Comparison of the diagnostic performance of high-frequency ultrasound as a first- or second-line diagnostic tool in non-palpable lesions of the breast

Can Cut-Off-Values for Tumor Size or Patient Age in Breast Ultrasound Reduce Unnecessary Biopsies or is it all About Bi-rads?- A Retrospective Analysis of 763 Biopsied T1-Sized Lesions

AIMS AND OBJECTIVES

To assess whether it is possible to establish a size cut-off-value for sonographically visible breast lesions in a screening situation, under which it is justifiable to obviate a biopsy and to evaluate the grayscale characteristics of the identified lesions.

MATERIALS AND METHODS

Images of sonographically visible and biopsied breast lesions of 684 patients were retrospectively reviewed and assessed for the following parameters: size, shape, margin, lesion boundary, vascularity, patient's age, side of breast, histological result, and initial BI-RADS category. Statistical analyses (t-test for independent variables, ROC analyses, binary logistic regression models, cross-tabulations, positive/negative predictive values) were performed using IBM SPSS (Version 21.0).

RESULTS

Of all 763 biopsied lesions, 223 (29.2%) showed a malignant histologic result, while 540 (70.8%) were benign. Although we did find a statistically significant correlation of malignancy and lesion size (p=0.031), it was not possible to define a cut-off value, under which it would be justifiable to obviate a biopsy in terms of sensitivity and specificity (AUC: 0.558) at any age. Lesions showing the characteristics of a round or oval shape, a sharp delineation and no echogenic rim (n=112) were benign with an NPV of 99.1%.

CONCLUSION

It is not possible to define a cut-off value for size or age, under which a biopsy of a sonographically visible breast lesion can be obviated in the screening situation. The combination of the 3 grayscale characteristics, shape (round or oval), margin (circumscribed) and no echogenic-rim sign, showed an NPV of 99.1%. Therefore, it seems appropriate to classify such lesions as BI-RADS 2.

Comparison of mammography and ultrasound in detecting residual disease following bioptic lumpectomy in breast cancer patients

Surgical biopsy is a method for diagnosing breast cancer. The aim of this study was to prospectively evaluate the relative accuracies of mammography (MMG) and ultrasound (US) in predicting residual disease following bioptic lumpectomy. Each prediction method was compared with the gold standard of surgical pathology. The results of MMG and US from 312 consecutive breast cancer patients diagnosed by surgical excision were analyzed. All the patients underwent re-excision mastectomy or lumpectomy and the imaging results were compared with the histopathological findings. The accuracy and sensitivity of each modality were investigated. A total of 312 patients with 312 primary breast cancers were investigated. Residual disease was identified in 118 patients. Of the 118 cases with residual disease, MMG and US were able to detect 77 (65.3%) and 32 (27.1%), respectively (chi-square P<0.001). MMG was also more sensitive compared with US in estimating residual ductal carcinoma in situ (DCIS) (94.2 vs. 33.3%, respectively; P<0.001). MMG was more accurate compared with US in detecting residual disease following bioptic lumpectomy and the diagnostic accuracy of MMG was associated with the presence of residual DCIS.

Screening Ultrasound in Women with Negative Mammography: Outcome Analysis

PURPOSE

To show the results of an audit of screening breast ultrasound (US) in women with negative mammography in a single institution and to analyze US-detected cancers within a year and interval cancers.

MATERIALS AND METHODS

During the year of 2006, 1974 women with negative mammography were screened with US in our screening center, and 1727 among them had pathologic results or any follow up breast examinations more than a year. We analyzed the distribution of Breast Imaging Reporting and Data System (BI-RADS) category and the performance outcome through follow up.

