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Real-time Ultrasound Elastography; Does it improve B-Mode Ultrasound Characterization of Solid Breast Lesions? Marwa Adel, MD Misr University for Science and Technology Cairo Scan Elastography is a non-invasive medical imaging technique that detects tumors based on their stiffness (elasticity) An image in which different degrees of stiffness show as different shades of light and dark is called an Elastogram Tissue elasticity imaging is performed with a conventional ultrasound probe does not require additional equipment. at the same time as the B mode image The interpretation criteria in elastography consist of elasticity score strain ratio Elasticity score Malignant Stiffer masses deform less easily dark Benign Softer masses deform more easily light Elasticity score Benign Malignant 1 2 3 4 5 Itoh A, Ueno E et al; Breast Disease; clinical application of US elastography for diagnosis, Radiology ,2006 Strain ratio Calculation of the SR value is based on comparing the average strain lesion a similar area in the adjacent breast tissue. Probability of malignancy INCREASES as the SR value INCREASES Aim of the study to evaluate the sensitivity and specificity of the real-time sonoelastography as compared with B- mode US for distinguishing between benign and malignant solid breast masses taking in consideration Density BI-RADS Biopsy results were the reference standard BI-RADS The Breast Imaging Reporting and Data System was developed through the American College of Radiology or ACR to help standardize feature analysis and final management of mammographic findings. BI-RADS Assessment Categories BIRADS 0 Need Additional Imaging Evaluation BIRADS 1 Negative BIRADS 2 Benign Finding BIRADS 3 Probably Benign Finding – Short Interval Follow-Up Suggested BIRADS 4 Suspicious Abnormality – Biopsy Should Be Considered BIRADS 5 Highly Suggestive of Malignancy – Appropriate Action Should Be Taken BIRADS 6 Known biopsy-proven malignancy, Ultrasound Analysis US criteria used to define a benign solid breast mass oval shape circumscribed margins orientation parallel to the chest wall abrupt interface between the mass and the surrounding tissue hypo- or isoechogenicity increased or unchanged posterior echoes no change in the surrounding tissue Ultrasound Analysis US features that characterize masses as malignant included irregular shape microlobulated or spiculated margins width-to–AP dimension ratio of 1.4 or less. thick echogenic halo microcalcifications in or out of the mass ductal extension. Breast density Mammographies are evaluated for the glandular density according to the American College of Radiology (ACR) classification that identified four major groups for classifying breast density. ACR classification for breast density (1) Predominantly fat (2) Fat with some fibroglandular tissue (3) Heterogeneously dense (4) Extremely dense The lesions were set as (D1) (D2) low density group high density group (ACR 1 & 2) (ACR 3 & 4) MATERIALS AND METHODS 188 patients with 216 lesions; age ranging between 18 and 72. Underwent : Physical examination of both breasts, & relevant history B- mode Ultrasonography using a linear transducer ( frequency 6 to 13 MHz). Elastography In addition, the vascularization of the majority of lesions was determined using color Doppler NB: 147 women underwent mammographic examination. Results Histological diagnosis 216 lesions 123 benign (57%) 93 malignant (43%) Histological diagnosis Pathologic diagnosis No. of cases Percent Malignant lesions 93 43 -Ductal invasive carcinoma 71 32.9 -Lobular invasive carcinoma 13 6 -Mucinous carcinoma 1 0.5 -Tubular carcinoma 2 0.9 -DCIS 6 2.8 Benign lesions 123 57 -Fibroadenoma 101 46.8 - Fat necrosis 9 4.2 - Itraductal papilloma 4 1.9 -Fibrocytic changes 3 1.4 -Atypical hyperplasia 1 0.5 -Intramammary lymph node 2 0.9 -Hamartoma 2 0.9 - Tubular adenoma 1 0.5 Histopathology HISTOPATHOLOGY 140 120 7 100 4 3 US benign Elastography Malignant 80 Num be r of US benign Elastography le s ions 101 benign 60 US Malignant Elastography 86 Malignant 40 20 15 0 Benign Malignant Bar graph demonstrating the distribution of ultrasound and elastographic classifications for malignant and benign lesions. Case Clinical summary:- A 26-year-old woman. Screening study Positive family history fibroadenoma Findings: Elastography score: 2 (benign). SR: 0.83 CASE Clinical Summary: A 34-year-old woman with a right breast palpable lump Fibroadenoma. elastography score 2 strain ratio value of 2.11 CASE Clinical Summary: A 45-year-old lady A right breast palpable lump. ACR 3 BIRADS 3 Biopsy mucinous carcinoma SR of 4.42 BIRADS 4 a Case Clinical summary: A 61-year-old woman Left breast papable mass BIRADS 5 Biopsy invasive duct carcinom Findings: Ultrasound elastography score: 4 Strain ratio :6.05 CASE Clinical Summary: A 47-year-old lady having her Routine Screening Mammogram. Biopsy invasive duct carcinoma. Findings: score 4 SR 5.72 CASE Clinical Summary: A 40 year old woman Bilateral mastalgia. ACR 2 Hamartoma Eastographic score 2 Case Clinical Summary: A 31 year-old- lady doing US follow up for a palpable left retroareolar intraductal solid lesion intraductal papilloma Elastography score 3 (benign) B-mode Elastography Sensitivity 85% 80 % Specificity 94% 97 % +ve predictive value 92.5% 97 % -ve predictive value 88% 82 % Elastography showed less sensitivity higher specificity than conventional sonography in the differentiation of benign from malignant solid lesions Elastography was SUPERIOR to B- mode US in diagnosing solid lesions in the low density group (D1) (96.6% vs. 92.4% specificity) and less in the dense glandular tissue (D2) (97.8% vs. 95.9% specificity. CONCLUSION Real-time sonoelastography is a useful technique for the characterization of benign and malignant solid lesions as it increases the diagnostic specificity comparable to B-Mode Ultrasound, particularly in both ACR 1 and 2, thus reducing the false-positive rate.
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