Www.research.ed.ac.uk
Real-time elastosonography of LIPOMATOUS VS MALIGNANT subcutaneous NEOPLASMS in dogs: PRELIMINARY RESULTSMaurizio Longo, Spela Bavcar, Ian Handel, Sionagh Smith, Tiziana LiutiFrom the Royal (Dick) School of Veterinary Studies and Roslin Institute, The University of Edinburgh, Roslin, EH25 9RG, UK Address all correspondence and reprint requests to Dr. Tiziana Liuti; e-mail: tiziana.liuti@ed.ac.ukKey words: subcutaneous, elastogram, ultrasound, elastography, lipoma, TsukubaRunning head 1: Longo et al.Running head 2: Elastosonography of subcutaneous lesionsAbstractReal-time elastography is a recently introduced ultrasound technique allowing the investigation of elastic properties of tissues. A diagnostic accuracy study was conducted to test the performance of this technique in the assessment of subcutaneous lesions in dogs. Fifty-two dogs were prospectively included in the preliminary study (34 malignant and 18 benign lesions). B-mode ultrasound was performed assessing the shape, margins, heterogeneity and echotexture of the lesions. On elastosonography, assessment of the percentage of softness/hardness was recorded. A qualitative assessment was performed according to the Tsukuba elasticity score with a 1 to 5 score, representing the increased percentage of high stiffness areas. Results were compared with cytology/histopathology of the lesions. ROC curves of the overall diagnostic sensitivity and specificity were obtained. Fisher’s exact test and Pearsons’s Chi-squared test estimated the relationship between the B-mode appearance of the lesions and final diagnosis. A hardness cut off of 50.25% was identified between lesions, with malignant neoplasms having higher percentages. A 100% specificity and 89% sensitivity for correctly detecting the nature of the lesion on elastosonography was established. Qualitative assessment of the Tsukuba elasticity score established 1.5 as the cut-off between elastograms of lipomatous and malignant lesions, with 100% sensitivity and 61% specificity in differentiating them. Real-time elastosonography is a novel, non-invasive and accurate technique for differentiating malignant from benign lipomatous lesions in dogs. This method could be considered as a complementary tool with additional diagnostic value for routine invasive procedures, such as fine needle aspirates.INTRODUCTIONSubcutaneous lesions are routinely detected during small animal clinical activity, especially in dogs. Among the different subcutaneous neoplasms, both benign and malignant masses can be identified, with the latter accounting for 20-40% of all subcutaneous primary neoplasms and requiring a thorough examination to be correctly diagnosed.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CcsO4bmRlbjwvQXV0aG9yPjxZZWFyPjIwMTA8L1llYXI+
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ADDIN EN.CITE.DATA 1, 4 Undoubtedly, early detection of malignant lesions could help orientate the therapeutic approach, assess therapeutic efficacy, and thus the prognosis of the patient. ADDIN EN.CITE <EndNote><Cite><Author>Cri?an</Author><Year>2014</Year><RecNum>39</RecNum><DisplayText><style face="superscript">5</style></DisplayText><record><rec-number>39</rec-number><foreign-keys><key app="EN" db-id="tdrrfapv9ad2eaees0apt0xnedxxwvpvds05" timestamp="1493721650">39</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Cri?an, D.</author><author>Badea, A. F.</author><author>Cri?an, M.</author><author>Rastian, I.</author><author>Solovastru, L. G.</author><author>Badea, R.</author></authors></contributors><titles><title>Integrative analysis of cutaneous skin tumours using ultrasonogaphic criteria. Preliminary results</title><secondary-title>Medical Ultrasonography</secondary-title></titles><periodical><full-title>Medical ultrasonography</full-title></periodical><pages>285-290</pages><volume>16</volume><number>4</number><keywords><keyword>Contrast Agent</keyword><keyword>Elastography</keyword><keyword>Skin</keyword><keyword>Skin Tumors</keyword><keyword>Ultrasonography</keyword></keywords><dates><year>2014</year></dates><isbn>18444172</isbn><urls></urls><electronic-resource-num>10.11152/mu.201.3.2066.164.dcafb</electronic-resource-num></record></Cite></EndNote>5 Moreover, raising concerns about the malignancy of a lesion could alter the surgical approach to a neoplasm, in terms of margins, to reduce the risk of residual neoplastic tissue or seeding. It may also alter the decision to pursue further diagnostic tests or (pre)treatments due to the risk related with sampling of the lesions, such as degranulation, in the case of mast cell tumours.3 B-mode ultrasonography only provides information about the shape, margins and echogenicity of lesions, and may display similar features between neoplastic and benign soft tissue lesions, as reported in humans.