| Chapter one:The diagnostic value of strain elastography in the adjustment of BI-RADS 4 lesions Background and aim:Although ultrasound elastography can improve the diagnosis of traditional ultrasound in the identification of benign or malignant breast nodules,the cut off values of elasticity parameters are not determined,and urgently needed to be further studied in order to improve the diagnostic efficiency of ultrasound using combined elasticity parameters and BI-RADS classification of traditional ultrasound.The purpose of this study is to investigate the diagnostic efficacy and optimal cut off value of the two commonly used parameters of strain elastography,elastic score and strain ratio,in the determination of benign and malignant breast nodules and the atypical BI-RADS 4 categories.Methods:192 breast cancer patients with a total of 200 breast nodules were included in the study.They visited the ultrasound department of our hospital from October 2017 to June2018.Inclusion criteria were:(1)Solid nodules of BI-RADS category 4 lesions by conventional ultrasound;(2)All nodules were imaged by strain elastography to obtain elastography score and strain ratio;(3)Nodules had pathological results of surgery or biopsy.The patients were all female,ranging in age from 16 to 75 years old,with an average age of 45±12.5 years old.Philips EPIQ7 Color Doppler Ultrasound Imaging System was used.ES and SR were obtained,The BI-RADS category of the nodules was recorded;according to the 5-point method proposed by Itoh,the lesions with ES of 1-3points were considered as benign and 4-5 points were considered as malignant;the normal adipose tissue around the lesions was selected as the control,the SR of the lesions was measured,and the best diagnostic threshold of SR was calculated by ROC curve.and the benign and malignant thresholds were calculated.Combined with this scale index,the category of nodules was re-adjusted.The criteria for rating adjustment were as follow: if both the ES and the SR indicate malignancy,the rating is to be upgraded by one sub-level;if both the elastography score and the strain ratio indicate benign,the rating is to be downgraded by one sub-level.Otherwise,it remains unchanged.Based on pathological results the diagnostic value of benign and malignant breast nodules in the study was determined,including,the conventional ultrasound BI-RADS rating,elastography score,strain ratio and the combination of the three,respectively.Results:(1)Elastography score: The ES(Elastography scores)of benign lesions werefrom1 to 4 points,with an average of 2.68±1.34 points,and the ES of malignant lesions was2 to 5 points,with an average of 4.14±1.01 points.The elastography score of malignant lesions was significantly higher than that of benign lesions,and the difference was statistically significant(z=-7.237,P<0.05).According to the 5-point method proposed by Itoh et al.,based on the ES of 3 as the critical value to determine the accuracy of the benign and malignant criteria of breast nodules,the ROC(Receiver Operating Characteristic Curve)was drawn,and the AUC(Area Under Curve)was calculated as0.79,the diagnostic sensitivity was 87.0%,and the specificity was 73%(2)Strain ratio: The SR(Strain Ratios)of benign lesions were from 0.25 to 0.96,with an average of 0.33±0.60.The SR of malignant lesions were from 0.15 to 0.50,with an average of 0.18±0.47.The SR of benign lesions was significantly higher than that of malignant lesions,and the difference was statistically significant(z=-7.152,P<0.05).The threshold for judging benign and malignant breast nodules calculated by the Youden index is 0.3,According to SR 0.3 as the critical value to determine the accuracy of the benign and malignant breast nodules,the ROC curve was drawn,and the AUC was 0.80,the diagnostic sensitivity was 79.0%,and the specificity was78.0%.(3)The AUC of conventional ultrasound BI-RADS classification,,elastography score method,strain ratio method and the combination of the three methods were: 0.83,0.79,0.80,0.90,respectively.The combination of the three methods to diagnose the AUC of benign and malignant breast nodules in this group was compared with the AUC of the BI-RADS score,ES and SR alone in the diagnosis of benign and alignant breast nodules in this group,and the differences were statistically significant(P<.05).Conclusion(1)The ES and the SR in the strain elastography technique can qualitatively and semi-quantitatively evaluate the relative hardness of the tissue,and therefore has high application value in the identification of benign and malignant breast lesions.