Ultraschall in der Medizin - European Journal of Ultrasound, Table of Contents

Ultraschall Med 2024; 45(05): 509-518
DOI: 10.1055/a-2189-5412

Original Article

Contrast-enhanced ultrasound reveals perfusion differences between benign lipoma and semi-malignant atypical lipomatous tumors: A prospective clinical study

Kontrastmittelverstärkter Ultraschall (CEUS) in der Differenzierung von Lipomen und semimalignen atypischen lipomatösen Tumoren: Eine prospektive klinische Studie

Paul Mick

¹Orthopaedics, University Hospital Heidelberg, Heidelberg, Germany (Ringgold ID: RIN27178)

,

Antonia Seeberger

¹Orthopaedics, University Hospital Heidelberg, Heidelberg, Germany (Ringgold ID: RIN27178)

,

Tobias Renkawitz

¹Orthopaedics, University Hospital Heidelberg, Heidelberg, Germany (Ringgold ID: RIN27178)

,

Burkhard Lehner

¹Orthopaedics, University Hospital Heidelberg, Heidelberg, Germany (Ringgold ID: RIN27178)

,

Mustafa Hariri

¹Orthopaedics, University Hospital Heidelberg, Heidelberg, Germany (Ringgold ID: RIN27178)

,

Christian Fischer

²Orthopaedic surgery, ARCUS Clinic Pforzheim, Pforzheim, Germany

,

Julian Doll

¹Orthopaedics, University Hospital Heidelberg, Heidelberg, Germany (Ringgold ID: RIN27178)

› Author Affiliations

Abstract

Purpose Soft tissue tumors (STT) are difficult to diagnose accurately, and distinguishing between benign and malignant tumors is challenging. Lipoma is the most common STT, while atypical lipomatous tumors (ALT) can dedifferentiate into malignant lipomatous tumors like grade 1 liposarcoma and require more radical therapy. This study aims to investigate the potential of contrast-enhanced ultrasound (CEUS) to differentiate between lipoma and ALT based on tumor perfusion.

Materials and Methods We prospectively examined 52 patients who were scheduled for biopsy for suspected lipoma or ALT. The CEUS examination was performed using SonoVue as a contrast agent to quantify tumor perfusion using VueBox V7.1 software. Peak enhancement (PE), rise time (RT), wash-in perfusion index (WiPI), and wash-out rate (WoR) were used to assess contrast enhancement inside the STT.

Results Among 50 tumors examined, 30 were lipomas, and 20 were ALTs. We found significant differences in perfusion between lipomas and ALTs (PE: 49.22 ± 45.75 a.u. vs. 165.67 ± 174.80; RT: 23.86 ± 20.47s vs. 10.72 ± 5.34 s; WiPI: 33.06 ± 29.94 dB vs. 107.21 ± 112.43 dB; WoR: 2.44 ± 3.70 dB/s vs. 12.75 ± 15.80 dB/s; p<.001). ROC analysis of PE resulted in a diagnostic accuracy of 74% for the detection of an ALT, and 77% for the detection of a lipoma.

Conclusion CEUS may enhance the differential diagnosis of benign lipomas and ALTs, with ALTs showing higher levels of perfusion. If larger prospective studies confirm these findings, CEUS could enhance diagnostic accuracy, guide surgical planning, and potentially reduce unnecessary treatments for patients presenting with ambiguous lipomatous tumors like lipoma or ALT.

Zusammenfassung

Ziel Die Unterscheidung zwischen gutartigen und bösartigen Weichteiltumoren gestaltet sich oftmals herausfordernd. Insbesondere benigne Lipome lassen sich nur schwer von semimalignen atypischen lipomatösen Tumoren (ALT) abgrenzen, welche in bösartige Liposarkome entdifferenzieren können. Diese Studie untersucht die Qualität des kontrastmittelverstärkten Ultraschalls (CEUS) zur Unterscheidung von Lipomen und ALT anhand der Tumor-Mikroperfusion.

Material und Methoden 52 Patienten, bei denen bei Verdacht auf ein Lipom oder ALT eine Biopsie geplant war, wurden präoperativ mittels CEUS und MRT untersucht. Die CEUS-Tumorperfusion wurde mithilfe der Software VueBox V7.1 quantifiziert. Die Perfusionsparameter „Peak enhancement“ (PE), „rise time“ (RT), „wash-in perfusion index” (WiPI), und „wash-out rate“ (WoR) wurden zur Beurteilung der Mikroperfusion im Tumor verwendet.

Ergebnisse 30 Lipome und 20 ALTs wurden ausgewertet. Es zeigten sich signifikante Unterschiede der Perfusionskinetik zwischen beiden Tumoren (PE: 49,22 ± 45,75 a.u. vs. 165,67 ± 174,80; RT: 23,86 ± 20,47s vs. 10,72 ± 5,34 s; WiPI: 33,06 ± 29,94 dB vs. 107,21 ± 112,43 dB; WoR: 2,44 ± 3,70 dB/s vs. 12,75 ± 15,80 dB/s; p<.001). Die CEUS-Tumorperfusion ergab nach ROC-Analyse eine Testgenauigkeit von 77% für die Erkennung eines Lipoms und von 74% für die Erkennung eines ALT.

Schlussfolgerung Die CEUS-Perfusionsanalyse ist geeignet, um gutartige Lipome und semimaligne ALTs besser abzugrenzen. ALTs zeigten signifikant höhere Perfusionswerte als Lipome. Wenn größere prospektive Studien diese Ergebnisse bestätigen, könnte CEUS die präoperative Diagnostik und somit die individuelle Therapie sowie Operationsplanung verbessern.