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Ub3ByYWs8L0F1dGhvcj48WWVhcj4yMDE0PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA 14, 15Both qualitative and quantitative assessment of lesions can be performed, depending on the physical technique used to generate the elastographic maps. A recently described, free-handed elastosonography technique in dogs called strain elastography allows qualitative assessment of the elastograms as well as additional objective measurements of the density of the lesions, adding more semi-quantitative and relative value to the studies.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5KZW9uPC9BdXRob3I+PFllYXI+MjAxNTwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA 16, 17The aim of this preliminary study was to test the accuracy of free handed real-time elastosonography in differentiating subcutaneous lipomas from spontaneous malignant neoplasms in dogs.METHODSA prospective diagnostic accuracy design study was conducted. Sample size was determined by the clinical statistician (I.H.) considering that two groups of n=17 in an unpaired analysis would have a power > 80% to detect a difference of effect size 1.0 (difference between groups divided by SD) in a two-sided T-test of size 0.05. Additional observations were added for non-parametric approaches. Client-owned dogs with spontaneous subcutaneous lesions and referred to the oncology Department for staging were prospectively included in the study, between October 2016-March 2017. The study protocol was approved by the by the Veterinary Ethical Review Committee (VERC) at the Royal (Dick) School of Veterinary Studies, University of Edinburgh (VERC approval 88.16), with informed client consent obtained for each patient prior to enrolment. Inclusion criteria were checked by a Board Certified oncology clinician (S.B.) and included the following: (1) presence of a subcutaneous palpable mass of unknown nature, (2) mass spontaneously occurring in the patient without previous history of surgery or scar tissue at the same location, (3) informed owner consent. If the neoplastic or benign nature of the lesions was known before the ultrasound examination, the subjects were excluded from the study. Patients were sedated with a standard sedation protocol including both opioids and alpha-2 agonist. Subjects were positioned in lateral or sternal recumbency depending on the location of the lesion: for lesions located dorsally a sternal recumbency was preferred. A resident in small animal diagnostic imaging (M.L.) performed the ultrasound examinations blinded of patient coding (MyLab Twice Esaote, Genova, Italy), with a linear electronic array (LA435) and a frequency ranging between 8-18 MHz. No previous palpation of the lesions was performed by the radiologist. B-mode ultrasound was initially performed on transverse and sagittal planes qualitatively assessing shape (ellipsoid vs irregular), margins (regular vs irregular), heterogeneity and echotexture (hyper-, iso-, or hypoechogenicity) of the lesions. Elastosonography of the lesions was performed subsequently by the same examiner (M.L.) (ElaXto function, Esaote, Genova, Italy) in sagittal plane. A sufficient amount of coupling gel was applied over the lesions and the ultrasound probe was oriented perpendicular to the skin surface. Rhythmic compressive and retractile movements of the probe over the lesion were performed until adequate compression and image quality was achieved. Persistence was adjusted for this purpose and a qualitative assessment of the compression was performed by using the ElaXto spring function, correlating the quality of the acquisition with the compression applied by the probe. Images were acquired using the Double ElaXto function, with dual display of B-mode and the elastographic image. On post processing the contour of the lesions was manually drawn in the B-mode image and simultaneously copied in the elastosonographic image by the same observer (M.L.) (Fig. 1). The percentage of soft and hard areas was calculated by the commercial software (ElaXto function, Esaote, Genova, Italy) and the measurements of the drawn areas were recorded for each lesion. Quality of the study was assessed by the supervisor Board certified radiologist (T.L.). A qualitative assessment of the elastographic pattern was performed by a single radiologist (M.L.) according to the Tsukuba elasticity score of 