Diagnostic performance of real-time strain sonoelastography in BI-RADS 4 and 5 breast masses

The Application Value of Using Semiquantitative and Quantitative Parameters in Multimodal Ultrasound to Distinguish Between Benign and Malignant BI-RADS 4 Lesions

ABSTRACT

This study aims to explore the value of real-time strain elastography (RTE) and contrast-enhanced ultrasonography (CEUS) in the diagnosis of breast BI-RADS 4 lesions. It collected 85 cases (totaling 85 lesions) diagnosed with breast BI-RADS 4 through routine ultrasound from October 2020 to December 2022 in Huangshan City People's Hospital. All lesions underwent RTE and CEUS examination before surgery, and the ImageJ software was used to measure the periphery of lesion images in the enhancement peak mode and grayscale mode to calculate the contrast-enhanced ultrasound area ratio. The diagnostic capabilities of single-modal and multimodal ultrasound examination for the malignancy of breast BI-RADS 4 lesions were compared using the receiver operating characteristic curve; the Spearman correlation analysis was adopted to evaluate the correlation between multimodal ultrasound and CEUS area ratio. As a result, among the 85 lesions, 51 were benign, and 34 were malignant. The areas under the curve (AUCs) of routine ultrasound (US), US + RTE, US + CEUS, and US + RTE + CEUS were 0.816, 0.928, 0.953, and 0.967, respectively, with the combined method showing a higher AUC than the single application. The AUC of the CEUS area ratio diagnosing breast lesions was 0.888. There was a strong positive correlation (r = 0.819, P < 0.001) between the diagnostic performance of US + RTE + CEUS and the CEUS area ratio. In conclusion, based on routine ultrasound, the combination of RTE and CEUS can further improve the differential diagnosis of benign and malignant lesions in breast BI-RADS 4.

Evaluating diagnostic significance: The utilization of elastography and contrast-enhanced ultrasound for differential diagnosis in breast lesions

OBJECTIVE

The primary aim of this study is to assess the diagnostic efficacy of elastography and contrast-enhanced ultrasound (CEUS) in the identification of breast lesions subsequent to the optimization and correction of the BI-RADS category 4 classification obtained through conventional ultrasound. The objective is to augment both the specificity and accuracy of breast lesion diagnosis, thereby establishing a reliable framework for reducing unnecessary biopsies in clinical settings.

METHODS

A cohort comprising 50 cases of breast lesions classified under BI-RADS category 4 was collected during the period from November 2022 and November 2023. These cases were examined utilizing strain elastography (SE), shear wave elastography (SWE), and CEUS. Novel scoring methodologies for ultrasonic elastography (UE) and CEUS were formulated for this investigation. Subsequently, the developed UE and CEUS scoring systems were used to refine and optimize the conventional BI-RADS classification, either in isolation or in conjunction. Based on the revised classification, the benign group was classified as category 3 and the suspected malignant group was classified as category 4a and above, with pathological results serving as the definitive reference standard. The diagnostic efficacy of the optimized UE and CEUS, both independently and in combination, was meticulously scrutinized and compared using receiver operating characteristic (ROC) curve analysis, with pathological findings as the reference standard.

RESULTS

Within the study group, malignancy manifested in 11 cases. Prior to the implementation of the optimization criteria, 78% (39 out of 50) of patients underwent biopsies deemed unnecessary. Following the application of optimization criteria, specifically a threshold of≥8.5 points for the UE scoring method and≥6.5 points for the CEUS scoring method, the incidence of unnecessary biopsies diminished significantly. Reduction rates were observed at 53.8% (21 out of 39) with the UE protocol, 56.4% (22 out of 39) with the CEUS protocol, and 89.7% (35 out of 39) with the combined UE and CEUS optimization protocols.

CONCLUSION

The diagnostic efficacy of conventional ultrasound BI-RADS category 4 classification for breast lesions is enhanced following optimized correction using UE and CEUS, either independently or in conjunction. The application of the combined protocol demonstrates a notable reduction in the incidence of unnecessary biopsies.

Determining the elastography strain ratio cut off value for differentiating benign from malignant breast lesions: systematic review and meta-analysis

Background

Elastography is an addition to grey-scale ultrasonic examination that has gained substantial traction within the last decade. Strain ratio (SR) has been incorporated as a semiquantitative measure within strain elastography, thus a potential imaging biomarker. The World Federation for Ultrasound in Medicine and Biology (WFUMB) published guidelines in 2015 for breast elastography. These guidelines acknowledge the marked variance in SR cut-off values used in differentiating benign from malignant lesions. The objective of this review was to include more recent evidence and seek to determine the optimal strain ratio cut off value for differentiating between benign and malignant breast lesions.

