BI-RADS US Research Articles

Assessment of breast lesions using BI-RADS US lexicon in mammographically dense breasts (ACR categories 3 and 4) with histopathological correlation

PurposeTo assess the role of ultrasonography in detection, and categorization of breast lesions in patients with mammographically dense breasts with the use of the BI-RADS US lexicon. Patients and methodsThis study included 60 female patients (age range from 20 to 80years, mean 38.3±11.9) complaining of mastalgia, breast lump or nipple discharge with mammographically dense breast tissue. Breast ultrasound was performed to all patients with a 12-MHz linear-array transducer. Sonographic findings of the breast lesions were described and categorized according to the BI-RADS US assessment categories. Biopsy procedures were performed for the sonographically detected breast lesions with histopathological examination of the biopsied tissue. ResultsThe main complaint was palpable breast mass encountered in 25 patients, 12 of mastalgia, 4 of nipple discharge, 12 patients were on screening and 7 on follow up. 36 patients were categorized as ACR 3 and 24 ACR 4 regarding the density of their breasts in mammography. Mammography revealed no abnormalities in 31 patients and abnormal in 29 patients, the commonest mammographic finding was breast mass, detected in 19 patients. Ultrasound detected breast lesions in 56 (93.3%) out of 60 patients. BI-RADS US category 2 was the most common category representing 36.7%. Ultrasonography had a diagnostic reliability for differentiating between benign and malignant breast lesions (p=0.869) in mammographically dense breasts while mammography was diagnostically unreliable (p=0.045). ConclusionUltrasound is a mandatory adjunct to mammography in detection and characterization of breast lesions in mammographically dense breasts.

Quantitative Assessment of In Vivo Breast Masses Using Ultrasound Attenuation and Backscatter

Clinical analysis of breast ultrasound imaging is done qualitatively, facilitated with the ultrasound breast imaging-reporting and data system (US BI-RADS) lexicon, which helps to standardize imaging assessments. Two descriptors in that lexicon, "posterior acoustic features" and the "echo pattern" within a mass, are directly related to quantitative ultrasound (QUS) parameters, namely, ultrasound attenuation and the average backscatter coefficient (BSC). The purpose of this study was to quantify ultrasound attenuation and backscatter in breast masses and to investigate these QUS properties as potential differential diagnostic markers. Radio frequency (RF) echo signals were from patients with breast masses during a special ultrasound imaging session prior to core biopsy. Data were also obtained from a well characterized phantom using identical system settings. Masses include 14 fibroadenomas and 10 carcinomas. Attenuation for the acoustic path lying proximal to the tumor was estimated offline using a least squares method with constraints. BSCs were estimated using a reference phantom method (RPM). The attenuation coefficient within each mass was assessed using both the RPM and a hybrid method, and effective scatterer diameters (ESDs) were estimated using a Gaussian form factor model. Attenuation estimates obtained with the RPM were consistent with estimates done using the hybrid method in all cases except for two masses. The mean slope of the attenuation coefficient versus frequency for carcinomas was 20% greater than the mean slope value for the fibroadenomas. The product of the attenuation coefficient and anteroposterior dimension of the mass was computed to estimate the total attenuation for each mass. That value correlated well with the BI-RADS assessment of "posterior acoustic features" judged qualitatively from gray scale images. Nearly all masses were described as "hypoechoic," so no strong statements could be made about the correlation of echo pattern findings in BI-RADS with the averaged BSC values. However, most carcinomas exhibited lower values for the frequency-average BSC than fibroadenomas. The mean ESD alone did not differentiate the mass type, but fibroadenomas had greater variability in ESDs within the ROI than that found for invasive ductal carcinomas. This study demonstrates the potential to use attenuation and QUS parameters associated with the BSC as quantitative descriptors.

Diagnostic Performance of Breast-Specific Gamma Imaging (BSGI) for Breast Cancer: Usefulness of Dual-Phase Imaging with 99mTc-sestamibi

