Efficacy of Sonoelastography in Distinguishing Benign from Malignant Breast Masses

Value of sonoelastography for diagnosis of breast non-mass lesions and comparison with BI-RADS: A systematic review and meta-analysis

BACKGROUND

Not all the breast lesions were mass-like, some were non-mass-like at ultrasonography. In these lesions, conventional ultrasonography had a high sensitivity but a low specificity. Sonoelastography can evaluate tissue stiffness to differentiate malignant masses from benign ones. Then what about the non-mass lesions? The aim of this study was to evaluate the current accuracy of sonoelastography in the breast non-mass lesions and compare the results with those of the American College of Radiology breast Imaging-Reporting and Data System (BI-RADS).

METHODS

An independent literature search of English medical databases, including PubMed, Web of Science, Embase & MEDLINE (Embase.com) and Cochrane Library, was performed by 2 researchers. The accuracy of sonoelastography was calculated and compared with those of BI-RADS.

RESULTS

Fourteen relevant studies including 1058 breast non-mass lesions were included. Sonoelastography showed a pooled sensitivity of 0.74 (95% CI: 0.70-0.78), specificity of 0.89 (95% CI: 0.85-0.91), diagnostic odds ratio (DOR) of 25.22 (95% CI: 17.71-35.92), and an area under the curve of 0.9042. Eight articles included both sonoelastography and BI-RADS. The pooled sensitivity, specificity, DOR and AUC were 0.69 versus 0.91 (P < .01), 0.90 versus 0.68 (P < .01), 19.65 versus 29.34 (P > .05), and 0.8685 versus 0.9327 (P > .05), respectively.

CONCLUSIONS

Sonoelastography has a higher specificity and a lower sensitivity for differential diagnosis between malignant and benign breast non-mass lesions compared with BI-RADS, although there were no differences in AUC between them.

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.

The Role of Ultrasonography and Elastography in Differentiating Benign From Malignant Breast Masses With Pathologic Correlation

Objective:

Elastography has the potential in differentiating benign from malignant masses. The objectives of the study were to evaluate morphology of the breast masses with routine ultrasonography and elastography, to assess the role of elastography and conventional B-mode ultrasonography in differentiating benign from malignant breast masses and to correlate elastography and B-mode ultrasonography results with pathologic findings.

Materials and Methods:

This prospective observational study was conducted over a period of 18 months from January 2018 to June 2019 on 86 patients with 101 clinically palpable breast lumps who underwent B-mode ultrasonography and elastography of the breast. Baseline data, sonographic features, a modified color score, and mean strain ratio were recorded and compared with final diagnosis.

Results:

Sonography showed a sensitivity of 89.8%; specificity of 96.15%; positive predictive value (PPV) and negative predictive value (NPV) of 95.65% and 90.91%, respectively; and overall diagnostic accuracy of 93.07%. New modified dual color score showed sensitivity of 97.8%, specificity of 87.0%, PPV of 86.79%, and NPV of 87.08% with a diagnostic accuracy of 92.08%. The risk of missing a malignant case with the new modified dual color score was 2.1%. Mean strain ratio showed sensitivity of 100%; specificity of 98.11%; PPV and NPV of 97.96% and 100%, respectively; and diagnostic accuracy of 99.01%.

Conclusion:

This study demonstrates the promise of elastography in identifying possible breast malignancies, thus preventing unnecessary invasive procedures.

Added Value of a New Strain Elastography Technique in Conventional Ultrasound for the Diagnosis of Breast Masses: A Prospective Multicenter Study

Objective

This study aimed to explore the value of elasticity score (ES) and strain ratio (SR) combined with conventional ultrasound in distinguishing benign and malignant breast masses and reducing biopsy of BI-RADS (Breast Imaging Reporting and Data System) 4a lesions.