RESULTS

Among 1727 women (age, 30-76 years, median 49.5 years), 1349 women (78.1%) showed dense breasts on mammography, 762 (44.1%) had previous breast US, and 25 women (1.4%) had a personal history of breast cancers. Test negatives were 94.2% (1.627/1727) [BI-RADS category 1 in 885 (51.2%), 2 in 742 (43.0%)]. The recall rate (=BI-RADS category 3, 4, 5) was 5.8%. Eight cancers were additionally detected with US (yield, 4.6 per 1000). The sensitivity, specificity, and positive predictive value (PPV1, PPV2) were 88.9%, 94.6%, 8.0%, and 28.0%, respectively. Eight of nine true positive cancers were stage I or in-situ cancers. One interval cancer was stage I cancer from BI-RADS category 2.

CONCLUSION

Screening US detected 4.6 additional cancers among 1000. The recall rate was 5.8%, which is in lower bound of acceptable range of mammography (5-12%), according to American College of Radiology standard.

Diagnostic evaluation of ductal carcinoma in situ of the breast: ultrasonographic, mammographic and histopathologic correlations

The aims of the study described here were to illustrate the spectrum of ultrasonographic features of ductal carcinoma in situ (DCIS) and to evaluate the ability of ultrasonography (US) to predict the grade and recurrence of DCIS on the basis of mammographic and histopathologic findings. We retrospectively evaluated the ultrasonographic features of 129 DCIS lesions from 127 consecutive women and compared these with their mammographic and histopathologic features. The mean size of DCISs on ultrasonography and mammography (MMG) was 3.67 ± 1.40 and 4.00 ± 1.74 cm, respectively, which do not differ statistically (p = 0.09). Despite the statistical difference in Breast Imaging Reporting and Data System (BI-RADS) classification on US and MMG (p = 0.000), the median BI-RADS classification is category 4c on both US and MMG (p = 0.01). There was no statistically significant difference in the distribution of microcalcification on MMG and US. Clusters <5 mm in greatest diameter are easily seen on MMG. At US, a scattered/linear distribution on MMG had a higher level of visibility than clustered distribution on MMG. The correlation between tumor size and DCIS with micro-invasion evaluated using US is higher than that obtained using MMG (p = 0.001 and 0.024, respectively). When US was used for the detection of DCIS, diagnostic accuracy was significantly associated with higher Van Nuys groups, the presence of micro-invasion and comedo carcinoma (p = 0.000, 0.022 and 0.011, respectively). However, mammographic diagnostic accuracy was found not to associate with higher Van Nuys groups, the presence of micro-invasion and comedo carcinoma (p = 0.054, 0.093 and 0.256, respectively). Ultrasonography may play an important role both in detecting DCIS and in evaluating its histopathologic features. Detection of DCIS using MMG alone may be suboptimal for patients with dense breasts, especially among Chinese women.

Ultrasonographic detection and characterization of asymptomatic ductal carcinoma in situ with histopathologic correlation

BACKGROUND

Most ductal carcinoma in situ (DCIS) of the breast is asymptomatic and usually manifests as calcifications in screening mammography. On the other hand, little is known about ultrasonographic (US) features of asymptomatic DCIS, for US is rarely used for the diagnosis and evaluation of DCIS because of low sensitivity in detecting microcalcifications.

PURPOSE

To evaluate US detection and characterization of DCIS in asymptomatic women and correlate these imaging findings with the histopathologic features.

MATERIAL AND METHODS

This retrospective study evaluated mammographic and US images of 60 DCIS cases from 59 asymptomatic women. US was performed in knowledge of mammographic findings. The following histopathologic parameters were analyzed: Van Nuys classification, architectural pattern, and presence of microinvasion. Image detectability and US features were correlated with these histopathologic parameters.

RESULTS

Of the 54 cases (90.0%) detected on mammography, 48 cases (88.9%) had microcalcifications only, 5 (9.3%) had microcalcifications with associated density, and 1 (1.9%) had soft tissue density alone. Of the 38 cases (63.3%) identified by US, 29 cases (76.3%) had a mass with or without microcalcifications, six (15.8%) had microcalcifications only, and three (7.9%) had other findings. US identified lesions were associated with higher Van Nuys groups, microinvasion and comedocarcinoma (P = 0.044, P = 0.024, and P = 0.032, respectively). The most common US finding was a not-circumscribed, oval mass with parallel orientation and normal acoustic transmission. Microcalcifications were seen on US in 31 (81.6%) of the 38 US visible cases; this finding showed a trend of association with Van Nuys group 2 and 3 but was not statistically significant (P = 0.063).

