RPS 1402b - Hand-held, contrast-enhanced, and automated whole-breast ultrasound

Purpose:

To evaluate our institutional experience of second-look ultrasound (SLUS) for targeted breast lesions identified on breast MRI. To determine our SLUS lesion detection rate (LDR), positive predictive value (PPV), and the effect on patient management (PM).

Methods and materials:

A retrospective review of SLUS at our institution between January 2016-2017 identified 316 patients who underwent breast ultrasound following breast MR. All non-SLUS cases were excluded and 66 patients with 73 target lesions were included. The index lesion (inital ultrasound identified/ MR indication), the target lesion (MR identified/ SLUS indication), and the SLUS were analysed with regard to imaging characteristics (location, size, morphology, enhancement), histopathology, and MDT outcomes to assess the efficacy of SLUS and its LDR, PPV, and PM.

Results:

57 of 73 target lesions were identified on SLUS: LDR 78.1%.

The MR imaging characteristics of the 73 target lesions were:
74.0% <10mm, 26.0% > 10mm, 84.2% mass-like enhancement, 14.0% non-mass enhancement, 1.8% no enhancement.

Of the 57 target lesions detected on SLUS:
42.1% were biopsy-proven malignant (n=24) - PPV of 63.4%.
29.8% were biopsy-proven benign (n=17) - NPV 93.6%.
28.1% were not biopsied due to stable benign radiological features or patient refusal (n=16).

SLUS confirmed suspected findings in 71.9% (n=41) and changed management in 36.8% (n=21), causing upstaging to WLE or mastectomy.

Conclusion:

Our study demonstrates the utility of SLUS breast imaging with 78.1% LDR, PPV 63.4%, and NPV 93.6%. SLUS changed patient management in 71.9% upstaging to WLE or mastectomy. SLUS is a pivotal imaging tool in the radiological assessment of breast lesions.​

Limitations:

1 year data, limited sample size.

Ethics committee approval

n/a

Funding:

No funding was received for this work.

Purpose:

To evaluate the clinical utility of second-look ultrasound (US) with MRI virtual navigation in the prone position for MRI-detected incidental breast lesions.

Methods and materials:

Between June 2016 and February 2019, 24 consecutive patients with 26 additional BI-RADS category 4 or 5 lesions that were detected on MRI but occult on second-look US were enrolled in the study. All suspicious lesions were located with US/MRI fusion virtual navigation in the prone position and then underwent US-guided biopsy or surgical excision. The detection rate was calculated compared with pre/postoperation MRI and pathological results. The MRI features and pathological types of these lesions were analysed.

Results:

A total of 24 lesions were successfully located with virtual navigation and performed with US-guided biopsy or localisation, and the detection rate of virtual navigation was 92.3% (24/26). 21 (87.5%, 21/24) proved to be benign lesions and 3 (12.5%, 3/24) malignant lesions at pathology. The remaining 2 lesions exhibited no abnormal findings on second-look US with virtual navigation and could be judged to be benign as there was no change during MRI follow-up after 6 months. Of the 26 MRI-detected lesions, 24 (92.3%, 24/26) were non-mass enhancements and 2 (7.6%, 2/26) were masses.

Conclusion:

The lesions detected on MRI but not visible on US tend to be benign. Second-look US with virtual navigation in the prone position can be an effective method for the evaluation of such lesions and can significantly increase the rate of US-guided interventional procedures which are preferable for MRI-guided ones.

Limitations:

Accurate alignment is difficult between different imaging modalities.

Ethics committee approval

The study was approved by our hospital’s institutional review board.

Funding:

Medical Health Science and Technology Project of Zhejiang Provincial Health Commission (2019PY061).

Purpose:

To evaluate the role of ultrasound (US) for detecting and characterising breast ductal carcinoma in situ (DCIS) of the breast.

Methods and materials:

US features of 178 preoperative lesions in 170 patients affected by DCIS were retrospectively evaluated by using the BIRADS ultrasound lexicon considering the lesion pattern (mass type, non-mass type, or occult), the presence of microcalcifications, architectural, and ductal distortions. For "mass-like" lesions, shape, margins, and echogenicity were considered. The ultrasound recognition rate of lesions and the distribution of ultrasound patterns was calculated, evaluating any statistically significant differences among the different lesion patterns.

Results:

63/178 lesions (35%) were detected by ultrasound; 52 (83%) were "mass-like" type and 11 (17%) "non-mass-like" type (6 architectural distortions, 5 ductal distortions) (p <0.05). In 10 patients (6%), breast lesions were identified only by US. The most common US appearance of DCIS finding in mass-type lesions was an irregular shape (79%), indistinct margins (87%), and hypoechogenicity (94%) (p <0.05). Microcalcifications associated with mass-type lesions were found in 23 cases (37%).

Conclusion:

US can allow a diagnosis of DCIS of the breast in case of mass-type lesions. The most common US finding is represented by mass-type, hypoechogenic lesion, and indistinct margins. Microcalcifications and architectural distortions are the most frequent US findings in non-mass lesions.