(2)The combination of the ES and the SR with the conventional BI-RADS category of breast,can improve the diagnostic efficiency of BI-RADS category 4lesions and reduce unnecessary biopsy.Chapter Two: Correlation between ultrasonic strain elasticity and immunohistochemical(IHC)subtypes of breast cancerBackground and aim:Breast cancer is one of the most common malignant tumors and one of the main causes of death in women all over the world.Early diagnosis and treatment is the key to improve the prognosis.Breast cancer is a tumor with high heterogeneity.In order to guide the treatment and prognosis evaluation more accurately,the molecular classification of breast cancer is further proposed on the basis of different histopathological types.Molecular typing of breast cancer is of great significance for clinical guidance.Ultrasound elastography can be a significant supplement to conventional ultrasound.However,in recent years,different articles have different research results on the relationship between tumor hardness and molecular typing of breast cancer.In this study,we will explore the difference between strain ratio and different molecular types of breast cancer,with a view to better using strain elasticity technology in clinical practice of breast cance.Methods:Part 1: 192 breast cancer patients with a total of 200 breast nodules were included in the study.They visited the ultrasound department of our hospital from October 2017 to June 2018.Inclusion criteria were:(1)Solid nodules of BI-RADS category 4 lesions by conventional ultrasound;(2)All nodules were imaged by strain elastography to obtain elastography score and strain ratio;(3)Nodules had pathological results of surgery or biopsy.The patients were all female,ranging in age from 16 to 75 years old,with an average age of 45±12.5 years old.Philips EPIQ7 Color Doppler Ultrasound Imaging System was used.ES and SR were obtained,The BI-RADS category of the nodules was recorded;according to the 5-point method proposed by Itoh,the lesions with ES of 1-3 points were considered as benign and 4-5 points were considered as malignant;the normal adipose tissue around the lesions was selected as the control,the SR of the lesions was measured,and the best diagnostic threshold of SR was calculated by ROC curve.and the benign and malignant thresholds were calculated.Combined with this scale index,the category of nodules was re-adjusted.The criteria for rating adjustment were as follow: if both the ES and the SR indicate malignancy,the rating is to be upgraded by one sub-level;if both the elastography score and the strain ratio indicate benign,the rating is to be downgraded by one sub-level.Otherwise,it remains unchanged.Based on pathological results the diagnostic value of benign and malignant breast nodules in the study was determined,including,the conventional ultrasound BI-RADS rating,elastography score,strain ratio and the combination of the three,respectively.Part 2: 176 breast cancer patients with a total of 179 breast nodules were included in the study.They visited the ultrasound department of our hospital from October 2017 to December 2019.Inclusion criteria were:(1)All patients were diagnosed as breast cancer by pathological results obtained after surgery or puncture examination,and the immunohistochemistry data is complete;(2)All patients have undergone elasticity imaging technique examination before surgery;(3).All patients have not received any form of treatment before the ultrasound examination.The patients were all female,ranging in age from 28 to 75 years old,with an average age of 47±11.5 years old.The maximum diameter of the mass recorded by conventional ultrasound was 5mm-65 mm,the average is(17.96±10.90)mm,and the median is 15 mm.With 15 mm as the cutoff value,the masses are divided into large mass group(>15 mm,79 pieces)and small mass group(≤ 15 mm,100 pieces).The pathological results,findings of the elastic images,tumor size,strain ratio and lesion of all patients were recorded.Analyze the pathological examination results of 179 breast cancer lesions,according to the ER(Estrogen Receptor),PR(Progesterone Receptor),Her-2(Human Epidermal Growth Factor Receptor-2)and Ki-67 levels,breast cancer was divided into Luminal A type,Luminal B type,Her-2 Overexpression type and TNBC(Triple