CONCLUSION

When DCIS was identified on US, it was associated with more aggressive histopathologic type. However, mammographic correlation is essential to differentiate benign from malignant lesion in cases seen by US; US findings of asymptomatic DCIS had a low suspicion of malignancy.

Breast Sonography - 2D, 3D, 4D Ultrasound or Elastography?

SUMMARY: The aim of this publication is to give an answer to the question whether 2D, 3D and 4D sonography of the breast can be replaced by elastography or whether elastography is an adjunct tool to B-mode imaging. The Breast Imaging and Reporting Data System (BI-RADS) ultrasound (US) descriptors of a lesion besides vascularity are based on B-mode imaging. US elastography displays the mechanical tissue properties. This information can be obtained by freehand compression and decompression. Acoustic radiation force impulse imaging (ARFI) produces stress with low-frequency push pulses. Manual compression by the transducer is not necessary. Shear wave elastography (SWE) is the combination of ARFI and the measurement of the consecutive shear wave propagations in the tissue. A quantification of the elasticity in kilopascal (kPa) is offered. Discussing B-mode imaging and elastography combined with the literature, elastography is seen as an addition to B-mode imaging with the potential to increase the specificity of the B-mode imaging-based BI-RADS assessment. In spite of additional elasticity information, the sensitivity remains high. A time-saving diagnostic algorithm for 2D, 3D US and elastography is described. In conclusion, it must be said that elasticity is not a stand-alone US modality able to replace 2D and 3D sonography.

Diagnostic algorithm: How to make use of new 2D, 3D and 4D ultrasound technologies in breast imaging

The aim of this publication is to present a time saving diagnostic algorithm consisting of two-dimensional (2D), three-dimensional (3D) and four-dimensional (4D) ultrasound (US) technologies. This algorithm of eight steps combines different imaging modalities and render modes which allow a step by step analysis of 2D, 3D and 4D diagnostic criteria. Advanced breast US systems with broadband high frequency linear transducers, full digital data management and high resolution are the actual basis for two-dimensional breast US studies in order to detect early breast cancer (step 1). The continuous developments of 2D US technologies including contrast resolution imaging (CRI) and speckle reduction imaging (SRI) have a direct influence on the high quality of three-dimensional and four-dimensional presentation of anatomical breast structures and pathological details. The diagnostic options provided by static 3D volume datasets according to US BI-RADS analogue assessment, concerning lesion shape, orientation, margin, echogenic rim sign, lesion echogenicity, acoustic transmission, associated calcifications, 3D criteria of the coronal plane, surrounding tissue composition (step 2) and lesion vascularity (step 6) are discussed. Static 3D datasets offer the combination of long axes distance measurements and volume calculations, which are the basis for an accurate follow-up in BI-RADS II and BI-RADS III lesions (step 3). Real time 4D volume contrast imaging (VCI) is able to demonstrate tissue elasticity (step 5). Glass body rendering is a static 3D tool which presents greyscale and colour information to study the vascularity and the vascular architecture of a lesion (step 6). Tomographic ultrasound imaging (TUI) is used for a slice by slice documentation in different investigation planes (A-,B- or C-plane) (steps 4 and 7). The final step 8 uses the panoramic view technique (XTD-View) to document the localisation within the breast and to make the position of a lesion simply reproducible.

Ultrasound demonstration of mammographically detected microcalcifications in patients with ductal carcinomain situ of the breast

BACKGROUND

Breast microcalcifications are difficult to depict by ultrasound (US). However, recent advances in US equipment and the refinement of breast imaging techniques have improved the detection and characterization of small breast lesions. The present study attempts to determine whether US examination is able to demonstrate nonpalpable breast lesions associated with mammographically detected microcalcifications without mass density or distortion, and to evaluate the clinical reliability of US-guided procedures, especially in cases of ductal carcinoma in situ(DCIS)of the breast.

