The impact of V-flow on preoperative diagnosis of thyroid tumors: individually and as part of multimodal sonographic imaging

Abstract

Purpose

V-flow is a dynamic ultrasound technique that visualizes perfusion patterns by displaying dynamic arrows that change in response to the flow of erythrocytes. Furthermore, it provides quantitative values for the maximum and mean velocity of blood flow as well as a percentage value for turbulence. The aim was to enhance the preoperative diagnostic accuracy of thyroid lesions by combining V-flow with established ultrasound modes.

Materials and Methods

B-mode, CCDS, elastography, CEUS, and V-flow were performed on 101 patients. After the ultrasound examination, every nodule was confirmed as benign or malignant via histopathology. The Kruskal–Wallis test, ROC curve, and binary logistic regression were used for the statistical analysis.

Results

93 benign regressive thyroid nodules and 8 carcinomas were included in this study. The average mean velocity value for benign lesions was measured at 19.5 cm/s and at 10.7 cm/s for malignant lesions (p = 0.039). The average turbulence percentage was 26.1% for benign nodules and 46.7% for carcinomas (p = 0.016). Carcinomas exhibited a slower and more turbulent perfusion pattern compared to benign tumors. A V-flow-centered system achieves a sensitivity of 100.0% and a specificity of 84.9% in predicting malignancy. This system could have reduced the number of unnecessary thyroid surgeries for benign lesions in our patient group by 70%.

Conclusion

The capillary perfusion of thyroid nodules represents a significant indicator of its status. By analyzing the velocity and turbulence level of microvascular blood flow, V-flow offers promising prospects for accurately distinguishing between benign and malignant thyroid lesions. When integrated into a comprehensive multimodal sonographic imaging approach, V-flow further enhances diagnostic accuracy.

Key Points

• V-flow allows for qualitative and quantitative analysis of microvascular perfusion

• Malignant tumors are associated with slower and more turbulent microvascular hemodynamics

• Combining V-flow with other ultrasound modes eases the diagnosis of thyroid carcinomas

Citation Format

• Brandenstein MK, Zhang L, Scharf G et al. The impact of V-flow on preoperative diagnosis of thyroid tumors: individually and as part of multimodal sonographic imaging. Fortschr Röntgenstr 2025; 197: 436–446

Zusammenfassung

Ziel

V-flow ist ein neuer dynamischer Ultraschallmodus, der Perfusion auf Kapillarebene darstellen kann. Hierfür werden Vektoren abgebildet, die sich abhängig von der Erythrozytenbewegung ändern. Des Weiteren liefert V-flow quantitative Werte für die mittlere und maximale Geschwindigkeit des Blutstroms sowie einen Prozentwert für den Grad an Turbulenzen im untersuchten Gebiet. Das Ziel dieser Studie war es, mithilfe dieses neuen Ultraschallmodus die präoperative Diagnostik solider Schilddrüsenknoten zu verbessern.

Material und Methoden

101 Patienten wurden sonografisch umfassend untersucht. Danach wurde jeder Knoten histopathologisch als benigne oder maligne gesichert. Die statistische Analyse erfolgte mithilfe von Kruskal–Wallis Test, ROC-Kurve und binär logistischer Regression.

Ergebnisse

93 gutartige Schilddrüsenknoten und 8 Karzinome wurden in diese Studie aufgenommen. Die durchschnittlich gemessene Geschwindigkeit lag bei 19,5 cm/s für gutartige und bei 10,7 cm/s für bösartige Knoten (p = 0,039). Der durchschnittliche Grad der Turbulenz betrug 26,1% für gutartige und 46,7% für bösartige Schilddrüsenläsionen (p = 0,016). Die Karzinome zeigten ein langsameres und turbulenteres Durchblutungsmuster. Durch Kombination verschiedener V-flow-Malignitätskriterien erstellten wir ein System zur Differenzierung zwischen gut- und bösartigen Schilddrüsenknoten (Sensitivität = 100%; Spezifität = 84,9%). Die Anwendung dieses Systems hätte die Anzahl nicht notwendiger Schilddrüsenoperationen bei gutartigen Knoten in diesem Kollektiv um 70% reduziert.

Schlussfolgerung

Die Mikrovaskularisation von Schilddrüsenknoten stellt einen wichtigen Indikator für seine Malignität dar. Durch die detaillierte Analyse von Flussgeschwindigkeit und Turbulenzen auf kapillärer Ebene trägt V-flow wesentlich zu präoperativen sonografischen Differenzierung von Schilddrüsenknoten als benigne oder maligne bei. Durch die Kombination bereits etablierter Ultraschallmodi mit dem V-flow kann die diagnostische Treffsicherheit bei der Diagnostik von Schilddrüsentumoren gesteigert werden.

Kernaussagen

• V-flow ermöglicht eine qualitative und quantitative Analyse kapillärer Perfusion.

• Karzinome imponieren durch eine turbulente Mikrovaskularisation mit langsamem Blutfluss.

• Die Kombination von V-flow mit anderen Ultraschallmodi erleichtert die Diagnostik von Schilddrüsenkarzinomen.