Limitations:

A limited number of patients.

Ethics committee approval

Yes.

Funding:

No funding was received for this work.

Purpose:

To compare the role of grey scale ultrasound and contrast-enhanced ultrasound (CEUS) in evaluating the response to neoadjuvant chemotherapy (NACT) in patients with locally advanced breast cancer (LABC).

Methods and materials:

This prospective IRB approved study comprised of 40 patients of LABC receiving NACT. Both studies were performed in 4 stages: before each of the 3 cycles of LABC and immediately prior to surgery. Grey scale ultrasound was done to evaluate tumour size. This was followed by contrast-enhanced ultrasound using a 4.8 ml bolus intravenous injection of second-generation ultrasound contrast agent. The CEUS quantitative parameters recorded were time to peak (TTP), mean transit time (MTT), and area under curve (AUC). Pathological tumour response (pTR) was evaluated after modified radical mastectomy, using the Miller Payne grading system. Statistical analysis was done for sensitivity, specificity, PPV, and NPV of each technique.

Results:

In the series of patients evaluated, 28 patients showed good pTR and 12 patients showed poor pTR. Grey scale ultrasound changes for size of tumour demonstrated sensitivity of 71.5%, specificity of 79.3%, PPV of 78.5%, and NPV of 73.8%, whereas quantitative CEUS parameters showed a sensitivity of 87.6%, specificity of 88.3%, PPV of 91.1%, and NPV of 82.4% in patients with good pTR. An increase in time to peak (TTP) after each cycle of NACT was the most accurate quantitative parameter.

Conclusion:

CEUS study using quantitative parameters was more sensitive and specific as compared to grey scale ultrasound changes of size measurements. CEUS quantitative parameters can be very useful for modifying individualised patient based NACT regimens.

Limitations:

Single-centre study.

Ethics committee approval

Informed consent was taken from all patients. Animal Board approval n/a.

Funding:

No funding was received for this work.

Purpose:

To investigate false-negative results of preoperative axillary ultrasound (AUS) in patients with breast cancer and to identify features related to false-negatives.

Methods and materials:

124 consecutive patients with newly diagnosed invasive breast cancer who underwent preoperative AUS between January-June 2018 were retrospectively included. All patients underwent sentinel lymph node biopsy or axillary lymph node dissection and pathology outcomes were considered as a gold standard. True and false-negative AUS groups were statistically compared in terms of age, BMI, tumour size, subtype, grade, estrogen receptor (ER), progesterone receptor (PR), HER2 status, proliferation index, lymphovascular invasion (LVI), and growth pattern (unifocal or multifocal).

Results:

Out of the 106 patients with normal AUS, 27 (25%) were found to be node-positive on pathologic assessment. On univariate analysis, LVI was found to be significantly different between true and false-negative groups [24%(19/79) versus 89%(24/27), p<0.0001]. Breast tumour size was smaller in the true-negative group with an average size of 14.0±9.0mm (versus 19.6±8.6mm, p=0.01). The presence of a higher grade and a multifocal growth pattern were more likely in the false-negative group [40%(32/79) versus 15%(4/27), p=0.03 and 90%(71/79) versus 67%(18/27), p=0.015]. There was no significant difference in age, BMI, subtype, ER, PR, and HER2 status and proliferation index. On multivariate analysis, only the presence of LVI achieved statistical significance [p<0.0001, OR 21.81(CI 95% 5.61–84.83)].

Conclusion:

Our results suggest that patients with false-negative AUS are more likely to have larger (>20mm) multifocal and higher grade (G2-G3) invasive cancers. In this setting, preoperative AUS results should be interpreted cautiously.

Limitations:

Small sample size. Retrospective, single-centre study. Low number of lobular subtype (18%).

Ethics committee approval

n/a

Funding:

No funding was received for this work.

Purpose:

Breast density is an independent risk factor for breast cancer. Mammography is supplemented with hand-held ultrasound (HHUS) to increase sensitivity. Automatic breast ultrasound (ABUS) is an alternative to HHUS. Our study wanted to assess the difference in execution and reading time between ABUS and HHUS.

Methods and materials:

N=221 women were evaluated consecutively between January 2019 and June 2019 (average age 53 years; range 24-89) within a multicentric comparative prospective trial between tomosynthesis and HHUS. The execution and reading time of ABUS and HHUS was calculated with an available stop watch. Time started for both procedures when the patient was ready on the examination table to be examined to the end of image acquisition and interpretation.

Results:

No patients interrupted the exam due to pain or discomfort. N=221 women underwent ABUS and HHUS, n=11 patients refused to undergo both procedures due to time constraints and refused ABUS, therefore 210 patients were enrolled with both ABUS and HHUS available. The average time to perform and read the exam was 5 minutes for HHUS (DS ±1.5) with a maximum time of 11 minutes and a minimum of 2 minutes. The average time with ABUS was 17 minutes (DS ±3.8, with a maximum time of 31 minutes and a minimum time of 9 minutes). The ABUS technique took longer to be performed in all patients, with an average difference of 11 minutes (range 3-23 minutes) per patient, p<0,001.