The aim of this study was to investigate the usefulness of breast-specific gamma imaging (BSGI) with dual-phase imaging for increasing diagnostic performance and interpreter confidence. We studied 76 consecutive patients (mean age: 49.3years, range: 33-61years) who received 925MBq (25mCi) (99m)Tc-sestamibi intravenously. Craniocaudal and mediolateral oblique planar images were acquired for all patients. Delayed images were obtained from all patients 1h after tracer injection, except for patients with no definite abnormal uptake. All images were classified into four categories: group 1 (definite negative) = no definite abnormal uptake; group 2 (possible negative) = symmetrically diffuse and amorphous uptake; group 3 (possible positive) = asymmetrically mild and nodular uptake; group 4 (definite positive) = asymmetrically intense and nodular uptake. To evaluate diagnostic performance, the BSGI studies were classified as positive (group 3 or 4) or negative (group 1 or 2) for malignancy according to a visual analysis. The final diagnoses were derived from histopathological confirmation and/or imaging follow-up after at least 6months (range: 6-14months) by both ultrasonography and mammography. The patients' ages ranged from 33 to 61years, with an average of 49.3years. Thirteen patients were diagnosed with malignancy, and 63 patients were diagnosed as negative for malignancy. Using early images, 43 patients were classified as group 1, 12 as group 2, 10 as group 3 and 11 as group 4. Based on early images, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of BSGI were 77%, 83%, 48%, 95% and 82%, respectively. Dual-phase BSGI had a sensitivity, specificity, PPV, NPV and accuracy of 69%, 95%, 75%, 94% and 91%, respectively. The BSGI specificity was significantly higher with dual-phase imaging than with single-phase imaging (p = 0.0078), but the sensitivity did not differ significantly (p = 1.0). Based on dual-phase imaging, the sensitivity, specificity, positive predictive value, negative predictive value and accuracy of BSGI for the evaluation of US BI-RADS 4 lesions were 60%, 86%, 67%, 83% and 78%, respectively. Dual-phase imaging in BSGI showed good diagnostic performance and would be useful for increasing interpreter diagnostic confidence, with higher specificity, positive predictive value and accuracy for breast cancer screening as well as the differential diagnosis of breast disease compared with single-phase imaging.

Lymphocytary Mastopathy in the Absence of Diabetes: A Case Report

INTRODUCTION: The diabetic mastopathy is a rare form of mastitis, characterized by fibrous lesions and inflammatory mammary stroma that simulates the infiltratingcarcinoma in the general Medicine and in the radiology. It is also known as fibrous mastopathy, diabetic mastopathy and sclerosing lymphocytic mastopathy. It occurs more frequently in association with type 1 diabetes of long standing, in patients with type 2 diabetes mellitus who have developed auto-immune diseases and in patients with no associated diseases. In this paper we report a case of a patient with histopathological diagnosis of lymphocytic mastopathy with no association with diabetes mellitus or other pathologies. CASE REPORT: Female patient, 28 years, complaining of pain and lump which appeared suddenly in the right breast. Physical examination revealed a hardened and irregular area with approximately 3, 0 x 2, 0 cm located at a “9 hours” periareolar region. A breast ultrasound was done and it showed BIRADS US 0, due to this a histopathological evaluation was recommended. A magnetic resonance imaging showed a nodular area between the external quadrants of the right breast, measuring about 3. 6 x 3. 2 cm with characteristics of a benign lesion. Then a core-biopsy was carried out and the histopathological diagnosis was fibrosis. Later, after a lumpectomy with an expansion of margins, the histopathological diagnosis was immunohistochemical lymphocytic mastopathy. At present, the patient hasn’t uttered any complaints and is happy with the aesthetic result of the surgery. DISCUSSION: The lymphocytary mastitis is a rare disorder, representing less than 1% of the benign breast lesions, and occurs in up to 13% of diabetic patients. In this case report, however, there is no association with diabetes or auto-immune diseases, thus we emphasize the peculiarity of the case. The histopathological description is characteristicand shows dense stroma fibrosis and periductal and perivascular lymphocytic infiltrate. The differential diagnosis of these lesions is infiltrative breast carcinoma.

Sonographic features of histopathologically benign solid breast lesions that have been classified as BI‐RADS 4 on sonography