negative breast Cancer)type.To explore the relationship between the IHC(Immunohistochemical)subtypes of breast cancer and the strain elastic parameter strain ratio were determined.Results:Part 1:(1)Elastography score: The ES(Elastography scores)of benign lesions werefrom1 to 4 points,with an average of 2.68±1.34 points,and the ES of malignant lesions was2 to 5 points,with an average of 4.14±1.01 points.The elastography score of malignant lesions was significantly higher than that of benign lesions,and the difference was statistically significant(z=-7.237,P<0.05).According to the 5-point method proposed by Itoh et al.,based on the ES of 3 as the critical value to determine the accuracy of the benign and malignant criteria of breast nodules,the ROC(Receiver Operating Characteristic Curve)was drawn,and the AUC(Area Under Curve)was calculated as0.79,the diagnostic sensitivity was 87.0%,and the specificity was 73%(2)Strain ratio: The SR(Strain Ratios)of benign lesions were from 0.25 to 0.96,with an average of 0.33±0.60.The SR of malignant lesions were from 0.15 to 0.50,with an average of 0.18±0.47.The SR of benign lesions was significantly higher than that of malignant lesions,and the difference was statistically significant(z=-7.152,P<0.05).The threshold for judging benign and malignant breast nodules calculated by the Youden index is 0.3,According to SR 0.3 as the critical value to determine the accuracy of the benign and malignant breast nodules,the ROC curve was drawn,and the AUC was 0.80,the diagnostic sensitivity was 79.0%,and the specificity was78.0%.(3)The AUC of conventional ultrasound BI-RADS classification,,elastography score method,strain ratio method and the combination of the three methods were: 0.83,0.79,0.80,0.90,respectively.The combination of the three methods to diagnose the AUC of benign and malignant breast nodules in this group was compared with the AUC of the BI-RADS score,ES and SR alone in the diagnosis of benign and alignant breast nodules in this group,and the differences were statistically significant(P<.05).Part 2:(1)There were 179 breast cancer masses in total.The average size of the masses was(17.96±10.90)mm,and the median was 15 mm,therefore 15 mm was taken as the cut-off value.The masses were divided into large masses(>15 mm,79 pcs)and small masses(≤15 mm,100 pcs).(2)The mean value of SR in the large masses group was significantly lower than that of the small masses group,and the difference was statistically significant(z=4.238,P<0.05).(3)When comparing the SR mean value of each IHC subtype in the small mass group,the hardness level from hard to soft was as following: Her-2 Overexpression,Luminal B,Luminal A,TNBC,and the difference was statistically significant(z=25.130,P<0.05).(4)The SR mean values of each IHC subtype in the large mass group showed the same situation as those in the small mass group,but the SR mean values of Her-2Overexpression breast cancer were significantly lower than other subtypes,and the difference was statistically significant(P<0.05);There was no significant difference in the SR mean values among the other Luminal A,Luminal B,and TNBC(z=3.209,P=0.201).Conclusion(1)The ES and the SR in the strain elastography technique can qualitatively and semi-quantitatively evaluate the relative hardness of the tissue,and therefore has high application value in the identification of benign and malignant breast lesions.(2)The combination of the ES and the SR with the conventional BI-RADS category of breast,can improve the diagnostic efficiency of BI-RADS category 4lesions and reduce unnecessary biopsy.(3)The SR value of breast cancer tumors of different sizes is different.The SR value of large tumors is significantly smaller than that of small tumors,indicating that the larger the tumor,the greater the hardness.(4)The hardness of breast cancer with different IHC subtypes is different,the hardness level from hard to soft was as following: Her-2 Overexpression,Luminal B,Luminal A,TNBC.Except for TNBC,the hardness level of other tumors was consistent with the invasive biological behavior and prognosis of breast cancer.(5)The difference of SR in the IHC subtypes of breast cancer which less than or equal to 15 mm has statistical significance.It shows that for breast cancer which less than 15 mm,the hardness level of the mass could be used to further predict the IHC subtypes of breast cancer. |
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