Methods

Comprehensive search of MEDLINE and Web of Science electronic databases with additional searches via Google Scholar and handsearching set from January 2000 to May 2020 was carried out. For retrieved studies, screening for eligibility, data extraction and analysis was done as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Diagnostic Test Accuracy (PRISMA-DTA) Statement guidelines of 2018. Quality and risk of bias assessment of the studies were performed using the revised Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool.

Results

A total of 424 articles, 412 from electronic database and 12 additional searches were retrieved and 65 studies were included in the narrative synthesis and subgroup analysis. The overall threshold effect indicated significant heterogeneity among the studies with Spearman correlation coefficient of Logit (TPR) vs Logit (FPR) at − 0.301, p-value = 0.015. A subgroup under machine model consisting seven studies with 783 patients and 844 lesions showed a favourable threshold, Spearman’s correlation coefficient,0.786 (p = 0.036).

Conclusion

From our review, currently the optimal breast SR cut-off point or value remains unresolved despite the WFUMB guidelines of 2015. Machine model as a possible contributor to cut-off value determination was suggested from this review which can be subjected to more industry and multi-center research determination.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40644-022-00447-5.

Breast mass characterization using shear wave elastography and ultrasound

PURPOSE

To evaluate the role of SWE in characterizing breast masses and ascertain whether additional use of SWE to ultrasound for evaluating BI-RADS 3 and 4a masses could help reduce long-term follow-up and unnecessary biopsies of these suspicious breast masses.

MATERIALS AND METHODS

This prospective, cross-sectional study was performed between June 2013 and November 2014. All enrolled patients underwent clinical breast examination, ultrasound, SWE and ultrasound-guided core biopsy of the breast mass. Breast Imaging Reporting and Data System (BI-RAD) categories were assigned to breast masses. For qualitative and quantitative variables of SWE, cut-off values for differentiation between benign and malignant breast masses were estimated. Modified BIRADS' (up/downgrading of BIRADS category) was done for BI-RADS 3/4a masses by combining individual SWE parameters and ultrasound findings. Sensitivity, specificity, positive and negative predictive value of modified BI-RADS' and ultrasound BI-RADS were compared.

RESULTS

A total of 119 women (mean age, 42.3±13.6 [SD] years; range: 13-87 years) with a single breast mass each were enrolled. Histopathologically, 57/119 (48%) breast masses were benign and 62 (52%) were malignant. On ultrasound, 42 breast masses were BI-RADS3 and 77 were BI-RADS 4 (4a, n=10; 4b, n=24; 4c, n=43) leading to 96.8% sensitivity and 70.2% specificity. On SWE, benign breast masses were oval/round, homogenous/reasonably homogenous, blue/green with lower elasticity values and malignant breast masses were irregular, inhomogeneous, red/orange with high elasticity values. On modified BI-RADS' using E-color and E-mean/E-max, specificity improved to 78.9% and 75.4% respectively.

CONCLUSION

Addition of SWE to ultrasound improves characterization of BI-RADS 3 and 4a masses. E-max, E-mean and E-color are the most useful SWE parameters to differentiate between malignant and benign breast masses.

Semi-Quantitative Strain Ratio Determined Using Different Measurement Methods: Comparison of Strain Ratio Values and Diagnostic Performance Using One- versus Two-Region-of-Interest Measurement

We evaluated the agreement and diagnostic performance of strain ratio values using measurements made with one and two user-defined regions of interest (ROIs) on breast elastography. Two hundred forty-three breast masses of 226 women (mean age: 48.2 y) were included. Ultrasonography (US) and elastography images of the masses were recorded. Strain ratio was measured twice on the same elastography image; strain ratio 1, applying one ROI at the target mass for measurement, and strain ratio 2, applying one ROI at the target mass and another ROI as reference strain. The two strain ratio measurements were in substantial agreement, with an intra-class correlation coefficient of 0.655 (95% confidence interval: 0.577-0.722). Specificity, positive predictive value and accuracy (cutoffs: 2.66 and 2.35) were significantly improved for US combined with the two strain ratio measurements (all p values < 0.05). Strain ratios measured using one or two user-defined ROIs were in substantial agreement, both contributing to the improved diagnostic performance of breast US.