To describe the sonographic (US) features associated with ultrasonography BI-RADS category 4 lesions that have a benign histopathological outcome. One hundred seventy-two histopathologically proven benign lesions in 169 patients, which had been classified as BI-RADS category 4 with ultrasonography, were retrospectively evaluated. Ultrasonography and histopathology findings were analyzed. The frequency of sonographic findings according to the histopathological diagnosis was determined. Among the 172 lesions, there were 66 (38%) fibroadenomas, 31 (18%) sclerosing adenoses, 24 (14%) fibrocystic changes, 16 (9%) mastitis/inflammations, 9 (5.5%) intraductal papillomas, 8 (5%) focal fibroses, 4 (2.5%) atypical ductal hyperplasias, 4 (2.5%) fat necroses, 2 (1%) phyllodes tumors, 1 (0.5%) tubular adenomas, 1 (0.5%) epidermal inclusion cysts, and 6 (3.5%) "other benign lesions." The most frequent sonographic findings were heterogeneity, indistinct margin, microlobulation in fibroadenomas; heterogeneity, irregular-indefinite margin, and antiparallel orientation in sclerosing adenosis; heterogeneity, microlobulation, and acoustic shadowing in fibrocystic changes. BI-RADS category 4 lesions demonstrate more than one suspicious ultrasonography feature, and biopsy is necessary to diagnose malignancy captured in 33% of lesions in this study. At this time, any lesion with more than one suspicious BI-RADS US feature cannot avoid a diagnostic biopsy.

Reliability investigation and influential factors analysis of BI-RADS-ultrasound categorization on the benign breast nodules

Objective To evaluate the reliability of benign nodules diagnosed by ultrasound and analyze the probable factors of infecting the BI-RADS ultrasound categorization of breast lesions. Methods A total of 792 cases with initial category 3 assessments on BI-RADS ultrasound categorization consistent with more than 2 years follow-up or pathologic results were contained. The reliability of probable benign lesions were studied retrospectively,and several factors that could influence the categorization were explored such as age,breast lumps size,multiplicity,palpability,and US radiologist's experience referring to ACR-BI-RADS and the new categorizations recommendation. Results Of 792 breast nodules, 781 (98.6%) were benign and 11 (1.4%) were malignant. If the new categorizations recommendation was applied, 35. 1% (278/792) of all cased would have been upgraded to BI-RADS 4,81. 8% (9/11)of malignant tumors would have been found. The breast masses diagnosed by the junior radiologists were more frequently upgraded to BI-RADS 4 than senior radiologists' findings (P <0. 05), the nodules in women 40 years or older and multiple lesions were more frequently upgraded to category 4 (P <0. 01). The presence of palpability and mass size had on significantly influence the BI-RADS US categorization of breast nodules. Conclusions BI-RADS-Ultrasound categorization is relatively reliable to diagnose breast benign nodules. The multiplicity of breast nodules,patient's age and US radiologist's experience were found to have significant influences on the categorizations of probably benign breast nodules. Key words: Ultrasonography; Breast diseases; BI-RADS classification

US-guided diffuse optical tomography for breast lesions: the reliability of clinical experience

To prospectively assess the reliability of US-guided diffuse optical tomography (US-DOT) using interobserver agreement for the diagnosis of breast lesions with individual real-time imaging and to assess the interobserver agreement of conventional sonography (US) combined with US-DOT for differentiation between benignity and malignancy breast lesions. An Institutional Review Board approved this study, and all subjects provided written informed consent. 122 breast lesions in 111 patients evaluated with US-guided core biopsy were included. Assessments with US and US-DOT for cases subjected to biopsy were obtained by two radiologists using individual real-time imaging prior to biopsy and were prospectively recorded by each performer. With DOT, the total haemoglobin concentration (THC) for each breast lesion was measured. Histopathological results from US-guided biopsies were used as a reference standard. To assess measurement interobserver agreement, the intraclass correlation coefficient (ICC) and the Bland-Altman plot were used for THC in US-DOT and the kappa values and ROC analysis were used to evaluate the diagnostic performances of the US BI-RADS final assessment in US and combined US and US-DOT. Of 122 US-guided core biopsied lesions, 83 (68.0%) were diagnosed as benign, and 39 (32.0%) as malignant. Excellent correlation was seen in the THC in US-DOT (ICC score 0.796; 95% confidence interval, 0.708-0.857). The interobserver agreement in BI-RADS final assessment with US and US-DOT (almost perfect; κ = 0.8618) was improved compared with that of US (substantial agreement, κ = 0.6574). However, the overall areas under the ROC curve did not show significant differences between US and combined US and US-DOT, 0.8894 and 0.8975, respectively (P = 0.981). The reliability of THC in US-DOT showed excellent correlation in overall real-time performance. Although the inter-observer agreement for BI-RADS final assessment of US was improved by using US-DOT, the performances of radiologists with respect to the characterization of breast masses as benign or malignant were not significantly improved with US-DOT.

