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Prediction of cervical lymph node metastasis in patients with papillary thyroid cancer using combined conventional ultrasound, strain elastography, and acoustic radiation force impulse (ARFI) elastography

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Abstract

Objectives

To investigate the value of combined conventional ultrasound (US), strain elastography (SE) and acoustic radiation force impulse (ARFI) elastography for prediction of cervical lymph node metastasis (CLNM) in papillary thyroid cancer (PTC).

Methods

A consecutive series of 203 patients with 222 PTCs were preoperatively evaluated by US, SE, and ARFI including virtual touch tissue imaging (VTI) and virtual touch tissue quantification (VTQ). A multivariate analysis was performed to predict CLNM by 22 independent variables. Receiver operating characteristic (ROC) curve analysis was used to evaluate the diagnostic performance.

Results

Multivariate analysis demonstrated that VTI area ratio (VAR) > 1 was the best predictor for CLNM, followed by abnormal cervical lymph node (ACLN), capsule contact, microcalcification, capsule involvement, and multiple nodules (all P < 0.05). ROC analyses of these characteristics showed the areas under the curve (Az), sensitivity, and specificity were 0.600–0.630, 47.7 %–93.2 %, and 26.9 %–78.4 % for US, respectively; and they were 0.784, 83.0 %, and 73.9 %, respectively, for VAR > 1. As combination of US characteristics with and without VAR, the Az, sensitivity, and specificity were 0.803 and 0.556, 83.0 % and 100.0 %, and 77.6 % and 11.2 %, respectively (P < 0.001).

Conclusions

ARFI elastography shows superior performance over conventional US, particularly when combined with US, in predicting CLNM in PTC patients.

Key Points

• Conventional ultrasound is useful in predicting cervical lymph node metastasis preoperatively.

• Virtual touch tissue imaging area ratio is the strongest predicting factor.

• Predictive performance is markedly improved by combining ultrasound characteristics with VAR.

• Acoustic radiation force impulse elastography may be a promising complementary tool.

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Abbreviations

CLNM:

Cervical lymph node metastasis

PTC:

Papillary thyroid carcinoma

SE:

Strain elastography

ARFI:

Acoustic radiation force impulse

VTI:

Virtual touch tissue imaging

VTQ:

Virtual touch tissue quantification

ROC:

Receiver operating characteristic

Az:

Areas under the curve

VAR:

Virtual touch tissue imaging area ratio

ACLN:

Abnormal cervical lymph node

SWV:

Shear wave velocity

FNAB:

Fine–needle aspiration biopsy

ROI:

Region of interest

OR:

Odds ratio

CI:

Confidence interval

PTMC:

Papillary thyroid microcarcinoma

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Acknowledgments

The scientific guarantor of this publication is Hui-Xiong Xu, head of the Department of Medical Ultrasound, Shanghai Tenth People’s Hospital, Ultrasound Research and Education Institute, Tongji University School of Medicine. This study was funded by a grant SHDC12014229 from the Shanghai Hospital Development Center, grants 14441900900 and 15411969000 from the Science and Technology Commission of Shanghai Municipality, a grant 2012045 from the Shanghai Municipal Human Resources and Social Security Bureau, and grants 81501475, 81401417 and 81472579 from the National Natural Science Foundation of China.The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article. No complex statistical methods were necessary for this paper. Institutional review board approval was obtained. Informed consent was obtained from all subjects (patients) to include their data for analysis in this study. Some malignant nodules (N = 57) in this study have been reported in two previously published articles: Xu JM, Xu XH, Xu HX, et al (2014) Conventional US, US elasticity imaging, and acoustic radiation force impulse imaging for prediction of malignancy in thyroid nodules. Radiology, 272(2): 577–586 and Zhang YF, Liu C, Xu HX, et al (2014) Acoustic radiation force impulse imaging: a new tool for the diagnosis of papillary thyroid microcarcinoma. Biomed Res Int, 2014: 416969.

Methodology: retrospective, observational, performed at one institution.

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    Authors and Affiliations

    1. Department of Medical Ultrasound, Shanghai Tenth People’s Hospital, Ultrasound Research and Education Institute, Tongji University School of Medicine, Shanghai, 200072, China

      Jun-Mei Xu, Hui-Xiong Xu, Yi-Feng Zhang, Le-Hang Guo, Lin-Na Liu, Chang Liu, Xiao-Wan Bo & Xiao-Long Li

    2. Thyroid Institute, Tongji University School of Medicine, Shanghai, 200072, China

      Jun-Mei Xu, Hui-Xiong Xu, Yi-Feng Zhang, Le-Hang Guo, Lin-Na Liu, Chang Liu, Xiao-Wan Bo, Shen Qu, Mingzhao Xing & Xiao-Long Li

    3. Department of Ultrasound, Guangdong Medical College Affiliated Hospital, 524001, Zhanjiang, China

      Xiao-Hong Xu & Hui-Xiong Xu

    4. Department of Endocrinology and Metabolism, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, 200072, China

      Shen Qu

    5. Department of Endocrinology, Diabetes & Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA

      Mingzhao Xing

    6. Department of Medical Ultrasound, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, No.301, Yanchangzhong Road, Shanghai, 200072, China

      Hui-Xiong Xu

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    1. Jun-Mei Xu
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    Correspondence to Hui-Xiong Xu.

    Additional information

    Hui-Xiong Xu and Mingzhao Xing contributed equally to this work.

    Appendices

    Appendix 1

    Table 5 Basic characteristics of the PTCs
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    Appendix 2

    Table 6 The US features of the PTCs
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    Xu, JM., Xu, XH., Xu, HX. et al. Prediction of cervical lymph node metastasis in patients with papillary thyroid cancer using combined conventional ultrasound, strain elastography, and acoustic radiation force impulse (ARFI) elastography. Eur Radiol 26, 2611–2622 (2016). https://doi.org/10.1007/s00330-015-4088-2

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