Handheld Ultrasound Research Articles

Comparison and Combination of Two Ultrasound Modalities, Handheld Ultrasound and Automated Breast Volume Scanner, With and Without Knowledge of MRI

Background: When a suspicios breast lesion is found on MRI but is not observed on conventional imaging, targeted ultrasound of the MRI-detected lesion is commonly performed for its detection and characterization. Nonetheless, there are limitations of handheld ultrasound (HHUS). Another ultrasound modality named automated breast volume scanner (ABVS) has achieved automation and high resolution recently. The detection rate and accuracy of conjunctive and disjunctive combination of each ultrasound modality (HHUS and ABVS) have not yet been evaluated. Objectives: To compare the diagnostic performance using HHUS, ABVS, and the combination method for suspicious lesions found on MRI. Patients and Methods: From March to September on 2014, we prospectively enrolled 40 consecutive breast cancer patients who underwent HHUS and ABVS for newly detected suspicious lesions found on MRI. All patients underwent mammography and HHUS before MRI. Whole breast ABVS and another HHUS were performed after MRI. We reviewed the detection rate and diagnostic accuracy of each imaging and analyzed the conjunctive and disjunctive combination results of two ultrasound modalities. We then compared them with or without knowledge of MRI. Results: In 120 suspicious lesions of 40 patients, seventy-six malignant and 44 nonmalignant lesions were included. With knowledge of MRI, cancer detection sensitivities of HHUS, ABVS, conjunctive and disjunctive combination were higher than those without knowledge of MRI (94.7%, 98.7%, 100%, 93.4% vs. 65.8%, 64.5%, 67.1%, 63.2%). In conjunctive combination of HHUS and ABVS, the detection sensitivities were improved in both cases with and without knowledge of MRI. Conclusion: With knowledge of MRI, HHUS and ABVS imaging detected most lesions and the conjunctive combination showed the highest detection sensitivity.

Automated Three-dimensional Breast US for Screening: Technique, Artifacts, and Lesion Characterization.

Automated breast (AB) ultrasonography (US) scanners have recently been brought to market for breast imaging. AB US devices use mechanically driven wide linear-array transducers that can image whole-breast US volumes in three dimensions. AB US is proposed for screening as a supplemental modality to mammography in women with dense breasts and overcomes important limitations of whole-breast US using handheld devices, such as operator dependence and limited reproducibility. A literature review of supplemental whole-breast US for screening was performed, which showed that both AB US and handheld US allow detection of mammographically negative early-stage invasive breast cancers but also increase the false-positive recall rate. Technicians with limited training can perform AB US; nevertheless, there is a learning curve for acquiring optimal images. Proper acquisition technique may allow avoidance of common artifacts that could impair interpretation of AB US results. Regardless, interpretation of AB US results can be challenging. This article reviews the US appearance of common benign and malignant lesions and presents examples of false-positive and false-negative AB US results. In situ breast cancers are rarely detected with supplemental whole-breast US. The most discriminating feature that separates AB US from handheld US is the retraction phenomenon on coronal reformatted images. The retraction phenomenon is rarely seen with benign findings but accompanies almost all breast cancers. In conclusion, women with dense breasts may benefit from supplemental AB US examinations. Understanding the pitfalls in acquisition technique and lesion interpretation, both of which can lead to false-positive recalls, might reduce the potential harm of performing supplemental AB US. Online supplemental material is available for this article. ©RSNA, 2018.

