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Contrast-Enhanced Ultrasound and Strain Elastography for Differentiating Benign and Malignant Parotid Tumors

Objectives Preoperative differentiation between benign parotid tumors (BPT) and malignant parotid tumors (MPT) is crucial for treatment decisions. The purpose of this study was to investigate the benefits of combining contrast-enhanced ultrasound (CEUS) and strain elastography (SE) for preoperative differentiation between BPT and MPT.
Shi L, Wu D, Yang X, Yan C, Huang P.
Ultraschall Med. 2023 Aug;44(4):419-427
Epub 2023 Feb 2. PMID: 36731495; PMCID: PMC10629480
Methods A total of 115 patients with BPT (n=72) or MPT (n=43) who underwent ultrasound (US), SE, and CEUS were enrolled. US and CEUS features and the elasticity score were evaluated. Receiver operating characteristic curve (ROC) analysis was used to assess the diagnostic performance of SE, CEUS, and SE + CEUS with respect to identifying MPT from BPT.
Results Solitary presentation, larger diameter, irregular shape, ill-defined margin, heterogeneous echogenicity, and calcification on US and higher elasticity score on SE had a significant association with malignancy. MPT also presented an unclear margin, larger size after enhancement, and “fast-in and fast-out” pattern on CEUS. The combination of SE and CEUS was effective for differentiating MPT from BPT (AUC: 0.88, 0.80-0.95), with a sensitivity of 86.0%, specificity of 88.9%, and accuracy of 87.8%, which were significantly higher than the values for SE (AUC: 0.75, 0.66-0.85) and CEUS (AUC: 0.82, 0.73-0.91) alone.
Conclusion The combination of CEUS and SE is valuable for distinguishing MPT from BPT.
Link (DOI) https://doi.org/10.1055/a-1866-4633
Ultrasound speciality CEUS, Strain Elastography


Short-Review by Prof. Julian Kuenzel:


  • Relatively large number of malignant parotid tumors (37%)
  • Exclusion of non-primary parotid carcinomas and lymphoma
  • Two blinded examiners independently reviewed images and loops
  • According to the results a multimodal ultrasound based diagnostic pathway is provided.


  • Retrospective and monocentric study design
  • Indication for CEUS is not clearly defined, which could lead to a selection bias
  • Sonoelastography was only performed with strain and not shear-wave technique.
  • Scoring system for breast was used to classify parotid tumors benign or malignant.

Personal opinion:

  • More practice and evidence in differentiating parotid tumors by means of ultrasound is warranted and this study gives interesting insights to it. Any improvements in preoperative differential diagnosis is valuable, in particularly for patient counseling, indication for ultrasound guided biopsy and treatment planning.