1 to 5, representing the increased percentage of high stiffness areas in the elastogram.18 Subsequently to ultrasound, all lesions were sampled by the same Board certified oncology clinician (S.B.) by means of fine needle aspirates, or biopsied by a Board certified surgeon, or both. Samples were blindly assessed by a Board certified veterinary pathologist (S.S.), unaware of results from previous ultrasound exams. Statistical analysis was performed by one author (I.H.) using a commercial software (The R statistical program, The R Foundation 2016 – 124 r-, Vienna, Austria), comparing ultrasonographic results with cytology and/or histopathology of the lesions.The Tsukuba elasticity scores and the relationship between soft/hard areas and hardness score and hard areas were first assessed via a scatterplot graph. A ROC curve of the overall diagnostic sensitivity and specificity was obtained. Fisher’s exact test estimated the correlation between margins/heterogeneity of the lesions and final diagnosis on histopathology/cytology. Pearsons’s Chi-squared test was used to estimate the relationship between echogenicity of the lesions (iso-, hypo-, hyperechogenicity) and final diagnosis. As the elasticity scores were not normally distributed, a non-parametric Wilcoxon rank sum test with continuity correction was used to compare the Tsukuba elasticity scores with the nature of the lesion (malignant vs benign).RESULTSFifty-two patients were included in the study (age 14-163 months, mean 113.57, median 116.5): 22 females (of which 17 were neutered) and 30 males (of which 26 were neutered). The mean and median weights were 24.21kg and 26.2kg, respectively (range 6.8-49.2 kg). The most highly represented breed was the Labrador Retriever (n=11), followed by Cocker Spaniel (n=4), Flat Coated Retriever (n=4), Staffordshire Bull Terrier (n=2), cross breed (n=3), Golden Retriever (n=3), English Springer Spaniel (n=3), West Highland White Terrier (n=3), Irish water Spaniel (n=2), Dalmatian (n=2), Collie Cross (n=2), Whippet (n=1), Weimaraner (n=1), Siberian Husky (n=1), Pug (n=1), Miniature Schnauzer (n=1), Miniature Poodle (n=1), Labradoodle (n=1), Irish Setter (n=1), Dachshund (n=1), Boxer (n=1), Border Collie (n=1), Bearded Collie (n=1) and Beagle (n=1). Fifty-two different lesions were scanned, one for each patient. Cytology was performed in 29 patients, a combination of cytology and histopathology in eight patients and histopathology alone in 15 patients. Eighteen lipomas and thirty-four malignant lesions were diagnosed (nine soft tissue sarcomas, nine mast cell tumours, seven anal sac adenocarcinomas, three histiocytic sarcomas, three mammary carcinomas, two extra-skeletal osteosarcomas, one plasma cell tumour). The measured percentages of softness ranged between 0-99.26% with corresponding measured areas between 0.14-24.36 cm2. The measured percentages of hardness ranged between 1.58-100% with corresponding measured areas between 0.24-23.57cm2. The Tsukuba elasticity scores detected were distributed as follows: 11 subcutaneous masses had a score of 1, 24 masses a score of 2, 10 masses a score of 3, 5 masses a score of 4, and 2 masses a score of 5.A near perfect linear relationship was plotted between the recorded hard and soft areas (Fig. 2). The hardness values did not correlate with hardness areas. Examination of the ROC plot identified a hardness cut-off of 50.25% identified between lesions, with malignant neoplasms having higher percentages. (Fig. 3) A 100% specificity (95% CI, 90-100%) and 89% sensitivity (95% CI, 65-99%) for correctly detecting the nature of the lesion on elastosonography was established (AUC 0.95, PPV=100%, NPV=94%, LR+=Inf, LR-=0.11). (Fig. 3)Fisher’s exact test and Pearsons’s Chi-squared test did not identify any statistically significant relationship between the shape of the lesions, margins, echogenicity, heterogeneity and the final diagnosis (p>0.05). Wilcoxon rank sum test identified a significant relationship (p=0.0002) between the Tsukuba elasticity scores and the two different categories (malignant: mean 2.02, median 2; benign: mean 1.64, median 2). Tsukuba classification scores differed between categories (W=154.5, p=0.0002). A 100% specificity (95% CI, 90-100%) and 61% sensitivity (95% CI, 36-83%) for differentiating malignant neoplasms was detected, based on the Tsukuba elasticity score. Malignant lesions showed higher scores (>1.5) in the elastogram (AUC 0.87, PPV=100%, NPV=83%, LR+=Inf, LR-=0.39) (Fig. 4).DISCUSSIONThe hypothesis of this study was that real-time elastosonography could be considered as a useful tool to