Personal Handheld Ultrasound Devices in the Hands of First Year Medical Students

Ultrasound education continues to be integrated into gross anatomy courses in the United States. The team based design of the anatomy course at Mayo Clinic School of Medicine incorporates team‐based ultrasound oriented activities that are formalized through defined course objectives and assessed in the final examination. Providing personal handheld ultrasound devices to first‐year medical students during the gross anatomy course has been the mainstay of ultrasound education for the past three years. Handheld ultrasound devices have been provided to students for limited periods in some medical schools within the United States, but unique to this curriculum, students are assigned devices that can be utilized outside formal class time. This provides unlimited opportunity to apply their understanding of three‐dimensional, living anatomy, while simultaneously promoting student comfort and engagement with advancing ultrasound technology. Student perception related to the use of ultrasound outside of formal curricular time was evaluated on a five point Likert scale. Both quantitative and qualitative analyses were used to interpret the data obtained from this study. A total of three surveys were sent to medical students over a period of twelve months with an average response rate of 58.9%. Students indicated that (1) ultrasound devices at personal disposal during the anatomy course improved understanding of anatomical structures imaged (mean 3.9, SD=+/− 1.01), (2) the handheld ultrasound device was easy to use (mean 3.9, SD = +/− 0.8), and (3) it would be beneficial if ultrasound was implemented as part of the longitudinal learning experience in medical school (mean 4.1, SD = +/− 0.7). Students were not convinced that (1) having a personal ultrasound device influenced future choice of medical specialty (mean 2.8, SD = +/− 1.0) and (2) the opportunity augmented coursework in the past three months of medical school at time of taking the survey (mean 2.7, SD =+/− 1.25). Results of the study indicated that access to personal handheld devices motivated students to use ultrasound devices and that they did so with increasing frequency outside of class time. In addition, students were able to apply and reinforce anatomical concepts by using landmarks to first locate and orientate the anatomic field and then interpret images of underlying structures. The fact that students did not see the value of ultrasound in determining future career choices or relate their learning of ultrasound to subsequent courses should not deter prospective opportunity for use of ultrasound in clinical practice. Basic ultrasound proficiency and an ability to effectively interpret scans are skills that in the long term will significantly decrease the learning curve in the use of technology as a diagnostic tool in future clinical settings.This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Handheld Ultrasound as a Novel Predictive Tool in Atrial Fibrillation: Prediction of Outcomes Following Electrical Cardioversion.

BackgroundAtrial fibrillation (AF) recurrence after successful direct current cardioversion (CV) is common, and clinical predictors may be useful. We evaluated the risk of early AF recurrence according to inferior vena cava (IVC) measurements by handheld ultrasound (HHU) at the time of CV.ObjectiveAssess HHU and objectively obtained measurements acquired at the point of care as potential clinical predictors of future clinical outcomes in patients with AF undergoing CV.MethodsMaximum IVC diameter (IVCd) and collapsibility with inspiration were measured by the Vscan HHU (General Electric Healthcare Division) in 128 patients immediately before and after successful CV for AF. Patients were followed by chart review for recurrence of AF.ResultsMean IVCd was 2.16 cm in AF pre-CV and 2.01 cm in sinus rhythm post-CV (P<.001). AF recurred within 30 days of CV in 34 of 128 patients (26.6%). Among patients with IVCd <2.1 cm pre-CV and decrease in IVCd post-CV, AF recurrence was 12.1%, compared to 31.6% in patients not meeting these parameters (odds ratio [OR] 0.299, P=.04). This association persisted after adjustment for age, ejection fraction <50%, left atrial enlargement, and amiodarone use (adjusted OR 0.185, P=.01). Among patients with IVCd post-CV <1.7 cm, AF recurrence was 13.5%, compared to 31.9% in patients not meeting this parameter (OR 0.185, P=.01). IVC parameters did not predict AF recurrence at 180 or 365 days.ConclusionsThe presence of a normal IVCd pre-CV that becomes smaller post-CV and the presence of a small IVCd post-CV were each independently associated with reduced likelihood of early, but not late, AF recurrence. HHU assessment of IVCd at the time of CV may be useful to identify patients at low risk of early recurrence of AF after CV.

Handheld ultrasound to avert maternal and neonatal deaths in 2 regions of the Philippines: an iBuntis\xae intervention study

BackgroundThe major causes of maternal and neonatal mortality in the Philippines are hemorrhages and obstructed labor due to placental implantation abnormalities (PIAs), twin pregnancies and fetal malpresentations. All of which are all easily detected by ultrasound. However, women in rural areas and low-income groups do not have access to ultrasound during their prenatal care. We aimed to provide additional evidence on the benefits of handheld ultrasound (HU) for screening pregnancy related abnormalities in order to avert maternal and neonatal deaths.MethodsUsing a HU, we trained community healthcare workers (CHWs) to identify 5 obstetrical conditions: fetal viability and number, placental localization, amniotic fluid volume (AFV) and fetal presentation. Women, between 20th and 24th weeks age of gestation from 2 regions of the Philippines, were scanned using the HU and the GE Logic 5 Premium ultrasound machine for validation. Maternal and neonatal deaths averted were estimated as health outcome measures of the study.ResultsFour hundred sixty women were scanned of which 146 (31.7%) showed abnormal ultrasound readings consisting of 17 PIAs, 123 fetal malpresentation, 3 twins and 3 AFV abnormalities. The use of HU could have possibly averted 29 (6.3%) maternal deaths and 14.6% neonatal deaths at the time of delivery. Thirty-two out of the 460 women (~7%) delivered at home and 93% in hospitals or birthing facilities/lying–in centers. We observed approximately 95% agreement between the ultrasound readings of the trainees and the trainers, and 99% agreement between the readings made from the HU with the validation machine.ConclusionCHWs could be trained in the use of HU for scanning 5 obstetrical parameters. Early detection of abnormalities in these 5 obstetrical parameters can lead to early referral to facilities that are better equipped to manage obstetrical emergencies. Prenatal ultrasound can be an excellent point of care test for screening pregnant women at risk for possible complications and even death during labor and delivery.Trial registrationThai Clinical Trial Registry identification number TCTR20171128004, retrospectively registered November 28, 2017.