Methods

This prospective, multicenter study included 910 patients from nine different hospitals. The acquisition and analysis of conventional ultrasound and strain elastography (SE) were obtained by radiologists with more than 5 years of experience in breast ultrasound imaging. The diagnostic sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under curve (AUC) of conventional ultrasound alone and combined tests with ES and/or SR were calculated and compared.

Results

The optimal cutoff value of SR for differentiating benign from malignant masses was 2.27, with a sensitivity of 60.2% and a specificity of 84.8%. When combined with ES and SR, the AUC of the new BI-RADS classification increased from 0.733 to 0.824 (p < 0.001); the specificity increased from 48.1% to 68.5% (p < 0.001) without a decrease in the sensitivity (98.5% vs. 96.4%, p = 0.065); and the PPV increased from 52.2% to 63.7% (p < 0.001) without a loss in the NPV (98.2% vs. 97.1%, p = 0.327). All three combinations of conventional ultrasound, ES, and SR could reduce the biopsy rate of category 4a lesions without reducing the malignant rate of biopsy (from 100% to 68.3%, 34.9%, and 50.4%, respectively, all p < 0.001).

Conclusions

SE can be used as a useful and non-invasive additional method to improve the diagnostic performance of conventional ultrasound by increasing AUC and specificity and reducing the unnecessary biopsy of BI-RADS 4a lesions.

Clinical Study of Ultrasound Elastography in Qualitative Diagnosis of Breast Masses

Breast mass is one of the clinical signs of breast lesions. Clinically, breast tumors can occur in breast cancer, breast tuberculosis, breast duct dilatation, breast cysts, breast fibroadenoma, and breast hyperplasia. Its pathogenesis is not clear. The occurrence of breast lesions is related to many factors, such as diet, trauma, genetic mutations, inheritance, endocrine disorders, breast development, and chronic stimuli. With the continuous improvement of examination equipment and continuous improvement of the treatment level, the incidence of breast masses is increasing. For a long time, clinicians have mostly used hand palpation methods to complete the diagnosis of breast masses based on the relatively hard properties of breast masses and adjacent tissues. It is more difficult to diagnose patients based on their clinical symptoms and signs, and it is easy to miss the diagnosis. Choosing the appropriate diagnostic method to confirm breast mass disease has become the first task for the diagnosis and treatment of breast mass. Ultrasound elastography is a new ultrasound examination method. It diagnoses the elasticity and hardness of breast masses by using corresponding characteristics. The imaging principle is to apply pressure to the tissue at the lesion site to determine its elasticity and hardness to identify the nature of the tumor. This article explores the clinical value of ultrasound elastography in the effective diagnosis of breast masses. Compared with the diagnosis results of ordinary ultrasound, the parameters such as the position, shape, size, boundary, internal echo, and rear echo of the focused mass were observed. Facts have proved that elastography can be used to make a qualitative differential diagnosis of benign and malignant breast masses from another angle according to the different characteristics of the hardness of the tissue being examined. It is non-invasive, non-radiative, low-cost, and easy for patients to accept. Provide valuable clinical diagnosis basis for early detection and treatment of breast masses.

Interacting Factors of Strain Ratio Values in Fibroadenomas and the Contribution of Color Scale

Background

The purpose of this retrospective study is to investigate the association of qualitative and semiquantitative strain elastography (SE) features with factors such as lesion size, skin-to-lesion distance, and patient's age in fibroadenomas and to discuss false-positive results.

Methods

A total of 120 lesions that were performed SE with histopathologically confirmed fibroadenoma were included in the study. All images were reviewed from the archiving system with a consensus of two radiologists. Tsukuba elasticity score was used for color scoring (from 1 to 5). Lesions with strain ratio (SR) ≥2.27 and color scale score of 4 or 5 were considered as false positive. The patients were divided into two groups according to the age: <50 and ≥50 years old. Regard of the size, lesions were divided into two groups: <15 mm and ≥15 mm. The distances of the lesions to the skin were also divided into two groups: <5 mm and ≥5 mm. Statistical analysis to identify associations between these groups and SR was carried out with Pearson Chi-square test and Fisher's exact test. The false-positive rates were calculated.