detect and differentiate subcutaneous lipomas from malignant neoplasms in dogs.In our study a highly significant and unexpected sensitivity was detected in a large population of patients with spontaneous subcutaneous nodules. Results suggest that a higher Tsukuba score is strongly related to the presence of malignancy, with lesions having a score greater than 1.5 more likely to be malignant. The novel application of this score alongside the assessment of density percentages may contribute to more accurate and earlier detection of malignant subcutaneous lesions. Results from the semi-quantitative assessment of elastograms established a high specificity and sensitivity in correctly diagnosing malignant subcutaneous neoplasms (Fig. 3). A hardness cut off of 50.25% between benign and malignant lesions on the elastogram was detected, which means that lesions above this level are less elastic and are more likely to be diagnosed as malignant on histopathology (Fig. 3). A minimal overlap between benign lesions and malignant neoplasms was identified around this cut off. We believe that the difficulties in drawing the contours of benign lipomas infiltrating between the muscles layers could have caused the inclusion of a small portion of normal muscular tissues in the manually drawn areas by the operator, producing inaccurate elasticities. Statistical analyses did not identify any significant relationships between the shape, regularity of the margins, and the final diagnosis. It could be hypothesised that the more irregularly defined a lesion is, then the more likely it is to be locally infiltrative and thus malignant, in accordance with what has been previously reported in human patients; however, this was not identified in our population. ADDIN EN.CITE <EndNote><Cite><Author>Elverici</Author><Year>2015</Year><RecNum>4</RecNum><DisplayText><style face="superscript">7</style></DisplayText><record><rec-number>4</rec-number><foreign-keys><key app="EN" db-id="tdrrfapv9ad2eaees0apt0xnedxxwvpvds05" timestamp="1493719469">4</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Elverici, Eda</author><author>Bar?a, Ay?e Nurdan</author><author>Akta?, Hafize</author><author>?zsoy, Arzu</author><author>Zengin, Betül</author><author>?avu?o?lu, Mehtap</author><author>Araz, Levent</author></authors></contributors><titles><title>Nonpalpable BI-RADS 4 breast lesions: Sonographic findings and pathology correlation</title><secondary-title>Diagnostic and Interventional Radiology</secondary-title></titles><periodical><full-title>Diagnostic and Interventional Radiology</full-title></periodical><pages>189-194</pages><volume>21</volume><number>3</number><keywords><keyword>Breast Diseases -- Pathology</keyword><keyword>Breast Neoplasms -- Urine</keyword><keyword>Breast Neoplasms -- Pathology</keyword><keyword>Breast Neoplasms -- Ultrasonography</keyword></keywords><dates><year>2015</year></dates><isbn>13053825</isbn><urls></urls><electronic-resource-num>10.5152/dir.2014.14103</electronic-resource-num></record></Cite></EndNote>7 Moreover the heterogeneity and variable echotexture of the neoplasms were not statistically related to the final diagnosis, supporting the fact that B-mode ultrasound alone is less sensitive in detecting malignant subcutaneous nodules, as previously reported in the literature.7,19The evaluation of the degree of softness and hardness was performed post-acquisition. It is possible that the manual contouring of lesions could have affected the evaluation, although the comparison of the manually drawn areas did not identify any statistically significant difference (Fig. 2). All the examinations were performed with the examiner blinded to patient clinical history, nature of the lesions and physical examination findings unrelated to the subcutaneous mass. Cytological and histopathological results were obtained post ultrasound examination, and hence could not influence the examiner’s assessment of the lesions. A semi-quantitative assessment of the percentage of soft and hard areas within the lesions was computed using commercially available software. A strain ratio was not performed because the lesions were very superficial and occupied most of the field of view. It was in fact not possible to include a sufficient amount of perilesional tissue within the image, and thereby was impossible to select the reference region of interest at the same depth of the lesion. These are fundamental criteria for performing a strain ratio assessment. ADDIN EN.CITE <EndNote><Cite><Author>Jeon</Author><Year>2015</Year><RecNum>11</RecNum><DisplayText><style