Factors influencing the performance of a diagnostic model including contrast-enhanced ultrasound in 1023 breast lesions: comparison with histopathology

Current status and future perspectives of contrast-enhanced ultrasound diagnosis of breast lesions

Advances in various imaging modalities for breast lesions have improved diagnostic capabilities not only for tumors but also for non-tumorous lesions. Contrast-enhanced ultrasound (CEUS) plays a crucial role not only in the differential diagnosis of breast lesions, identification of sentinel lymph nodes, and diagnosis of lymph node metastasis but also in assessing the therapeutic effects of neoadjuvant chemotherapy (NAC). In CEUS, two image interpretation approaches, i.e., qualitative analysis and quantitative analysis, are employed and applied in various clinical settings. In this paper, we review CEUS for breast lesions, including its various applications.

Contrast-enhanced ultrasound to predict malignant upgrading of atypical ductal hyperplasia

BACKGROUND

A malignancy might be found at surgery in cases of atypical ductal hyperplasia (ADH) diagnosed via US-guided core needle biopsy (CNB). The objective of this study was to investigate the diagnostic performance of contrast-enhanced ultrasound (CEUS) in predicting ADH diagnosed by US-guided CNB that was upgraded to malignancy after surgery.

METHODS

In this retrospective study, 110 CNB-diagnosed ADH lesions in 109 consecutive women who underwent US, CEUS, and surgery between June 2018 and June 2023 were included. CEUS was incorporated into US BI-RADS and yielded a CEUS-adjusted BI-RADS. The diagnostic performance of US BI-RADS and CEUS-adjusted BI-RADS for ADH were analyzed and compared.

RESULTS

The mean age of the 109 women was 49.7 years ± 11.6 (SD). The upgrade rate of ADH at CNB was 48.2% (53 of 110). The sensitivity, specificity, positive predictive value, and negative predictive value of CEUS for identification of malignant upgrading were 96.2%, 66.7%,72.9%, and 95.0%, respectively, based on BI-RADS category 4B threshold. The two false-negative cases were low-grade ductal carcinoma in situ. Compared with the US, CEUS-adjusted BI-RADS had better specificity for lesions smaller than 2 cm (76.7% vs. 96.7%, P = 0.031). After CEUS, 16 (10 malignant and 6 nonmalignant) of the 45 original US BI-RADS category 4A lesions were up-classified to BI-RADS 4B, and 3 (1 malignant and 2 nonmalignant) of the 41 original US BI-RADS category 4B lesions were down-classified to BI-RADS 4A.

CONCLUSIONS

CEUS is helpful in predicting malignant upgrading of ADH, especially for lesions smaller than 2 cm and those classified as BI-RADS 4A and 4B on ultrasound.

Diagnostic performance of contrast-enhanced ultrasound in breast lesions: what diagnostic models could be used for lesions of different sizes?

Background

Previous studies show the size of lesions could affect the diagnostic accuracy of contrast-enhanced ultrasound (CEUS). It is unclear whether CEUS has good diagnostic performance for lesions ≤2.0 and ≤1.0 cm. It is beneficial for the early diagnosis to explore the application of CEUS in breast lesions of different sizes. This study aims to analyze the diagnostic performance of CEUS and explore diagnostic models better suited to breast lesions of different sizes.

Methods

A total of 1,059 lesions (656 benign and 403 malignant) examined by ultrasound and CEUS with definite pathological results were included in this retrospective study and divided into training (n=847) and validation (n=212) sets. All lesions were divided into three groups according to size. Diagnostic models (M0: all lesions; M1: ≤1.0 cm, M2: >1.0-2.0 cm, and M3: >2.0 cm) were developed through logistic regression analyses of CEUS features from the training set. Diagnostic performance was evaluated using the area under the receiver operating characteristic curve (AUC) and validated in the validation set.

Results

The median age of patients was 45±11 years (range, 18-80 years). The AUC values of M0 combined with the Breast Imaging Reporting and Data System (BI-RADS) in the training and validation sets were 0.921 and 0.922, respectively (P=0.893). The AUC values of M0 combined with BI-RADS in the three groups were 0.844, 0.936 and 0.928 respectively. M0 was less effective in diagnosing lesions ≤1.0 cm (0.844 vs. 0.921, P=0.029). The AUC of M1 combined with BI-RADS for lesions ≤1.0 cm was higher than that of M0 (0.893 vs. 0.844, P=0.047), and M2 and M3 had no statistical difference in diagnostic performance when compared with M0 (P=0.243; P=0.246).