Evaluation of an automated breast volume scanner according to the fifth edition of BI-RADS for breast ultrasound compared with hand-held ultrasound

ObjectivesTo investigate the automated breast volume scanner (ABVS) in comparison with hand-held ultrasound (HHUS) according to the fifth edition of BI-RADS ultrasound. Material and methodsA total of 831 lesions in 786 patients who underwent both HHUS and ABVS were included. Three radiologists independently evaluated the sonographic features of each lesion according to the fifth BI-RADS edition. The kappa coefficient (κ) was calculated for each BI-RADS descriptor and final assessment category. The accuracy of malignancy prediction and diagnostic performance of the BI-RADS descriptors were assessed using multivariate logistic regression and area under the receiver operator characteristic curve (AUC), respectively. ResultsABVS and HHUS showed moderate to good interobserver agreement (κ = 0.53–0.67 and 0.55–0.70, respectively) except in associated features (κ = 0.31 and 0.36, respectively) for BI-RADS lexicons. Irregular shape, a non-circumscribed margin, and posterior features (combined or shadowing) were independently associated with malignancy in both ABVS and HHUS. Calcification presence on ABVS (odds ratio [OR], 95% confidence interval [CI]: 2.09, 1.11–3.94) and non-parallel orientation on HHUS (OR, 95% CI: 2.04, 1.10–3.78) were independently associated with malignancy. There were no significant differences between ABVS and HHUS in sensitivity (84.2% vs. 84.2%), specificity (80.5% vs. 83.9%), or AUC (0.88 vs. 0.90). ConclusionsAccording to the fifth BI-RADS edition, ABVS is not statistically significantly different from HHUS with regard to interobserver variability and diagnostic performance.

A multicenter hospital-based diagnosis study of automated breast ultrasound system in detecting breast cancer among Chinese women.

The automated breast ultrasound system (ABUS) is a potential method for breast cancer detection; however, its diagnostic performance remains unclear. We conducted a hospital-based multicenter diagnostic study to evaluate the clinical performance of the ABUS for breast cancer detection by comparing it to handheld ultrasound (HHUS) and mammography (MG). Eligible participants underwent HHUS and ABUS testing; women aged 40-69 years additionally underwent MG. Images were interpreted using the Breast Imaging Reporting and Data System (BI-RADS). Women in the BI-RADS categories 1-2 were considered negative. Women classified as BI-RADS 3 underwent magnetic resonance imaging to distinguish true- and false-negative results. Core aspiration or surgical biopsy was performed in women classified as BI-RADS 4-5, followed by a pathological diagnosis. Kappa values and agreement rates were calculated between ABUS, HHUS and MG. A total of 1,973 women were included in the final analysis. Of these, 1,353 (68.6%) and 620 (31.4%) were classified as BI-RADS categories 1-3 and 4-5, respectively. In the older age group, the agreement rate and Kappa value between the ABUS and HHUS were 94.0% and 0.860 (P<0.001), respectively; they were 89.2% and 0.735 (P<0.001) between the ABUS and MG, respectively. Regarding consistency between imaging and pathology results, 78.6% of women classified as BI-RADS 4-5 based on the ABUS were diagnosed with precancerous lesions or cancer; which was 7.2% higher than that of women based on HHUS. For BI-RADS 1-2, the false-negative rates of the ABUS and HHUS were almost identical and were much lower than those of MG. We observed a good diagnostic reliability for the ABUS. Considering its performance for breast cancer detection in women with high-density breasts and its lower operator dependence, the ABUS is a promising option for breast cancer detection in China.