face="superscript">16</style></DisplayText><record><rec-number>11</rec-number><foreign-keys><key app="EN" db-id="tdrrfapv9ad2eaees0apt0xnedxxwvpvds05" timestamp="1493720158">11</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Jeon, Sunghoon</author><author>Lee, Gahyun</author><author>Lee, Sang‐Kwon</author><author>Kim, Hyunwoo</author><author>Yu, Dohyeon</author><author>Choi, Jihye</author></authors></contributors><titles><title>ULTRASONOGRAPHIC ELASTOGRAPHY OF THE LIVER, SPLEEN, KIDNEYS, AND PROSTATE IN CLINICALLY NORMAL BEAGLE DOGS</title><secondary-title>Veterinary Radiology & Ultrasound</secondary-title></titles><periodical><full-title>Veterinary Radiology & Ultrasound</full-title></periodical><pages>425-431</pages><volume>56</volume><number>4</number><keywords><keyword>Elastography</keyword><keyword>Strain</keyword><keyword>Dog</keyword></keywords><dates><year>2015</year></dates><isbn>1058-8183</isbn><urls></urls><electronic-resource-num>10.1111/vru.12238</electronic-resource-num></record></Cite></EndNote>16Although the Tsukuba classification score was designed to standardize the assessment of breast lesions in humans with good interobserver results,18 the authors used this method as a complementary tool to define the type of elastogram collected. This classification score showed a highly statistically significant relationship in assessing the benign or malignant nature of the lesions, with a cut-off of 1.5. Although few benign lesions showed Tsukuba elasticity scores of 2 and 3, this tool may be used in dogs as a good indicator of possible malignancy in conjunction with the assessment of the percentages of hardness and/or softness. The most common tumours were soft tissue sarcomas, anal sac adenocarcinomas and mast cell tumours that commonly represent the main differential diagnosis for spontaneous subcutaneous nodules in dogs. A major limitation of this study was the differing numbers of neoplastic lesions representing each malignant tumour type. It is possible that a specific elastosonographic pattern could be related to different type of neoplasms; however, the lower number of cases in each category did not allow the detection of any particular trends. Finally other subcutaneous tumours, such as hemangiosarcoma, were not represented in our population hence potentially showing peculiar elastographic results that are not provided in this study. Moreover it is possible that the high sensitivity and specificity established could be related to the operator skill and consistency, since it has been previously reported that free handed elastosonography is more subjective to operator skills and experience compared to ARFI (acoustic radiation force impulse elastography). ADDIN EN.CITE <EndNote><Cite><Author>Jeon</Author><Year>2015</Year><RecNum>11</RecNum><DisplayText><style face="superscript">16</style></DisplayText><record><rec-number>11</rec-number><foreign-keys><key app="EN" db-id="tdrrfapv9ad2eaees0apt0xnedxxwvpvds05" timestamp="1493720158">11</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Jeon, Sunghoon</author><author>Lee, Gahyun</author><author>Lee, Sang‐Kwon</author><author>Kim, Hyunwoo</author><author>Yu, Dohyeon</author><author>Choi, Jihye</author></authors></contributors><titles><title>ULTRASONOGRAPHIC ELASTOGRAPHY OF THE LIVER, SPLEEN, KIDNEYS, AND PROSTATE IN CLINICALLY NORMAL BEAGLE DOGS</title><secondary-title>Veterinary Radiology & Ultrasound</secondary-title></titles><periodical><full-title>Veterinary Radiology & Ultrasound</full-title></periodical><pages>425-431</pages><volume>56</volume><number>4</number><keywords><keyword>Elastography</keyword><keyword>Strain</keyword><keyword>Dog</keyword></keywords><dates><year>2015</year></dates><isbn>1058-8183</isbn><urls></urls><electronic-resource-num>10.1111/vru.12238</electronic-resource-num></record></Cite></EndNote>16 However, the evaluator in the present study was a diagnostic imaging resident, suggesting that elastosonography could be similarly performed by a less experienced radiologist. In conclusion, this preliminary study shows that real-time elastosonography for the assessment of subcutaneous lesions in dogs is a useful procedure for differentiating malignant from lipomatous subcutaneous neoplasms in dogs. This novel technique could potentially be used as an early detection tool, in association with the Tsukuba classification score, to provide information about the probability of malignancy of subcutaneous lesions in dogs. Cytology and histopathology remain the gold standard for final diagnosis; however, elastosonography could be considered as a complementary tool to raise