Conclusions

The diagnostic performance of CEUS was closely related to lesion size. Establishing a new diagnostic model for lesions ≤1.0 cm can improve the CEUS diagnostic performance for breast lesions ≤1.0 cm.

The value of contrast-enhanced ultrasound in the diagnosis of BI-RADS-US 4a lesions less than 2 cm in diameter

BACKGROUND: Breast cancer is the most common malignant tumor in women. Early diagnosis of benign and malignant breast tumors is of great significance. OBJECTIVE: To retrospectively analyze the value of contrast-enhanced ultrasonography (CEUS) in the diagnosis of Breast Imaging-Reporting and Data System (BI-RADS) 4a breast lesions less than 2 cm in diameter. METHODS: CEUS was performed for 143 breast masses less than 2 cm in diameter that were diagnosed as BI-RADS 4a by ultrasound and reclassified. Considering pathological diagnosis as the gold standard, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of reclassified lesions after CEUS for the diagnosis of benign and malignant masses were analyzed. RESULTS: BI-RADS 4a breast masses with a diameter less than 2 cm (n = 143) were confirmed by pathology; 103 and 40 were classified as benign and malignant, respectively. The sensitivity, specificity, PPV, and NPV of CEUS for the diagnosis were 90%, 86%, 72%, and 95%, respectively. The area under the receiver operating characteristic (ROC) curve of CEUS for the diagnosis of benign and malignant tumors after CEUS was 0.904. CONCLUSION: CEUS can help to improve the diagnostic accuracy of BI-RADS 4a masses with a diameter less than 2 cm.

Application of contrast-enhanced ultrasound in the pathological grading and prognosis prediction of hepatocellular carcinoma

BACKGROUND

To explore the clinical application value of contrast-enhanced ultrasound (CEUS) in the pathological grading and prognosis prediction of hepatocellular carcinoma (HCC).

METHODS

A retrospective analysis was performed of 128 patients with primary HCC who underwent CEUS examination in our hospital from January 2017 to June 2020. Patients were divided into three groups: highly-differentiated group, moderately-differentiated group, and poorly-differentiated group. Quantitative analysis of the relationships between the rise time (RT), time to peak (TTP), mean transit time (mTT), intensity maximum (Imax), enhancement rate, and pathological grade of CEUS was performed. In addition, the follow-up patients were divided into a recurrence group and non-recurrence group, and the relationships between RT, TTP, mTT, Imax, and enhancement rate of CEUS were analyzed.

RESULTS

Among the 128 patients, 23 were highly-differentiated, 63 were moderately-differentiated, and 42 were poorly-differentiated. In addition, there were 31 patients in the recurrence group and 97 patients in the non-recurrence group. RT, TTP, and enhancement rate had significant differences in the highly-differentiated, moderately-differentiated, and poorly-differentiated groups. At the same time, RT and TTP were positively correlated with the differentiation degree, while the enhancement rate was negatively correlated with the differentiation degree. Furthermore, RT, TTP, and enhancement rate were statistically significant for the diagnosis of HCC with high, moderate, and poor differentiation, among which RT had the highest diagnostic accuracy. In the recurrence group, RT, TTP, and Imax were lower than those in the non-recurrence group, and the enhancement rate was greater than that in the non-recurrence group. Moreover, low levels of RT, TTP, and Imax along with positive microvascular invasion (MVI) and poor differentiation were risk factors for HCC recurrence, and there was no significant relationship between the average tumor diameter and HCC recurrence.

CONCLUSIONS

CEUS can significantly show the differences between the RT, TTP, and enhancement rate of HCC across different levels of differentiation. It can also predict whether the disease will relapse. Moreover, low levels of RT, TTP, and Imax as well as positive MVI and poor differentiation can cause the recurrence of HCC.

Contrast-Enhanced Ultrasonography in the Diagnosis and Treatment Modulation of Breast Cancer

The aim of this paper is to highlight the role of contrast-enhanced ultrasound in breast cancer in terms of diagnosis, staging and follow-up of the post-treatment response. Contrast-enhanced ultrasound (CEUS) is successfully used to diagnose multiple pathologies and has also clinical relevance in breast cancer. CEUS has high accuracy in differentiating benign from malignant lesions by analyzing the enhancement characteristics and calculating the time-intensity curve’s quantitative parameters. It also has a significant role in axillary staging, especially when the lymph nodes are not suspicious on clinical examination and have a normal appearance on gray-scale ultrasound. The most significant clinical impact consists of predicting the response to neoadjuvant chemotherapy, which offers the possibility of adjusting the therapy by dynamically evaluating the patient. CEUS is a high-performance, feasible, non-irradiating, accessible, easy-to-implement imaging method and has proven to be a valuable addition to breast ultrasound.

