Significant Differentiation of Focal Breast Lesions: Calculation of Strain Ratio in Breast Sonoelastography

doi:10.1016/j.acra.2009.12.006

Academic Radiology

Volume 17, Issue 5, May 2010, Pages 558-563

https://doi.org/10.1016/j.acra.2009.12.006 Get rights and content

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.

Section snippets

Materials and methods

A total of 227 consecutive patients with breast tumors on palpation, ultrasound, and/or mammography who presented to the special outpatient service of two German breast centers certified according to the guidelines of the German Cancer Society and the German Society of Senology were included in this prospective study between January and August 2008 (113 at center A and 114 at center B). Breast lesions were histologically confirmed in all patients. The women recruited at both centers had a mean

Results

All 227 specimens obtained were adequate for histologic examination; 113 benign and 114 malignant focal breast lesions were diagnosed. The histologic diagnoses are summarized in Table 1.

The mean ages were 42.9 ± 16.0 years for patients with benign breast lesions and 62.7 ± 13.3 years for those with malignant lesions; the difference was not significant (P > .05).

The mean lesion diameter was 1.6 ± 0.9 cm. The focal lesions were <2 cm in size in 54% of the patients and were located at depths of up

Discussion

This is the first study of sonoelastography of the breast using semiquantitative analysis of SRs. Earlier studies of tissue elasticity relied on complicated experimental setups, which are not feasible in the routine clinical setting 18, 19, 20. Our group also performed the first study showing that B-mode scanning and sonoelastography can be performed in the same session (7). This new approach was evaluated in >400 patients undergoing routine diagnostic assessments of breast lesions (8). Our

References (25)

E. Konofagou et al.
A new elastographic method for estimation and imaging of lateral displacements, lateral strains, corrected axial strains and Poisson's ratios in tissues
Ultrasound Med Biol
(1998)
E.B. Mendelson et al.
Toward a standardized breast ultrasound lexicon, BI-RADS
ultrasound. Semin Roentgenol
(2001)
A. Thomas et al.
Real-time sonoelastography of the cervix: tissue elasticity of the normal and abnormal cervix
Acad Radiol
(2007)
A. Thomas et al.
Real-time sonoelastography performed in addition to B-mode ultrasound and mammography: improved differentiation of breast lesions?
Acad Radiol
(2006)
Q. Zhu et al.
Real-time ultrasound elastography: its potential role in assessment of breast lesions
Ultrasound Med Biol
(2008)
A. Thomas et al.
Tissue Doppler and strain imaging for evaluating tissue elasticity of breast lesions
Acad Radiol
(2007)
J. Bercoff et al.
In vivo breast tumor detection using transient elastography
Ultrasound Med Biol
(2003)
I. Cespedes et al.
Elastography: elasticity imaging using ultrasound with application to muscle and breast in vivo
Ultrason Imaging
(1993)
K.M. Hiltawsky et al.
Freehand ultrasound elastography of breast lesions: clinical results
Ultrasound Med Biol
(2001)
A. Tardivon et al.
Elastography of the breast: a prospective study of 122 lesions
J Radiol
(2007)

S.M. Tan et al.

Improving B mode ultrasound evaluation of breast lesions with real time ultrasound elastography—a clinical approach

Breast

(2008)

T.A. Krouskop et al.

Elastic moduli of breast and prostate tissues under compression

Ultrason Imaging

(1998)

Cited by (165)

