Combined Use of Shear Wave Elastography, Microvascular Doppler Ultrasound Technique, and BI-RADS for the Differentiation of Benign and Malignant Breast Masses

Abstract

ObjectiveTo evaluate the value of the combined use of Breast Imaging Reporting and Data System (BI-RADS), qualitative shear wave elastography (SWE), and AngioPLUS microvascular Doppler ultrasound technique (AP) for distinguishing benign and malignant breast masses.Materials and MethodsA total of 210 pathologically confirmed breast lesions in 210 patients were reviewed using BI-RADS, qualitative SWE, and AP. The sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), accuracy, and area under the receiver operating characteristic curve (AUC) of BI-RADS and the combination of qualitative SWE and/or AP with BI-RADS were compared, respectively.ResultsCompared with using BI-RADS alone, the use of combined qualitative SWE and/or AP with BI-RADS had higher AUC values (P < 0.001). Besides this, the combination of qualitative SWE and AP with BI-RADS had the best diagnostic performance for differentiating between benign and malignant masses. When AP and SWE were combined with BI-RADS, 49/76 benign masses were downgraded from BI-RADS category 4a into BI-RADS category 3, while no benign masses were upgraded from BI-RADS category 3 into BI-RADS category 4a. Three sub-centimeter malignant masses were downgraded from BI-RADS category 4a into BI-RADS category 3, while three malignant masses remain in BI-RADS category 3 due to a benign manifestation in both AP and qualitative SWE. Moreover, 5/6 of them were sub-centimeter masses, and 4/6 of them were intraductal carcinoma. The sensitivity, specificity, PPV, NPV, accuracy, and AUC were 91.0%, 81.1%, 69.3%, 95.1%, 84.3%, and 0.861 (95% confidence interval, 0.806–0.916; P < 0.001), respectively. Compared with BI-RADS alone, the sensitivity slightly decreased, while the specificity, PPV, NPV, and accuracy were significantly improved.ConclusionCombination of qualitative SWE and AP with BI-RADS improved the diagnostic performance in differentiating benign from malignant breast lesions, which is helpful for avoiding unnecessary biopsies. However, we should be careful about the downgrading of sub-centimeter BI-RADS 4a category lesions.

Diagnostic value of multimodal ultrasound strategies in the differentiation of non‐mass‐like breast lesions

“…In addition, Wang and coworkers suggested the highest AUC value of 0.861 combined BI-RADS with SWE and AP. 13 The above results were all consistent with our findings of AP + SWE in serial.…”

“…However, the previous study reported that the sensitivity, specificity, PPV, and NPV of performing SWE alone were 83.6%, 79.0%, 65.1%, and 91.1%, respectively. 13 The discrepancies may firstly be due to the different study populations, since the previous work collected mainly ML lesions, while our study emphasized NML lesions. Secondly, the stiffness of ML is considered to be more pronounced than NML due to its relatively clear boundaries and confined range, thus may be the reason to affect the diagnostic performance of SWE.…”

“…Reasons may be because NML lesions were more likely to be associated with ductal carcinoma in situ (DCIS), 3,18,19 and Collins et al 20 direction of blood flow. Due to the prominent characteristic in detecting micro-vessels, 13 AP could elevate the image sensitivity of breast lesions, especially in NML, hence, it has aroused broad attention among researchers. In the present study, the mono-application of AP in diagnosing NML indicated the sensitivity, specificity, PPV, NPV, and accuracy were 87.9%, 74.1%, 80.6%, 83.3%, and 81.7%, respectively.…”

“…Plane‐wave ultra‐sensitive flow imaging (Angio PLUS), or AP technology for short, is a micro‐flow imaging technique that adds a spatial frequency axis to plane‐wave continuous data acquisition, allowing for complete segmentation of blood and tissue movement signals, extraction of very low‐velocity micro‐flow signals, and the ability to differentiate the direction of blood flow. Due to the prominent characteristic in detecting micro‐vessels, 13 AP could elevate the image sensitivity of breast lesions, especially in NML, hence, it has aroused broad attention among researchers. In the present study, the mono‐application of AP in diagnosing NML indicated the sensitivity, specificity, PPV, NPV, and accuracy were 87.9%, 74.1%, 80.6%, 83.3%, and 81.7%, respectively.…”

“…Accordingly, NML lesions could be divided into five different patterns in AP 13 : (1) non‐vascular pattern: no blood vessels detected in the lesion; (2) linear or curvilinear pattern: single or few continuous linear of elongated uncrossed curvilinear vessels in the lesion; (3) tree‐like pattern: uniformly thick and branching vessels, resembling dendrites in the lesion; (4) root hair‐like pattern: twisted and irregular vessels in the lesion, with thickened and distorted vessels (<2) in the peripheral site; (5) crab claw‐like pattern: radiating (thickened and twisted vessels >2) or small burr‐like vessels in the peripheral site. Particularly, patterns 1 to 3 were considered benign, while patterns 4 and 5 were considered malignant.…”