Accuracy of mammography and ultrasonography and their BI-RADS in detection of breast malignancy

BACKGROUND

We aimed to compare the diagnostic accuracy of mammography and ultrasonography and their breast imaging-reporting and data system (BI-RADS) classification versus breast core needle biopsy (CNB) findings in distinguishing the breast masses.

METHODS

This cross-sectional study was conducted during 2016-2018 on female patients who were referred to a radiology center in Babol, northern Iran, for routine screening and/or for CNB. Patients underwent sonography and mammography by a senior radiologist. The breast lesions were also evaluated according to BI-RADS classification. CNB was performed on the breast masses by the same radiologist and pathological procedures were performed by an expert pathologist. Descriptive statistics were used to analyze the data.

RESULTS

In total, 213 breast masses were finally assessed, of which 107 (50.2 %) masses were benign and 106 (49.8 %) masses were malignant. The sensitivity for mammography and ultrasound alone was 72.6% and 68.9%, respectively. This rate for combined mammography and ultrasound was 84.9%. About BI-RADS classification, 28 masses were classified as BI-RADS 3, 99 as BI-RADS 4A, 4 as BI-RADS 4B, 18 as BI-RADS 4C, and 64 as BI-RADS 5. BI-RADS 4A had the highest sensitivity (70.1%) among BI-RADS categories. The highest specificity pertained to BI-RADS 3 and 5 (100%) among BI-RADS categories. Also, the highest accuracy was related to BI-RADS 5 (80.3%).

CONCLUSION

The results of the present study showed that combined mammography and ultrasound had a higher rate of accuracy than mammography or ultrasound alone. Furthermore, the imaging methods BI-RADS classification had an acceptable positive predictive value.

Diagnostic Value of Contrast-Enhanced Ultrasonography With SonoVue in the Differentiation of Benign and Malignant Breast Lesions: A Meta-Analysis

PURPOSE

A meta-analysis was conducted to evaluate the diagnostic performance of contrast-enhanced ultrasonography using the contrast agent SonoVue to differentiate benign from malignant breast lesions.

METHOD

A comprehensive search of the literature was performed using the Embase, PubMed, and Web of Science databases to retrieve studies published before February 2020. Data were extracted, and pooled sensitivity, specificity, and diagnostic odds ratios were calculated with meta-analysis software. Heterogeneity was evaluated via the Q test and I² statistic. Meta-regression and subgroup analyses were applied to evaluate potential sources of heterogeneity. Publication bias was assessed using the Deeks' funnel plot asymmetry test. A summary receiver operating characteristic curve (SROC) was constructed.

RESULTS

A total of 27 studies including 5378 breast lesions subjected to CEUS examination with SonoVue were included in the meta-analysis. The pooled sensitivity and specificity values were 0.90 (95% confidence interval [CI], 0.88-0.91; inconsistency index [I²] = 75.7%) and 0.83 (95% CI, 0.82-0.85; I² = 91.0%), respectively. The pooled diagnostic odds ratio was 48.35% (95% CI, 31.22-74.89; I² = 77.6%). The area under the summary receiver operating characteristic curve (AUC) was 0.9354. Meta-regression analysis revealed the region of patient residence and dose of contrast agent as potential sources of heterogeneity (P < .01). Subgroup analysis showed a higher area under the summary receiver operating characteristic curve for European and higher contrast agent dose subgroups (P < .05).

CONCLUSION

Contrast-enhanced ultrasonography with SonoVue displays high sensitivity, specificity, and accuracy when differentiating benign from malignant breast lesions. Despite its current limitations, this technique presents a promising tool for diagnosing breast lesions in clinical practice.

Value of contrast-enhanced ultrasound area ratio in identifying benign and malignant small breast masses

Background

Tumor size affects clinical staging and is closely related to prognosis. Therefore, early diagnosis of breast cancer is one of the most important methods to reduce mortality and improve prognosis. However, minimal breast cancer is difficult to differentiate from small benign breast masses due to insufficient typical malignant signs. The significantly increased range of enhancement can be an important indication for the prediction of malignancy; however, quantitative studies on the extent of enhancement are rarely reported. The purpose of this study was to investigate the value of contrast-enhanced ultrasound (CEUS) area ratio in finding benign and malignant small breast masses.

Methods

A retrospective analysis was conducted on 88 patients with breast masses confirmed by surgery or needle biopsy (the maximal diameter not over 1 cm). 88 breast masses were divided into the younger age group (not over 40 years old) and older age group (over 40 years old) according to the patient's age. The receiver operating characteristic (ROC) curve was used to determine the cutoff values of CEUS area ratio in diagnosing benign or malignant small breast masses in each group. The efficiency of different cutoff values in finding benign and malignant small breast masses of the distinct groups was analyzed.