METHODS

The subjects consisted of 73 patients with breast cancer diagnosed preoperatively as DCIS by stereotactic core needle biopsies, all of whom had microcalcifications without other abnormalities on mammography. The radiological appearance and size of the clustered microcalcifications were evaluated. US examinations were performed preoperatively, and the detection rates were assessed. Sonographically detected lesions underwent US-guided wire localization followed by surgical excision.

RESULTS

The lesions associated with microcalcifications were identified sonographically in 54 of 73 cases (74%), and the pathological examination revealed breast cancer in all of the corresponding specimens. Lesions with linear-branching shape, segmental-linear distribution and category-5 calcifications on mammography had a high level of visibility on US. The US visible cases had a larger size of calcified area on mammography when compared with US invisible cases. Pathologically, the lesions were more frequently seen on US in cases with minimally invasive cancer or with comedo type DCIS.

CONCLUSIONS

US examination is an effective method for identifying and localizing breast microcalcifications, and can be used as an alternative to stereotactic localization in selected patients with early breast cancer.

The role of ultrasonography as an adjunct to mammography in the detection of breast cancer. a systematic review

The aim of this review was to summarise the diagnostic performance of ultrasonography as an adjunct to mammography in the detection of breast cancer and to identify clinical indications. A systematic review was performed of all publications in MEDLINE and EMBASE between 1990 and 2000 on the role of ultrasonography as an adjunct to mammography. 22 studies were included, showing a large variety of indications for ultrasonography and variations in the diagnostic performance of mammography and ultrasonography. There were six studies comparing a combined diagnosis of mammography and ultrasonography together with mammography alone, of which three studies had an increased sensitivity at the cost of a lower specificity. The methods of selecting the study population and interpretation of ultrasonography significantly influenced the diagnostic performance of mammography and ultrasonography relative to each other (P=0.003, P=0.03, respectively). Based on the studies reviewed, little evidence-based support was found to confirm the well recognised value of ultrasonography as an adjunct to mammography in the detection of breast cancer in clinical practice. Furthermore, no clinical indications for additional ultrasonography could be defined. The heterogeneity in the diagnostic performance in these studies may be explained by the methods of patient selection and ultrasonography interpretation, as well as by their poor quality.

US of mammographically detected clustered microcalcifications

PURPOSE

To determine whether ultrasonography (US) can depict breast masses associated with mammographically detected clustered microcalcifications and whether the visibility at US is different between benign and malignant lesions.

MATERIALS AND METHODS

Ninety-four patients with 100 mammographically detected microcalcification clusters prospectively underwent US with a 10- or 12-MHz transducer before mammographically guided presurgical hook-wire localization. The visibility of breast masses at US was correlated with histologic and mammographic findings.

RESULTS

Surgical biopsy revealed 62 benign lesions, 30 intraductal cancers, and eight invasive cancers. At US, breast masses associated with microcalcifications were seen in 45 (45%) of 100 cases. US depicted more breast masses associated with malignant (31 [82%] of 38) than with benign (14 [23%] of 62) microcalcifications (P: <.001). In malignant microcalcification clusters larger than 10 mm, US depicted associated breast masses in all 25 cases. There was no statistically significant difference in shape and distribution of calcific particles, as well as in breast composition, at mammography between US visible and invisible groups.

CONCLUSION

Given a known mammographic location, US with a high-frequency transducer can depict breast masses associated with malignant microcalcifications, particularly clusters larger than 10 mm. US can be used to visualize large clusters of microcalcifications that have a very high suspicion of malignancy.

Ultrasound guided core biopsy of suspicious mammographic calcifications using high frequency and power Doppler ultrasound

AIM

The pre-operative diagnosis of suspicious mammographic microcalcifications usually requires stereotactic needle biopsy. The aim of this study was to evaluate if high frequency 13 MHz ultrasound (HFUS) and power Doppler (PD) can aid visualization and biopsy of microcalcifications.

