Comparative evaluation of strain ratio on sonographic elastography and T2* values on 3 Tesla magnetic resonance imaging in differentiating malignant from benign axillary lymph nodes in breast cancer

Shweta Sharma, Richa Bansal, Shubham Jain


Background: The study aimed to assess whether strain ratio and T2* values can improve the sensitivity and specificity of differentiating metastatic from benign axillary lymph nodes in breast cancer patients taking histopathology as reference standard.

Methods: The study was done on 43 patients. A multi-echo transverse T2*W MR sequence was obtained with TE = 0.9- 1.5 ms, TR=37.2 ms and flip angle = 25°. Sonographic elastography was done using high frequency linear probe (L3-16 MHz). Manual selection of the region of interest was done on suspicious lymph nodes for calculation of T2* values and strain ratio. ROC curves were obtained for various T2* and strain ratio values in comparison to histopathological findings as gold standard.

Results: Correlation with histopathology was better with T2* values than strain ratio. The sensitivity and specificity were calculated using cut off values obtained from ROC curve (31.225 ms for T2* value and 1.85 for SR) and were 70.37%, 68.75% for strain ratio and 96.29%, 93.75% for T2* value respectively. The positive predictive value and negative predictive value were also assessed, values being higher for T2* than strain ratio. Comparison of areas under ROC curve was statistically significant with p=0.018.

Conclusions: T2* can be used as a potential biomarker for differentiating metastatic from benign axillary lymph nodes owing to its high sensitivity, specificity and relative ease of performance. Quantitative assessment of changes in T2* values may allow more objective analysis of signal changes with significant differences between benign and malignant lymph nodes, even in case of partial infiltration. 


Axillary lymph nodes, Sonographic elastography, Strain ratio, T2* value, ROC curve

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Li C, Meng S, Yang X, Wang J, Hu J. The value of T2* in differentiating metastatic from benign axillary lymph nodes in patients with breast cancer--a preliminary in vivo study. PLoS One. 2014;9:1.

Andreea GI, Pegza R, Lascu L, Bondari S, Stoica Z, Bondari A. The Role of Imaging Techniques in Diagnosis of Breast Cancer. Curr Heal Sci J. 2011;37(2):55-61.

Arslan G, Altintoprak KM, Yirgin IK, Atasoy MM, Celik L. Diagnostic accuracy of metastatic axillary lymph nodes in breast MRI. Springerplus. 2016;5(1):735.

Choi JJ, Kang BJ, Kim SH, Lee JH, Jeong SH, Yim HW et al. Role of sonographic elastography in the differential diagnosis of axillary lymph nodes in breast cancer. J Ultrasound Med. 2011;30:429-36.

Liberman L, Cody 3rd HS, Hill AD, Rosen PP, Yeh SD, Akhurst T et al. Sentinel lymph node biopsy after percutaneous diagnosis of nonpalpable breast cancer. Radiology. 1999;211(3):835-44.

Wojcinski S, Dupont J, Schmidt W, Cassel M, Hillemanns P. Real-time ultrasound elastography in 180 axillary lymph nodes: elasticity distribution in healthy lymph nodes and prediction of breast cancer metastases. BMC Med Imaging. 2012;12(1):35.

Bedi DG, Krishnamurthy R, Krishnamurthy S, Edeiken BS, Le-Petross H, Fornage BD et al. Cortical morphologic features of axillary lymph nodes as a predictor of metastasis in breast cancer: In vitro sonographic study. Am J Roentgenol. 2008;191(3):646-52.

Bonnema J, van Geel N, Van Ooijen B, Mali SP, Tjiam SL, Henzen-Logmans SC et al. Ultrasound-guided aspiration biopsy for detection of nonpalpable axillary node metastases in breast cancer patients: new diagnostic method. World J Surg. 1997;21(3):270-4.

Uematsu T, Sano M, Homma K. In vitro high-resolution helical CT of small axillary lymph nodes in patients with breast cancer: Correlation of CT and histology. Am J Roentgenol. 2001;176(4):1069-74.

Shetty SK, Harisinghani MG. Magnetic resonance techniques in lymph node imaging. Appl Radiol. 2004;33(7):34-44.

Dudea SM, Botar-Jid C, Dumitriu D, Vasilescu D, Manole S, Lenghel ML. Differentiating benign from malignant superficial lymph nodes with sonoelastography. Med Ultrasonography. 2013;15:132-9.

Lyshchik A, Higashi T, Asato R, Tanaka S, Ito J, Hiraoka M et al. Cervical lymph node metastases: Diagnosis at sonoelastography - Initial experience. Radiology. 2007;243(1):258-67.

Zhang Y, Lv Q, Yin Y, Xie M, Xiang F, Lu C, et al. The value of ultrasound elastography in differential diagnosis of superficial lymph nodes. Front Med China. 2009;3(3):368-74.

Latif MA, Shady M, Hegazy MAE, Abdo YM. B-mode ultrasound, sono-elastography and diffusion-weighted MRI in differentiation of enlarged axillary lymph nodes in patients with malignant breast disease. Egypt J Radiol Nucl Med. 2016;47(3):1137-49.

Korteweg MA, Visser F, Polders DL, Takahara T, Mali WPTM, Veldhuis WB. Gadofosveset as a negative contrast agent for detecting metastatic axillary lymph nodes in breast cancer patients on diffusion and T2* weighted images: a proof of principle. In: Proceedings of the Eighteenth Meeting of the International Society for Magnetic Resonance in Medicine. Berkeley. Calif: Int Society Magnetic Resonance Med. 2010;5837.