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Significant Differentiation of Focal Breast Lesions

Posted Apr 30, 2010 Updated Apr 7, 2023
By Anke Thomas MD , Friedrich Degenhardt Prof , André Farrokh MD , Sebastian Wojcinski MD , Torsten Slowinski MD , Thomas Fischer MD
8 min read

Rationale and Objectives

Initial data suggest that elastography can improve the specificity of ultrasound in differentiating benign and malignant breast lesions. The aim of this study was to compare elastography and B-mode ultrasound to determine whether the calculation of strain ratios (SRs) can further improve the differentiation of focal breast lesions.

Materials and Methods

A total of 227 women with histologically proven focal breast lesions (113 benign, 114 malignant) were included at two German breast centers. The women underwent a standardized ultrasound procedure using a high-end ultrasound system with a 9-MHz broadband linear transducer. B-mode scans and sonoelastograms were analyzed by two experienced readers using the Breast Imaging Reporting and Data System criteria. SRs were calculated from a tumor-adjusted region of interest (mean color pixel density) and a comparable region of interest placed in the lateral fatty tissue. Sensitivity, specificity, and cutoff values were calculated for SRs (receiver-operating characteristic analysis).

Results

The women had a mean age of 54 years (range, 19–87 years). The mean lesion diameter was 1.6 ± 0.9 cm. Sensitivity and specificity were 96% and 56% for B-mode scanning, 81% and 89% for elastography, and 90% and 89% for SRs. An SR cutoff value of 2.45 (area under the curve, 0.949) allowed significant differentiation ( P < .001) of malignant (mean, 5.1 ± 4.2) and benign (mean, 1.6 ± 1.0) lesions. The quantitative method of SR calculation was superior to subjective interpretation of sonoelastograms and B-mode scans, with a positive predictive value of 89% compared to 68% and 84% for the other two methods.

Conclusions

Calculation of SRs contributes to the standardization of sonoelastography with high sensitivity and allows significant differentiation of benign and malignant breast lesions with higher specificity compared to B-mode ultrasound but not elastography.

Elasticity is an important property of biologic tissues that changes with age and in the presence of pathology. It is defined as the elongation (stretching) of tissue under strain. Elasticity therefore is a measure of the amount of pressure that needs to be applied to induce elastic deformation of the tissue . Tissue elasticity can be visualized by sonoelastography, an imaging modality based on the analysis of ultrasound information . Numerous studies have recently shown that information on tissue elasticity has clinical benefit in the diagnostic evaluation of different organ systems . Several investigators have shown that elastography can improve specificity in characterizing focal breast lesions . Elastography is the visualization of tissue properties traditionally evaluated by palpation, which is an established clinical technique to characterize focal breast lesions. Studies investigating breast sonoelastography have focused on lesions that are notoriously difficult to characterize, namely, Breast Imaging Reporting and Data System (BI-RADS) category 3 and 4 lesions and lesions occurring in the presence of lipomatous involution. If sonoelastography can identify true benign lesions in women with indeterminate lesions on the basis of other diagnostic modalities, this new technique might in the future obviate the need for histologic confirmation in these cases .

Sonoelastographic information can be obtained by real-time scanning or by offline analysis . In so-called strain imaging, the change in tissue elasticity under compression is calculated, and the information is color coded and superimposed on B-mode images. This method is limited by a lack of standardization. Elastic properties can be described quantitatively by calculating strain ratios (SR). We therefore conducted a prospective study to investigate whether the calculation of SRs can also improve the differentiation of focal breast lesions. This was done by comparing SRs with B-mode ultrasound and conventional sonoelastography.

Materials and methods

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Ultrasound Examination

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Figure 1, Diagram of the two regions of interest (ROIs) for strain ratio (SR) calculation.

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Evaluation of Ultrasound Scans

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Image Analysis

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Figure 2, Box plots of strain ratios (SRs) for benign and malignant focal breast lesions. A cutoff value of 2.455 allowed significant ( P < .001) differentiation of malignant and benign focal lesions. Scars were the only lesions that could not be differentiated on the basis of SRs.

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Histology

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Statistical Analysis

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Results

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Table 1

Histologic Diagnoses of 227 Benign and Malignant Breast Lesions

Benign Lesions ( n = 113) Malignant Lesions ( n = 114) Fibroadenoma 64 Invasive ductal cancer 84 Mastopathy 15 Invasive lobular cancer 19 Scar 5 Other malignant lesions 11 Other benign lesions 29

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Figure 3, Representative image of a fibroadenoma. The dual-mode scan shows moderately soft tissue (green) . The lesion was assigned an elastography score of 2, and a low strain ratio of 1.44 was calculated.

Figure 4, Typical elastogram of invasive ductal cancer. The lesion was hard (blue) compared to surrounding tissue. A high strain ratio of 6.5 was calculated.

Figure 5, Elastogram of invasive lobular cancer (left) shows the lesion to be composed of softer tissue (blue and green) compared to invasive ductal cancer ( Fig 4 ). The strain ratio was likewise increased (3.26).

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Table 2

Sensitivity, Specificity, and Positive Predictive Value of the Three Methods Compared

Parameter B-Mode Scan Elastography Strain Ratio Sensitivity 96% 81% 90% Specificity 56% 89% 89% Positive predictive value 68% 84% 89%

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Figure 6, Receiver-operating characteristic analysis for a strain ratio cutoff of 2.455 with areas under the curves of 0.929 for center A and 0.962 for center B; the weighted κ value was 0.474 (measure of agreement).

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Discussion

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Limitations

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Academic Radiology, Volume 17, Issue 5
Journals General Radiology
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