Keywords

Keywords

Lipoma - CEUS - perfusion - ALT

References
1 Kransdorf MJ, Murphey MD. Radiologic evaluation of soft-tissue masses: a current perspective. AJR Am J Roentgenol 2000; 175: 575-587
2 Fenzl L, Mehrmann M, Kremp K. et al. Weichteiltumoren : Epidemiologie, Klassifikation und Stadieneinteilung [Soft tissue tumors: Epidemiology, classification and staging]. Radiologe 2017; 57: 973-986
3 Nagano S, Yokouchi M, Setoguchi T. et al. Differentiation of lipoma and atypical lipomatous tumor by a scoring system: implication of increased vascularity on pathogenesis of liposarcoma. BMC musculoskeletal disorders 2015; 16: 36-36
4 Dalal KM, Antonescu CR, Singer S. Diagnosis and management of lipomatous tumors. Journal of Surgical Oncology 2008; 97: 298-313
5 Laurino L, Furlanetto A, Orvieto E. et al. Well-differentiated liposarcoma (atypical lipomatous tumors). Semin Diagn Pathol 2001; 18: 258-262
6 Gaskin CM, Helms CA. Lipomas, Lipoma Variants, and Well-Differentiated Liposarcomas (Atypical Lipomas): Results of MRI Evaluations of 126 Consecutive Fatty Masses. American Journal of Roentgenology 2004; 182: 733-739
7 Bassett MD, Schuetze SM, Disteche C. et al. Deep-seated, well differentiated lipomatous tumors of the chest wall and extremities. Cancer 2005; 103: 409-416
8 Kooby DA, Antonescu CR, Brennan MF. et al. Atypical lipomatous tumor/well-differentiated liposarcoma of the extremity and trunk wall: Importance of histological subtype with treatment recommendations. Annals of Surgical Oncology 2004; 11: 78-84
9 Nishio J. Contributions of Cytogenetics and Molecular Cytogenetics to the Diagnosis of Adipocytic Tumors. Journal of Biomedicine and Biotechnology 2011; 2011: 524067
10 Lucas DR, Nascimento AG, Sanjay BKS. et al. Well-differentiated Liposarcoma: The Mayo Clinic Experience with 58 Cases. American Journal of Clinical Pathology 1994; 102: 677-683
11 Brisson M, Kashima T, Delaney D. et al. MRI characteristics of lipoma and atypical lipomatous tumor/well-differentiated liposarcoma: retrospective comparison with histology and MDM2 geneamplification. Skeletal Radiology 2013; 42: 635-647
12 Ryan S, Visgauss J, Kerr D. et al. The Value of MRI in Distinguishing Subtypes of Lipomatous Extremity Tumors Needs Reassessment in the Era of MDM2 and CDK4 Testing. Sarcoma 2018; 2018: 1901896
13 Wu M, Hu Y, Hang J. et al. Qualitative and Quantitative Contrast-Enhanced Ultrasound Combined with Conventional Ultrasound for Predicting the Malignancy of Soft Tissue Tumors. Ultrasound Med Biol 2022; 48: 237-247
14 De Marchi A, Prever EBd, Cavallo F. et al. Perfusion pattern and time of vascularisation with CEUS increase accuracy in differentiating between benign and malignant tumours in 216 musculoskeletal soft tissue masses. European journal of radiology 2014; 84: 142-150
15 Loizides A, Peer S, Plaikner M. et al. Perfusion pattern of musculoskeletal masses using contrast-enhanced ultrasound: a helpful tool for characterisation?. European radiology 2012; 22: 1803-1811
16 De Marchi A, Pozza S, Charrier L. et al. Small Subcutaneous Soft Tissue Tumors (<5 cm) Can Be Sarcomas and Contrast-Enhanced Ultrasound (CEUS) Is Useful to Identify Potenzially Malignant Masses. International journal of environmental research and public health 2020; 17: 8868
17 Wang P, Wu M, Li A. et al. Diagnostic Value of Contrast-Enhanced Ultrasound for Differential Diagnosis of Malignant and Benign Soft Tissue Masses: A Meta-Analysis. Ultrasound in Medicine & Biology 2020; 46: 3179-3187
18 O‘Donnell PW, Griffin AM, Eward WC. et al. Can Experienced Observers Differentiate between Lipoma and Well-Differentiated Liposarcoma Using Only MRI?. Sarcoma 2013; 2013: 982784
19 Bird JE, Morse LJ, Feng L. et al. Non-Radiographic Risk Factors Differentiating Atypical Lipomatous Tumors from Lipomas. Frontiers in Oncology 2016; 6
20 Mashima E, Sawada Y, Nakamura M. Recent Advancement in Atypical Lipomatous Tumor Research. International Journal of Molecular Sciences 2021; 22: 994
21 Asano Y, Miwa S, Yamamoto N. et al. A scoring system combining clinical, radiological, and histopathological examinations for differential diagnosis between lipoma and atypical lipomatous tumor/well-differentiated liposarcoma. Scientific Reports 2022; 12: 237
22 Kransdorf MJ, Bancroft LW, Peterson JJ. et al. Imaging of Fatty Tumors: Distinction of Lipoma and Well-differentiated Liposarcoma. Radiology 2002; 224: 99-104
23 Kunz P, Kiesl S, Gross S. et al. Intra-observer and Device-Dependent Inter-observer Reliability of Contrast-Enhanced Ultrasound for Muscle Perfusion Quantification. Ultrasound Med Biol 2020; 46: 275-285