Results

The CEUS area ratio of malignant mass was larger than benign masses (P<0.05). The CEUS area ratio of malignant masses in the younger age group was larger than that in the older age group (P<0.05). The results of the ROC curve analysis showed that the area under the curve (AUC) and the cutoff values of the entire group, the younger age group, and the older age group were 0.887, 1.65; 0.909, 1.95; and 0.908, 1.22, respectively. When the cutoff value of the older age group was reduced from 1.65 to 1.22, its diagnostic sensitivity was improved significantly (P<0.05).

Conclusions

CEUS area ratio has specific application value in finding benign and malignant small breast masses. Proper reduction of the cutoff value of elderly patients can further improve its diagnostic sensitivity without significantly reducing the specificity.

Mammary hamartoma: is ultrasound-guided vacuum-assisted breast biopsy sufficient for its treatment?

Background

Mammary hamartomas were mostly benign tumors with rare rate of recurrence and malignant transformation. Ultrasound (US)-guided vacuum-assisted breast biopsy (VABB) has been reported sufficiently safe in treating many breast benign tumors but remained undefined in mammary hamartoma for its usual underdiagnosis in US. Thus, this study aims to evaluate the efficiency of US-guided VABB in treating mammary hamartomas.

Methods

From May 2015 to March 2019, 3,388 lesions of 2,534 patients underwent percutaneous US-guided VABB, among which 31 mammary hamartomas proved by pathology were included in this study. Patients were followed up by US three, six and twelve months later, then at 1-year intervals. Lesions were classified to analyze the possible factors associated with excision rate, bleeding volume and complications.

Results

Of the 31 patients, recurrence was seen in 1 case in 1 year after the procedure and complete excision rate was 96.8% (30/31). The bleeding volume ranged from 1 to 15 mL (mean number ± standard deviation, 6.5±3.4 mL) and significant statistical differences were detected in patient age and the largest diameter of lesions. The main complications included pain (22.6%), hematomas (9.7%) and ecchymosis (3.2%).

Conclusions

US-guided VABB ensures an outstanding complete excision rate and provides an alternative solution to treat mammary hamartomas.

Prospective evaluation of contrast-enhanced ultrasound of breast BI-RADS 3-5 lesions

BACKGROUND

To determine the benefit of contrast-enhanced ultrasound (CEUS) in the assessment of breast lesions.

METHODS

A standardized contrast-enhanced ultrasound was performed in 230 breast lesions classified as BI-RADS category 3 to 5. All lesions were subjected to qualitative and quantitative analysis. MVI (MicroVascular Imaging) technique was used to derive qualitative analysis parameters; blood perfusion of the lesions was assessed (perfusion homogeneity, type of vascularization, enhancement degree). Quantitative analysis was conducted to estimate perfusion changes in the lesions within drawn regions of interest (ROI); parameters TTP (time to peak), PI (peak intensity), WIS (wash in slope), AUC (area under curve) were obtained from time intensity (TI) curves. Acquired data were statistically analyzed to assess the ability of each parameter to differentiate between malignant and benign lesions. The combination of parameters was also evaluated for the possibility of increasing the overall diagnostic accuracy. Biological nature of the lesions was verified by a pathologist. Benign lesions without histopathological verification (BI-RADS 3) were followed up for at least 24 months.

RESULTS

Out of 230 lesions, 146 (64%) were benign, 67 (29%) were malignant, 17 (7%) lesions were eliminated. Malignant tumors showed statistically significantly lower TTP parameters (sensitivity 77.6%, specificity 52.7%) and higher WIS values (sensitivity 74.6%, specificity 66.4%) than benign tumors. Enhancement degree also proved to be statistically well discriminating as 55.2% of malignant lesions had a rich vascularity (sensitivity 89.6% and specificity 48.6%). The combination of quantitative analysis parameters (TTP, WIS) with enhancement degree did not result in higher accuracy in distinguishing between malignant and benign breast lesions.

CONCLUSIONS

We have demonstrated that contrast-enhanced breast ultrasound has the potential to distinguish between malignant and benign lesions. In particular, this method could help to differentiate lesions BI-RADS category 3 and 4 and thus reduce the number of core-cut biopsies performed in benign lesions. Qualitative analysis, despite its subjective element, appeared to be more beneficial. A combination of quantitative and qualitative analysis did not increase the predictive capability of CEUS.