Keywords

thyroid - V-flow - hemodynamics/flow dynamics - multimdodal sonographic imaging - adenocarcinoma - microvascularization

• References

• 1 Pizzato M, Li M, Vignat J. et al. The epidemiological landscape of thyroid cancer worldwide: GLOBOCAN estimates for incidence and mortality rates in 2020. Lancet Diabetes Endocrinol 2022;
• 2 Padovano M, Scopetti M, Tomassi R. et al. Mapping complications in thyroid surgery: statistical data are useful for medico-legal management of a recurrent safety issue. Updates Surg 2022;
• 3 Russ G, Bonnema SJ, Erdogan M. et al. European Thyroid Association Guidelines for Ultrasound Malignancy Risk Stratification of Thyroid Nodules in Adults: The EU-TIRADS. Eur Thyroid 2017;
• 4 Rago T, Vitti P. Risk Stratification of Thyroid Nodules: From Ultrasound Features to TIRADS. Cancers (Basel) 2022;
• 5 Brito JP, Gionfriddo M, Al Nofal A. et al. The accuracy of thyroid nodule ultrasound to predict thyroid cancer: systematic review and meta-analysis. J Clin Endocrinol Metab 2014;
• 6 Jung EM, Thurn S, Brandenstein M. et al. High resolution flow (HR Flow) and Glazing Flow in cases of hepatic flow changes: Comparison to color-coded Doppler sonography (CCDS). Clin Hemorheol Microcirc 2021;
• 7 Brandenstein M, Wiesinger I, Künzel J. et al. Multiparametric Sonographic Imaging of Thyroid Lesions: Chances of B-Mode, Elastography and CEUS in Relation to Preoperative Histopathology. Cancers (Basel) 2022;
• 8 Ma X, Zhang B, Ling W. et al. Contrast-enhanced sonography for the identification of benign and malignant thyroid nodules: Systematic review and meta-analysis. J Clin Ultrasound 2016;
• 9 Yigang D, Yingying S. V Flow: a novel visualization of blood flow-210285X6P-20170728, Mindray online portal. 2022 Accessed July 10, 2023 at: https://www.mindraynorthamerica.com/wp-content/uploads/2020/04/WP_V-Flow.pdf
• 10 David E, Martinelli O, Pacini P. et al. New Technologies in the Assessment of Carotid Stenosis: Beyond the Color-Doppler Ultrasound-High Frame Rate Vector-Flow and 3D Arterial Analysis Ultrasound. Diagnostics (Basel) 2023;
• 11 You BY, Lai SS, Yu AC. Vector projectile imaging: time-resolved dynamic visualization of complex flow patterns. Ultrasound Med Biol 2014;
• 12 Kammerer S, Stroszczynski C, Jung EM. Functional ultrasound imaging of the venous valve of the great saphenous vein in the area around the crosse using the novel vector flow technique. Clin Hemorheol Microcirc 2020;
• 13 Seifert P, Schenke S, Zimny M. et al. Diagnostic Performance of Kwak, EU, ACR, and Korean TIRADS as well as ATA Guidelines for the Ultrasound Risk Stratification of Non-Autonomously Functioning Thyroid Nodules in a Region with Long History of Iodine Deficiency: A German Multicenter Trial. Cancers 2021;
• 14 Liu Y, Li X, Yan C. et al. Comparison of diagnostic accuracy and utility of artificial intelligence-optimized ACR TI-RADS and original ACR TI-RADS: a multi-center validation study based on 2061 thyroid nodules. Eur Radiol 2022;
• 15 Seminati D, Capitoli G, Leni D. et al. Use of Diagnostic Criteria from ACR and EU-TIRADS Systems to Improve the Performance of Cytology in Thyroid Nodule Triage. Cancers 2021;
• 16 Yan S, Shou J, Yu J. et al. Ultrafast Ultrasound Vector Doppler for Small Vasculature Imaging. IEEE Trans Ultrason Ferroelectr Freq Control 2023;
• 17 Ulisse S, Baldini E, Lauro A. et al. Papillary Thyroid Cancer Prognosis: An Evolving Field. Cancers (Basel) 2021;
• 18 Bojunga J. Ultrasound of Thyroid Nodules. Ultraschall Med 2018;
• 19 Skowrońska A, Milczarek-Banach J, Wiechno W. et al. Accuracy of the European Thyroid Imaging Reporting and Data System (EU-TIRADS) in the valuation of thyroid nodule malignancy in reference to the post-surgery histological results. Pol J Radiol 2018;
• 20 Russ G, Royer B, Bigorgne C. et al. Prospective evaluation of thyroid imaging reporting and data system on 4550 nodules with and without elastography. Eur J Endocrinol 2013;
• 21 Zhang J, Zhang X, Meng Y. et al. Contrast-enhanced ultrasound for the differential diagnosis of thyroid nodules: An updated meta-analysis with comprehensive heterogeneity analysis. PLoS One 2020;
• 22 Solbiati L, Osti V, Cova L. et al. Ultrasound of thyroid, parathyroid glands and neck lymph nodes. Eur Radiol 2001;
• 23 Sidhu PS, Cantisani V, Dietrich CF. et al. The EFSUMB Guidelines and Recommendations for the Clinical Practice of Contrast-Enhanced Ultrasound (CEUS) in Non-Hepatic Applications: Update 2017. Ultraschall Med 2018;