Conclusion:

A significant difference was observed in the execution and reading time of the two exams, where the US method was more rapid and tolerated.

Limitations:

A potential sources of bias.

Ethics committee approval

The study received IRB approval and informed consent was obtained from all participating patients.

Funding:

No funding was received for this work.

Purpose:

To evaluate the role of ABUS in correlation to CESM in the loco-regional staging of breast cancer.

Methods and materials:

The study is a prospective analysis that included 75 female patients with proved breast cancers. Evaluation was in regard to the size, multiplicity, and the stromal invasion around the tumour. Cases were subjected to automated breast ultrasound and contrast-based mammography, which was performed using low and high exposures following i.v. injection of a contrast agent.

Results:

Eligible cases were 62 in number. CESM and ABUS showed high accuracy of assessment of the tumour multiplicity (82.2%). ABUS showed a higher accuracy of the stromal involvement (93.5%) than CESM (66.1%). There was no significant difference in the size between the pathology and the CESM. The latter showed a percentage of agreement of 38.7%. Yet, there was a statistical significance (p < 0.001) between the ABUS and the pathology in the detection of the size of the tumour.

Conclusion:

ABUS is a non-invasive modality that can be used for the staging of breast cancer. It provided accurate assessment of the stromal involvement and multiplicity of the cancer. CESM outperformed ABUS in the measurement of the size of the index cancer.

Limitations:

Not all cases performed mastectomy, which may affect the study outcome.

Ethics committee approval

The study had an Ethics committe approval and patients gave informed written consent.

Funding:

No funding was received for this work.

Purpose:

To study the influence of breast density on patient's compliance during conventional hand-held breast ultrasound (US) or automated breast ultrasound (ABUS).

Methods and materials:

Between January 2019 and June 2019, n=221 female patients (mean age: 53; age range: 24-89) included in a multicentric prospective comparative trial comparing digital breast tomosynthesis and US underwent both US and ABUS. All participants had independently interpreted US and ABUS regarding patient’s compliance. The diagnostic experience with US or ABUS was described with a modified testing morbidities index (TMI), a validated instrument for assessing the short-term quality of life related to diagnostic testing. The scale ranged from 0 (the worst possible experience) to 5 (an acceptable experience). Pain or discomfort before and during testing, fear or anxiety before and during testing, and embarrassment during testing were recorded. Standard statistics were used to compare data of US and data of ABUS.

Results:

None of the patients interrupted the ABUS exam. The mean TMI score was 4.6 (SD ± 0.5) for US and 4.3 (SD ± 0.8) for ABUS. The overall difference between the patient's experience on US and ABUS was statistically significant with p<0.0001. The difference between the patient's experience in women with BI-RADS 4 for breast density was statistically significant with p<0.02 in favour of US (4.7 ± 0.4) vs 4.5 (SD ± 0.6) for ABUS. Patients' experience with breast density 1 was better for US (4.7 ± 0.4) vs 4.3 (SD ± 0.6) for ABUS, p<0.01. Pain or discomfort during testing was higher in patients >40 years.

Conclusion:

Compliance of ABUS was lower than US, especially in women <40 years. Breast density did not influence the ABUS experience.

Limitations:

A potential sources of bias.

Ethics committee approval

The study received IRB approval.

Funding:

No funding was received for this work.

Purpose:

The non-invasive radiological-imaging differential diagnosis of breast cancer (BC) is still unsatisfactory due to the less specific descriptors and the non-anatomical scanning and interpreting. We aimed to improve sonomorphology for a better differential diagnosis and a better assessment of the initial extension of breast diseases through the new integrative concept of full breast ultrasonography (FBU), represented by the radial ductal scanning, colour Doppler, and strain sonoelastography.

Methods and materials:

We conducted a retrospective study of 1,223 consecutive FBU in 944 patients, referred for screening, diagnostic, or follow-up in two imaging centres with different equipments, and we compared the initial US BI-RADS assessment with the pathological reports or the follow-up exams for the benign findings. Statistical analysis included the evaluation of the sensibility and specificity of the technique and other correlations of the findings.

Results:

The US BI-RADS assessment was in accordance with the pathological reports in 99.2% cases. We found no significant correlation between BC-Density-Age, but significant association of BC + Benign pathology. The benign findings were multiple, combined, and with unpredictable evolution (regression or progression to the atypia or DCIS). The suspect infra-centimetric findings had short-interval follow-up (2-3 months). BC represented unifocal lesion in 60% of cases, multifocal and lobar type in 38% of cases, and multicentric lesions in 2% of cases. The most important descriptor for BC was the incident angle of the plunging artery and, when associated with a score 4 or 5 Ueno, the accuracy was close to 100%.

Conclusion:

FBU offered a new hierarchy of the US descriptors, useful differential diagnosis of breast tumours, and anatomical redefinition of the multifocality and multicentricity of BC, with better initial evaluation of the disease’s extension.

Limitations:

Initial study.

Ethics committee approval

n/a

Funding: