Abstract
Objective
We report 54 patients with histologically evaluated musculoskeletal masses who underwent grey-scale and contrast-enhanced ultrasound (CEUS), followed by ultrasound-guided biopsy. We hypothesise that the definition of a CEUS-based enhancement pattern improves the characterisation of tumour malignancy.
Methods
Fifty-four patients with soft-tissue masses were examined according to our standardised ultrasound procedure. After CEUS, quantitative and qualitative perfusion analyses were performed and each mass was assigned to one of four preliminarily defined perfusion patterns (P1–P4). Additionally, mass size and localisation were recorded. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) in the definition of malignancy were calculated for relevant combinations of localisation, size and perfusion pattern.
Results
The single event probability for malignancy was 0% for the P1 and P4 perfusion patterns, and 60% for P2 and 80% for P3. The best combined sensitivity (89%) and specificity (85%) was achieved in a “three-feature combination” of size >3.3 cm, mass location below the superficial fascia and either P2 or P3 perfusion pattern with a PPV of 86% and NPV of 88%.
Conclusion
The proposed definition of perfusion pattern types with CEUS may serve as a new and reliable diagnostic tool for distinguishing malignant soft-tissue masses from their benign counterparts.
Key Points
• CEUS can assess “tumour perfusion”.
• Four typical perfusion patterns are seen on CEUS of musculoskeletal masses.
• Knowledge of tumour size, localisation and perfusion pattern can help patient management.
Similar content being viewed by others
References
Bodner G, Schocke MF, Rachbauer F et al (2002) Differentiation of malignant and benign musculoskeletal tumors: combined color and power Doppler US and spectral wave analysis. Radiology 223:410–416
Schulte M, von Baer A, Schultheiss M, Scheil-Bertram S (2010) Classification of solid soft tissue tumours by ultrasonography. Ultraschall Med 31:182–1903
Lagalla R, Iovane A, Caruso G, Lo Bello M, Derchi LE (1998) Color Doppler ultrasonography of soft-tissue masses. Acta Radiol 39:421–426
Widmann G, Riedl A, Schoepf D, Glodny B, Peer S, Gruber H (2009) State-of-the-art HR-US imaging findings of the most frequent musculoskeletal soft-tissue tumors. Skeletal Radiol 38:637–649
Berquist TH, Ehman RL, King BF, Hodgman CG, Ilstrup DM (1990) Value of MR imaging in differentiating benign from malignant soft-tissue masses: study of 95 lesions. AJR Am J Roentgenol 155:1251–1255
Datir A, James SL, Ali K, Lee J, Ahmad M, Saifuddin A (2008) MRI of soft-tissue masses: the relationship between lesion size, depth, and diagnosis. Clin Radiol 63:373–378, discussion 379-380
Crim JR, Seeger LL, Yao L, Chandnani V, Eckardt JJ (1992) Diagnosis of soft-tissue masses with MR imaging: can benign masses be differentiated from malignant ones? Radiology 185:581–586
Lakkaraju A, Sinha R, Garikipati R, Edward S, Robinson P (2009) Ultrasound for initial evaluation and triage of clinically suspicious soft-tissue masses. Clin Radiol 64:615–621
Persson BM, Rydholm A (1986) Soft-tissue masses of the locomotor system. A guide to the clinical diagnosis of malignancy. Acta Orthop Scand 57:216–219
Pisters PW, Leung DH, Woodruff J, Shi W, Brennan MF (1996) Analysis of prognostic factors in 1,041 patients with localized soft tissue sarcomas of the extremities. J Clin Oncol 14:1679–1689
Wunder JS, Healey JH, Davis AM, Brennan MF (2000) A comparison of staging systems for localized extremity soft tissue sarcoma. Cancer 88:2721–2730
van der Woude HJ, Verstraete KL, Hogendoorn PC, Taminiau AH, Hermans J, Bloem JL (1998) Musculoskeletal tumors: does fast dynamic contrast-enhanced subtraction MR imaging contribute to the characterization? Radiology 208:821–828
Erlemann R, Reiser MF, Peters PE et al (1989) Musculoskeletal neoplasms: static and dynamic Gd-DTPA-enhanced MR imaging. Radiology 171:767–773
Verstraete KL, De Deene Y, Roels H, Dierick A, Uyttendaele D, Kunnen M (1994) Benign and malignant musculoskeletal lesions: dynamic contrast-enhanced MR imaging—parametric “first-pass” images depict tissue vascularization and perfusion. Radiology 192:835–843
Therasse P, Arbuck SG, Eisenhauer EA et al (2000) New guidelines to evaluate the response to treatment in solid tumors. European Organization for Research and Treatment of Cancer, National Cancer Institute of the United States, National Cancer Institute of Canada. J Natl Cancer Inst 92:205–216
Zuber-Jerger I, Schacherer D, Woenckhaus M, Jung EM, Scholmerich J, Klebl F (2009) Contrast-enhanced ultrasound in diagnosing liver malignancy. Clin Hemorheol Microcirc 43:109–118
Rettenbacher T (2007) Focal liver lesions: role of contrast-enhanced ultrasound. Eur J Radiol 64:173–182
Jang HJ, Yu H, Kim TK (2009) Contrast-enhanced ultrasound in the detection and characterization of liver tumors. Cancer Imaging 9:96–103
Lassau N, Koscielny S, Opolon P et al (2001) Evaluation of contrast-enhanced color Doppler ultrasound for the quantification of angiogenesis in vivo. Invest Radiol 36:50–55
Loizides A, Widmann G, Freuis T, Peer S, Gruber H (2011) Optimizing ultrasound-guided biopsy of musculoskeletal masses by application of an ultrasound contrast agent. Ultraschall Med 32:307–310
Jain RK (1987) Transport of molecules in the tumor interstitium: a review. Cancer Res 47:3039–3051
Jain RK (1988) Determinants of tumor blood flow: a review. Cancer Res 48:2641–2658
World Medical Association Declaration of Helsinki (2008) Ethical principles for medical research involving human subjects. Fifty-ninth World Medical Association General Assembly, Seoul
De Schepper AM, Vanhoenacker F, Gielen J (2006) Imaging of the soft tissue tumors, 3rd edn. Springer, Heidelberg
Simon MA, Finn HA (1993) Diagnostic strategy for bone and soft-tissue tumors. J Bone Joint Surg Am 75:622–631
Enzinger FM, Weiss SW (1995) Soft tissue tumors, 3rd edn. Mosby, St. Louis
Simon MA, Biermann JS (1993) Biopsy of bone and soft-tissue lesions. J Bone Joint Surg Am 75:616–621
Brisse H, Orbach D, Klijanienko J, Freneaux P, Neuenschwander S (2006) Imaging and diagnostic strategy of soft tissue tumors in children. Eur Radiol 16:1147–1164
Myhre-Jensen O (1981) A consecutive 7-year series of 1331 benign soft tissue tumours. Clinicopathologic data. Comparison with sarcomas. Acta Orthop Scand 52:287–293
Hussein R, Smith MA (2005) Soft tissue sarcomas: are current referral guidelines sufficient? Ann R Coll Surg Engl 87:171–173
Moulton JS, Blebea JS, Dunco DM, Braley SE, Bisset GS 3rd, Emery KH (1995) MR imaging of soft-tissue masses: diagnostic efficacy and value of distinguishing between benign and malignant lesions. AJR Am J Roentgenol 164:1191–1199
Daniel A Jr, Ullah E, Wahab S, Kumar V Jr (2009) Relevance of MRI in prediction of malignancy of musculoskeletal system—a prospective evaluation. BMC Musculoskelet Disord 10:125
Balzarini L, Sicilia A, Ceglia E, Tesoro Tess JD, Trecate G, Musumeci R (1996) Magnetic resonance in primary bone tumors: a review of 10 years of activities. Radiol Med 91:344–347
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Loizides, A., Peer, S., Plaikner, M. et al. Perfusion pattern of musculoskeletal masses using contrast-enhanced ultrasound: a helpful tool for characterisation?. Eur Radiol 22, 1803–1811 (2012). https://doi.org/10.1007/s00330-012-2407-4
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00330-012-2407-4