MATERIALS AND METHODS

Forty-four consecutive patients presenting with microcalcifications without associated mammographic or palpable masses were examined with HFUS and PD. Ultrasound-guided core biopsy (USCB) was performed where possible. Stereotactic biopsy was carried out when US-guided biopsy was unsuccessful. Surgery was performed if a diagnosis of malignancy was made on core biopsy or if the repeat core biopsy was non-diagnostic.

RESULTS

Forty-one patients (93%) had ultrasound abnormalities corresponding to mammographic calcification. USCB was performed on 37 patients. In 29/37, USCB obtained a definitive result (78.4%). USCB was non-diagnostic in 4/9 benign (44.4%) and 4/28 (14.3%) malignant lesions biopsied. The complete and absolute sensitivities for malignancy using USCB were 85.7% (24/28) and 81% (23/28), respectively. USCB correctly identified invasive disease in 12/23 (52.2%) cases. There was no significant difference in the presence of abnormal flow on PD between benign and malignant lesions. However, abnormal PD vascularity was present in 43.5% of invasive cancer and was useful in directing successful biopsy in eight cases.

CONCLUSION

The combination of high frequency US with PD is useful in the detection and guidance of successful needle biopsy of microcalcifications particularly where there is an invasive focus within larger areas of DCIS.

Digital imaging improves upright stereotactic core biopsy of mammographic microcalcifications

AIM

This comparative study was carried out to assess the effect of using digital images compared to conventional film-screen mammography on the accuracy of core biopsy of microcalcifications using upright stereotactic equipment.

MATERIALS AND METHODS

The biopsy results from a consecutive series of 104 upright stereotactic 14-gauge core biopsies performed with conventional X-ray (Group A) were compared with 40 biopsies carried out using stereotaxis with digital imaging (Group B). In all cases specimen radiography was performed and analysed for the presence of calcifications. Pathological correlation was then carried out with needle and surgical histology.

RESULTS

The use of digital add-on equipment increased the radiographic calcification retrieval rate from 55 to 85% (P < 0.005). The absolute sensitivity of core biopsy in pure ductal carcinoma in situ (DCIS) cases rose from 34 to 69% (P < 0.03), with the complete sensitivity increasing from 52 to 94% (P < 0.005). For DCIS with or without an invasive component the absolute sensitivity rose from 41 to 67% (P = 0.052), while the complete sensitivity was 59% before and 86% after the introduction of digital imaging (P < 0.04).

CONCLUSION

Digital equipment improves the performance of upright stereotactic core biopsy of microcalcifications, giving a significantly increased success rate in accurately obtaining calcifications. This leads to an improvement in absolute and complete sensitivity of core biopsy when diagnosing DCIS.

How reliable is modern breast imaging in differentiating benign from malignant breast lesions in the symptomatic population?

AIM

To assess the ability of mammography and ultrasound individually and in combination to predict whether a breast abnormality is benign or malignant in patients with symptomatic breast disease.

MATERIALS AND METHODS

Patients included were those in whom histological confirmation of the abnormality following surgical excision was available. Mammographic and ultrasound appearances were prospectively classified using a four-point scale (1 = no significant lesion, 2 = benign lesion, 3 = possibly malignant, 4 = probably malignant).

RESULTS

Histological confirmation following surgical excision was available in 559 patients, of which 303 were benign and 256 were malignant. The imaging classification was correlated with histology in these 559 lesions. In predicting final histology, the sensitivity and specificity of mammography alone were 78.9 and 82.7%, respectively, of ultrasound alone were 88.9 and 77.9%, respectively, and of mammography and ultrasound in combination were 94.2 and 67.9%, respectively. Only one patient had both a mammogram and ultrasound reported as normal (category 1 for both tests) in whom subsequent histology revealed a carcinoma (0.4% of all carcinomas).

CONCLUSION

We found that the extensive use of ultrasound increases the cancer detection rate in this selected population by 14%.