Automated 3-D Ultrasound Elastography of the Breast: An In Vivo Validation Study
2024, Ultrasound in Medicine and Biology
Studies have indicated that adding 2-D quasi-static elastography to B-mode ultrasound imaging improved the specificity for malignant lesion detection, as malignant lesions are often stiffer (increased strain ratio) compared with benign lesions. This method is limited by its user dependency and so unsuitable for breast screening. To overcome this limitation, we implemented quasi-static elastography in an automated breast volume scanner (ABVS), which is an operator-independent 3-D ultrasound system and is especially useful for screening women with dense breasts. The study aim was to investigate if 3-D quasi-static elastography implemented in a clinically used ABVS can discriminate between benign and malignant breast lesions.
Volumetric breast ultrasound radiofrequency data sets of 82 patients were acquired before and after automated transducer lifting. Lesions were annotated and strain was calculated using an in-house-developed strain algorithm. Two strain ratio types were calculated per lesion: using axial and maximal principal strain (i.e., strain in dominant direction).
Forty-four lesions were detected: 9 carcinomas, 23 cysts and 12 other benign lesions. A significant difference was found between malignant (median: 1.7, range: [1.0–3.2]) and benign (1.0, [0.6–1.9]) using maximal principal strain ratios. Axial strain ratio did not reveal a significant difference between benign (0.6, [–12.7 to 4.9]) and malignant lesions (0.8, [–3.5 to 5.1]).
Three-dimensional strain imaging was successfully implemented on a clinically used ABVS to obtain, visualize and analyze in vivo strain images in three dimensions. Results revealed that maximal principal strain ratios are significantly increased in malignant compared with benign lesions.
Value of Ultrasonic Elastography and Conventional Ultrasonography in the Differential Diagnosis of Non-Mass-like Breast Lesions
2019, Ultrasound in Medicine and Biology
The purpose of this study was to evaluate the diagnostic value of ultrasonic elastography (UE) and conventional ultrasonography (CUS) in the differential diagnosis of non-mass-like (NML) breast lesions. Static sonograms of 39 pathologically diagnosed NML breast lesions were reviewed. Lesions were evaluated by CUS and UE using CUS subjective ratings (benign, malignant or indeterminate), a 5-point subjective elasticity scoring system and the quantitative strain ratio (SR). Receiver operating characteristic curves and diagnostic tests were used to assess the diagnostic value of CUS and UE. Areas under the receiver operating characteristic curves (Az) of the CUS, 5-point elasticity and SR methods were 0.848 (p < 0.001), 0.895 (p < 0.001) and 0.943 (p < 0.001), respectively. In diagnosing NML breast lesions, there was no significant difference between the 5-point elasticity and CUS methods. The combination of UE and CUS helps to improve the accuracy of the ultrasonic diagnosis of NML breast lesions.
Sonoelastography of retroareolar carcinomas
2019, Journal of Gynecology Obstetrics and Human Reproduction
To review the sonographic and elastographic features of retroareolar carcinomas.
Institutional review board approval was obtained. Among 967 sonographically guided biopsies (2013–2014) (14-gauge cores), 53 yielded the diagnosis of retroareolar carcinoma (located less than 2 cm from the nipple on mammograms). Out of these 53 lesions, 30 were assessed additionally with strain elastography prior to the biopsy in addition to conventional sonographic analysis. Imaging features were analyzed in consensus by two radiologists. Elasticity score was evaluated by the score defined by Itoh (Tsukuba score). Descriptive analysis was performed.
A total of 30 lesions were included (30 patients; mean age, 66.03 (±12.88)). The mean size of the lesions at diagnosis was 23.97 mm (±13.64). Sonographically, most of lesions appeared as hypoechoic masses (96.5%, 28/29) displaying an irregular shape (75.9%, 22/29), non parallel orientation (58.6%, 17/29), non circumscribed margins (86.2%, 25/29), posterior attenuation (93.3%, 28/29). Among the 30 lesions, 3.3% (1/30) of lesions appeared as an attenuation and distortion without discrete mass. Most of the lesions were categorized as BI-RADS category 5 (76.7%, 23/30). Approximately half of lesions (53.3%, 16/30) appeared as firm and larger than 2D mode with strain elastography according to the Tsukuba score.
Retroareolar carcinoma displayed malignant features at US and elastographic examination. In our study population, the addition of elastography to breast US in this location did not improve diagnostic accuracy.
Ultrasound elastography
2019, Encyclopedia of Biomedical Engineering
Ultrasound elastography is a modern ultrasound imaging technology, which enables the evaluation of the health of organs and tissues with their elastic property, stiffness. Based on old-fashioned “palpation principle,” elastography applies slight compressive force on the examined organ with the ultrasound transducer, and then the ultrasound signals emitted from the transducer are reflected by the organ, which are received by the transducer as RF echo signals or B-mode images. By processing the received signals, the degree of deformation, called strain, inside the organ can be estimated, which is represented with color-coded maps, called elastograms. Strains in elastograms are varied depending on the stiffness of the tissue within the organ. Since malignant lesions are usually much stiffer than benign tissues, ultrasound devices equipped with elastography option enable the evaluation of the nature of lesions situated at small depth, for example, breast, thyroid, testicles, prostate, and some groups of lymph nodes. They can increase the accuracy of ultrasound in diagnostics and the evaluation of the malignancy of the lesions, which also helps to indicate more precisely the areas that require the biopsy.
Elastography in thyroid nodules
2023, Laryngo- Rhino- Otologie
Imaging studies in idiopathic granulomatous mastitis
2023, Idiopathic Granulomatous Mastitis

View all citing articles on Scopus

View full text

Original investigationSignificant Differentiation of Focal Breast Lesions: Calculation of Strain Ratio in Breast Sonoelastography

Rationale and Objectives

Materials and Methods

Results

Conclusions

Section snippets

Materials and methods

Results

Discussion

Ultrasound Med Biol

ultrasound. Semin Roentgenol

Acad Radiol

Acad Radiol

Ultrasound Med Biol

Acad Radiol

Ultrasound Med Biol

Ultrason Imaging

Ultrasound Med Biol

J Radiol

Breast

Elastic moduli of breast and prostate tissues under compression

Ultrason Imaging

Original investigation
Significant Differentiation of Focal Breast Lesions: Calculation of Strain Ratio in Breast Sonoelastography