0.286. The κ values for interobserver agreement were highest using UE, at 0.881 (observer 1 vs observer 2), 0.828 (observer 1 vs observer 3), and 0.946 (observer 2 vs observer 3).

Conclusions

UE as an adjunct ultrasound modality holds some promise in screening and monitoring lymphadenopathy.

To date, open cervical lymph node (LN) biopsy combined with pathologic examination remains the gold standard to determine whether LNs metastasize . However, the procedure can alter patterns of lymphatic drainage for up to 1 year following surgery and may portend a poor prognosis, especially for patients to present late to the hospital . Fine-needle aspiration cytology has proven to be an efficient tool for diagnosis, but it is an invasive approach and is subject to sampling and analytic uncertainty. Thus, improved and more reliable criteria for determining which nodules should be followed up and which should be aspirated are needed . In response, significant research efforts have been directed toward identification using noninvasive methods for diagnosing enlarged LNs. This technique must be safe, accurate, and accessible, like many standard medical screening tests.

Ultrasonography, compared to computed tomography and magnetic resonance imaging, has proven to be a valuable tool for the detection of LNs, but making a clear differentiation between benign nodal diseases and malignant lymphadenopathy remains difficult. Recently, ultrasound elastography (UE) has been presented as a novel technique to aid cancer research. It can be superimposed during B-mode ultrasound (B-US) examination to assess and measure tissue elasticity.

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Materials and methods

Patients, Procedure, and Examination Technique

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Ultrasound, PDI, and UE Evaluation

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Figure 1, Sonographic features in enlarged cervical lymph nodes.

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Pathologic Examination

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Statistical Analysis

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Results

B-US

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Table 1

The P Value of X2 Test of the Ultrasonographic Indexes of Lymph Nodes

L/T Hilum PDI Pattern UE Score Strain Ratio Sonomor-phologic features ≥2 <2 Normal ∗ Abnormal † I or V II, III, or IV 1or 2 3or 4 ≤1.5 >1.5 Benign 37 (28.9%) 21 (16.4%) 14 (10.9%) 44 (34.3%) 45 (35.2%) 13 (10.2%) 51 (39.8%) 7 (5.5%) 31 (24.2%) 27 (21.1%) Malignant 21 (16.4%) 49 (38.3%) 4 (3.1%) 66 (51.6%) 4 (3.1%) 66 (51.6%) 35 (27.3%) 35 (27.3%) 5 (3.9%) 65 (50.8%)P .000 .003 .000 .000 .000 Contingency coefficient 0.320 0.255 0.593 0.373 0.456 Odds ratio (95% confidence interval) 4.111 (1.961–8.619) 5.250 (1.622–16.998) 57.115 (17.498–186.429) 7.286 (2.908–18.254) 10.230 (5.245–42.472)

L/T, ratio of long-axis to short-axis diameter; PDI, power Doppler imaging; UE, ultrasound elastography.

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PDI

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Table 2

Comparison of Sensitivity, Specificity, Accuracy for B- US, PDI, and UE

Imaging Modality Sensitivity Specificity Accuracy PPV NPV Youden’s Index (Sensitivity − [1 − Specificity]) B-US 88.6% (62/70) 46.6% (27/58) 69.5% (89/128) 66.7% (62/93) 77.1% (27/35) 35.2% PDI 94.3% (66/70) 77.6% (45/58) ∗ 86.7% (111/128) ∗ 83.5% (66/79) ∗ 91.8% (45/49) 75.3% ∗ UE 92.8 % (65/70) 53.4% (31/58) ∗ † 75% (96/128) ∗ † 70.7% (65/92) † 86.1% (31/36) 46.3% †

B-US, B-mode ultrasound; NPV, negative predictive value; PDI, power Doppler imaging; PPV, positive predictive value; UE, ultrasound elastography.

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UE

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Figure 2, Tuberculosis lymphadenitis. (a, b) Sonograms obtained from a 32-year-old woman with symptoms of dry cough and weight loss. (c, d) In this lymph node (LN), which was 18 × 12 × 7 mm, a hyperechoic area of 5 × 3 mm was seen on power Doppler imaging (PDI). Gross pathology and histologic samples proved that the area was typical caseous necrosis of tuberculosis. (e–g) In a negative LN, hyperechoic area corresponding to the hilum was observed, and blood flow distributing evenly from the hilum was seen on PDI. The node also appeared as a soft mass on elastography, in which ≥80% of the node was green or red. Finally, the soft, uniform, pale to creamy tan nodal parenchyma and distinct hilum were proved by pathology. (h–j) In a positive LN, no hyperechoic area corresponding to the hilum was noted, and random blood flow was observed in its capsule and interior. The node was entirely blue or mixed with small areas of green. Open biopsy validated the inner bleeding of the resected LN.

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Interobserver Variability

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Discussion

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Acknowledgment

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Academic Radiology, Volume 17, Issue 7
Journals General Radiology
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