suspicion, orientate the therapeutic or diagnostic approach, and to provide follow-up information on the progression of disease. LIST OF AUTHOR CONTRIBUTIONSCategory 1(a) Conception and DesignMaurizio Longo, Spela Bavcar, Ian Handel, Tiziana Liuti(b) Acquisition of DataMaurizio Longo, Spela Bavcar, Sionagh Smith, Tiziana Liuti(c) Analysis and Interpretation of Data Maurizio Longo, Spela Bavcar, Ian Handel, Sionagh Smith, Tiziana LiutiCategory 2(a) Drafting the ArticleMaurizio Longo(B) Revising Article for Intellectual Content Maurizio Longo, Spela Bavcar, Ian Handel, Sionagh Smith, Tiziana LiutiCategory 3(a) Final Approval of the Completed ArticleMaurizio Longo, Spela Bavcar, Ian Handel, Sionagh Smith, Tiziana LiutiREFERENCES ADDIN EN.REFLIST 1.Br?nden LB, Eriksen T, Kristensen AT. Mast cell tumours and other skin neoplasia in Danish dogs - data from the Danish Veterinary Cancer Registry. Acta Veterinaria Scandinavica. 2010;52: 6.2.De Queiroz GF, Matera JM, Zaidan Dagli ML. Clinical Study of Cryosurgery Efficacy in the Treatment of Skin and Subcutaneous Tumors in Dogs and Cats. 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Diagnostic and Interventional Radiology. 2015;21: 189-194.8.Barr RG. Sonographic breast elastography: a primer. Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine. 2012;31: 773-783.9.Stoian D, Timar B, Craina M, Bernad E, Petre I, Craciunescu M. Qualitative strain elastography - strain ratio evaluation - an important tool in breast cancer diagnostic. Medical ultrasonography. 2016;18: 195.10.Landoni V, Francione V, Marzi S, Pasciuti K, Ferrante F, Saracca E, et al. Quantitative analysis of elastography images in the detection of breast cancer. European Journal of Radiology. 2012;81: 1527-1531.11.Glinska-Suchocka K, Jankowski M, Kubiak K, Spuzak J, Dzimira S, Nicpon J. Application of shear wave elastography in the diagnosis of mammary gland neoplasm in dogs. Polish journal of veterinary sciences. 2013;16: 477-482.12.Feliciano MA, Maronezi MC, Pavan L, Castanheira TL, Simoes AP, Carvalho CF, et al. ARFI elastography as a complementary diagnostic method for mammary neoplasia in female dogs - preliminary results. J Small Anim Pract. 2014;55: 504-508.13.Maronezi MC, Feliciano MAR, Crivellenti LZ, Sim?es APR, Bartlewski PM, Gill I, et al. Acoustic radiation force impulse elastography of the spleen in healthy dogs of different ages. Journal of Small Animal Practice. 2015;56: 393-397.14.Ophir J, Alam SK, Garra BS, Kallel F, Konofagou EE, Krouskop T, et al. Elastography: Imaging the elastic properties of soft tissues with ultrasound. Journal of Medical Ultrasonics. 2002;29: 155.15.Treece G, Lindop J, Chen L, Housden J, Prager R, Gee A. Real-time quasi-static ultrasound elastography. Journal of the Royal Society Interface Focus. 2011;1: 540-552.16.Jeon S, Lee G, Lee SK, Kim H, Yu D, Choi J. Ultrasonographic elastography of the liver, spleen, kidneys and prostate in clinically normal beagle dogs. Veterinary Radiology & Ultrasound. 2015;56: 425-431.17.Lee G, Jeon S, Lee SK, Kim H, Yu D, Choi J. Strain elastography using dobutamine-induced carotid artery pulsation in canine thyroid gland. Veterinary Radiology & Ultrasound. 2015;56: 549-553.18.Itoh A, Ueno E, Tohno E, Kamma H, Takahashi H, Shiina T, et al. Breast Disease: Clinical Application of US Elastography for Diagnosis. Radiology. 2006;239: 341-350.19.Dietrich C, Jenssen C, Arcidiacono P, Cui X-W, Giovannini M, Hocke M, et al. Endoscopic ultrasound: Elastographic lymph node evaluation. Endoscopic Ultrasound. 2015;4: 176-190.FIGURESFig. 1 Dual mode elastographic image of a histologically confirmed subcutaneous mast cell tumour. On the left the B-mode image is displayed as a reference for manual contouring. The green spring on the right bottom of the image indicates compressive and retractile movements of sufficient quality. The lesion displays a Tsukuba elasticity score of 2.Fig.2 Scatter plot of the manually drawn areas on the elastograms for % hardness and % softness evaluation. Malignant lesions are displayed in blue and benign lesions in red. A near perfect linear relationship was plotted between the recorded hard and soft areas.Fig. 3 ROC plot of the sensitivity and specificity of the percentage of hardness compared to final diagnosis. A hardness cut-off of 50.25% between malignant neoplasms and lipomas is identified. Fig. 4 ROC plot of the sensitivity and specificity of the Tsukuba elasticity score compared to final diagnosis. A cut-off of 1.5 between lipomas and malignant neoplasms is identified. ADDIN ................
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