Results

There was no statistically significant difference between patients' age, lesion size, skin-to-lesion distance, and SR values. The false-positive rate was 21.66% for SR, while it was 3.33% for color scale.

Conclusion

SR values of the fibroadenomas were not affected by factors such as age, lesion size, and depth. In addition, false-positive rates significantly decrease when color scale scores are evaluated for fibroadenomas.

Shear wave versus strain elastography in the differentiation of benign and malignant breast lesions

Background/aim

To evaluate and compare the diagnostic performances of shear wave elastography (SWE) and strain elastography (SE) in the differentiation of benign and malignant breast lesions.

Materials and methods

The current study included 87 breast lesions in 84 patients. The Breast Imaging Reporting and Data System (BIRADS) categories were determined with ultrasound features. The maximum shear wave velocity (SWV), mean SWV, maximum SWV to fat SWV ratio, and mean SWV to fat SWV ratio were measured using SWE. The strain ratio (SR) was calculated as the ratio of lesion strain to the adjacent fat strain using SE. Receiver operating characteristic (ROC) curves were constructed to assess and compare the diagnostic performances of each parameter.

Results

Forty-five benign and 42 malignant lesions were diagnosed. The sensitivity and specificity of the BIRADS classification was 100% and 35.6%, respectively. Selecting a cutoff SR value of 3.22 led to an 88.1% sensitivity and an 88.4% specificity (AUC: 0.913 [95% CI: 0.854–0.971], P < 0.001). Selecting cutoff maximum SWV value of 3.41 m/s led to an 88.1% sensitivity and an 86.7% specificity (AUC: 0.918 [95% CI: 0.858–0.978], P < 0.001). The diagnostic performance of the maximum SWV, mean SWV, and maximum SWV to fat SWV ratio were similar to the diagnostic performance of the SR (P = 1.00, P = 1.00, P = 0.629, respectively).

Conclusion

SE and SWE are both feasible imaging modalities in the differentiation of malignant and benign breast lesions with similar diagnostic performances.

Comparative Study of Pattern-Based Versus Size Ratio Ultrasound Strain Elastographic Techniques on Breast Masses

OBJECTIVES

The aim of this study was to compare the diagnostic performance of strain elastographic techniques involving pattern-based elastography versus size ratio elastography on breast masses.

METHODS

Female patients presenting to the radiology department for ultrasound (US)-guided biopsies, fine-needle aspirations, or localizations of breast masses were invited to undergo US elastographic assessments of the lesions before the breast procedures. The masses were evaluated for color score and color map size ratio elastographic assessments with one US machine and size ratio and grayscale strain pattern elastographic assessments with another machine. With the histopathologic diagnosis as the reference standard, the sensitivity, specificity, and area under the receiver operating characteristic curve were compared among the 4 groups.

RESULTS

A total of 154 breast masses from 139 women were assessed. The sensitivity and specificity were 0.615 (95% confidence interval, 0.470-0.747) and 0.824 (0.736-0.892), respectively for the color score, 0.962 (0.868-0.995) and 0.765 (0.670-0.843) for the size ratio, 0.904 (0.790-0.968) and 0.745 (0.649-0.826) for the color map size ratio, and 0.635 (0.490-0.764) and 0.422 (0.324-0.523) for the grayscale strain pattern. The areas under the receiver operating characteristic curve were 0.729 for the color score, 0.874 for the size ratio (P = .001 with the color score as a reference), 0.836 for the color map size ratio (P = .002), and 0.556 for the grayscale strain pattern (P < .001).

CONCLUSIONS

Size ratio elastography had higher sensitivity and better diagnostic accuracy compared to color score elastography. This superiority was demonstrated on two different US systems, and size ratio elastography should thus be considered over color score elastography in the adjunctive US assessment of breast lesions.