Power Doppler sonography: evaluation of solid breast lesions and correlation with lymph node metastasis

The purpose of this study was to assess the role of power Doppler US in differentiating benign from malignant solid breast masses when used in conjunction with grayscale sonography (US) and the relationship with axillary lymph node metastasis. Grayscale US of 353 solid lesions was categorized using the US BI-RADS final assessment system prospectively. On power Doppler US, the presence of identified or penetrating vessels within the mass was evaluated, respectively. Diagnostic accuracy was calculated at grayscale US with and without power Doppler US. Among malignant cases, tumor vascularity was correlated with lymph node involvement. When the size of the masses was controlled, the identified or penetrating vessels were significantly more frequent in malignant lesions (P<.05). By using the identified and penetrating vessels in the mass as one of the diagnostic criteria for malignancy, the diagnostic accuracy was improved. In 54 infiltrating ductal carcinomas, although lymph node involvement was more frequently seen in the group having identified or penetrating vessels (40 and 35.3%) than in the avascular group (16.7 and 27%), it was not statistically significant (P>.05). We suggest that identified or penetrating vessels within the mass on power Doppler US can be one of the malignant criteria.

Power Doppler sonography: Anything to add to BI-RADS US in solid breast masses?

Objective To evaluate the contribution of power Doppler ultrasonography (PDUS) to breast imaging reporting and data system ultrasonography (BI-RADS US) categorization of solid breast masses. Materials and methods Totally 94 solid lesions with histopathological results in 49 patients were included in the study. US features of the lesions were classified according to American College of Radiologists (ACR) BI-RADS US lexicon. Lesions were evaluated qualitatively according to their PDUS properties and quantitatively with spectral analysis. Hypervascularity, penetration of vessels into the mass or branching-disordered course and resistivity index values higher than 0.85 were accepted as probable malignant criteria. Results Fifty-five of 94 lesions were benign (58.5%), while 39 (41.5%) were malignant histopathologically. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of US and PDUS in the diagnosis of malignant lesions were 100%, 58.2%, 62.9%, 100% and 71.8%, 81.8%, 73.7%, 80.4%, respectively. Criteria used for the distinction of malignant and benign lesions like number of vessels ( p < 0.05), distribution of tumoral vessels, morphology of vessels and resistivity index values higher than 0.85 showed statistically significant difference ( p < 0.001). When sonographic findings were combined with PDUS and spectral analysis findings, sensitivity, specificity, PPV and NPV were 100%, 52.7%, 60% and 100%, respectively. Conclusion PDUS and spectral analysis have no contribution to BI-RADS US. For the spectral analysis, when RI value is one or greater, malignancy risk significantly increases.

3066: Ultrasonographic differentiation of benign and malignant breast mass using ACR Bi-RADS US lexicons

In the evaluation of breast mass, ultrasonography is a valuable adjunctive to mammography in tumor characterization by analysis of shape, orientation, margin, lesion boundary, echo pattern, posterior acoustic features and surrounding tissue. It is important for radiologists to be familiar with these ultrasonographic features of benign and malignant breast mass to improve the sensitivity and specificity of diagnosis. In this exhibit, we will present various ultrasonographic findings of benign and malignant breast mass based on over 1000 histology confirmed cases and by using ACR BI-RADS US lexicons.

2292: Factors affecting the efficacy of mammotome excision for removal of benign breast lesions

Objectives: To assess the performance of Mammotome excision in the percutaneous removal of benign breast masses, and evaluate the factors influencing the rate of residual lesion and complications including hematoma. Methods: We reviewed 263 cases of percutaneous removal of breast mass using large core Mammotome (Ethicon Endo-surgery, Cincinnati, USA). All lesions were US BIRADS 3 category or benign lesion confirmed by previous biopsy. Indications to remove the mass were patient’s anxiety, fear for malignancy, difficulty for following up and so on. We retrospectively analyzed the characteristics of masses removed, presence of any complication, success of complete removal. Results: Pathologic results were mostly benign (98%) but four lesions were malignant or borderline. No clinically significant complication occurred. Imaginary complete removal rate was 95% immediately after procedure and 92% in 6 months follow up sonography. The cases with residual lesions showed larger size, shorter distance from the nipple and larger number of removed mass. Hematomas were more frequently observed in lesions close to the nipple. Conclusions: US-guided percutaneous removal using mammotome was useful method for the treatment of benign breast masses, but we should pay attention to the lesions close to the nipple to prevent hematoma and residual lesions.

2355: Palpable breast lesions: The application of BI-RADS US and reassessment of FNAB

2355: Palpable breast lesions: The application of BI-RADS US and reassessment of FNAB