The Utility of Handheld Ultrasound in the Management of Patients with Congestive Heart Failure

Assessment of the jugular venous pulsation (JVP) is a pivotal component of the clinical evaluation of heart failure patients, as it can be used as a proxy for right atrial pressure. In many patients, JVP assessment is particularly challenging, due to body habitus, anatomical variations, and the presence of tricuspid regurgitation. Use of a point-ofcare handheld ultrasound as an adjunct to the traditional physical exam can provide significant clinical utility in heart failure patients where volume status is uncertain. This paper highlights three clinical cases to support this claim, with accompanying images.

Using Handheld Ultrasound to Reduce Rarely Appropriate Echocardiograms

Using Handheld Ultrasound to Reduce Rarely Appropriate Echocardiograms

Application and Development of Handheld Ultrasound in the Field of Medicine and Healthcare

Application and Development of Handheld Ultrasound in the Field of Medicine and Healthcare

Multimodal ultrasound tomography for breast imaging: a prospective study of clinical feasibility

BackgroundTo describe the clinical set-up and evaluate the feasibility of multimodal ultrasound tomography (MUT) for breast imaging.MethodsThirty-two consecutive patients referred for breast imaging and 24 healthy volunteers underwent MUT. In the 32 patients, the examination discomfort was compared to that of mammography (n = 31), handheld ultrasound (HUS) (n = 27) and magnetic resonance imaging (MRI) (n = 4) on a scale from 1 (lowest discomfort) to 10 (highest discomfort). MUT investigation time was recorded. Findings automatically detected by MUT were correlated with conventional imaging and biopsy results.ResultsBreast MUT was well tolerated by all 56 participants; 55 bilateral exams were uneventful. During one exam, the digitalisation card failed and the exam was successfully repeated within three days. Mean examination discomfort was 1.6 (range = 1–5) for MUT, 1.5 (range = 1–5) for HUS, 5.3 (range = 3–7) for MRI, and 6.3 (range = 1–10) for mammography. MUT examination time was 38 ± 6 min (mean ± standard deviation). In the patients referred for breast imaging, MUT detected four lesions and indicated malignancy in three of these cases. These findings were confirmed by additional imaging and biopsy.ConclusionMUT is feasible in a clinical context considering examination time and patient acceptance. These interesting initial diagnostic findings warrant further studies.

Handheld Ultrasound devices (HHUSD): A short review of the equipment available on the market as of September 2017

Michael Bachmann NielsenDepartment of Radiology, Rigshospitalet,DK 1302 Copenhagen,Denmark mbn@dadlnet.dk

The Use of Handheld Ultrasound in Early Diagnosis and Treatment of Life Threatening Cardiac Condition: A Case Report of Early Diagnosis and Treatment of Cardiac Tamponade

The Use of Handheld Ultrasound in Early Diagnosis and Treatment of Life Threatening Cardiac Condition: A Case Report of Early Diagnosis and Treatment of Cardiac Tamponade

The research of contrast on acceptance of automated breast volume scanner, digital screening mammography and handheld ultrasound

Objective To compare patients′ satisfaction and comfort associated with automated breast volume scanner (ABVS), handheld ultrasound (HHUS) and mammography (MMG). Methods Five hundred and twenty-eight women who performed ABVS examination and previously had undergone MMG and HHUS were enrolled. BMI, bra size, with or without lesion, lesion size, pain score of MMG, ABVS and HHUS were documented and analyzed. Results The pain score of MMG was significantly higher than that of ABVS [4.0 (2.0, 6.0) vs 2.0(1.0, 4.0)] (P<0.05). 92.4% of the cases were preferred for the ABVS examination, which was higher than that for the MMG (45.5%), and was similar to HHUS (94.7%). Bra size, BMI, with or without lesion and lesion size could affect the pain degree of ABVS. Conclusions Routine use of ABVS will be well tolerated by patients than MMG. Key words: Ultrasonography, mammary; Breast diseases; Automated breast volume scanner; X-rays

Can Automated Breast Volume Scanning be an Alternative Tool to Handheld Ultrasonography for Breast Cancer Screening?

BACKGROUND: To assess diagnostic value of automated breast volume scanning(ABVS) versus handheld ultrasonography (HHUS) in breast cancer screening. MATERIALS AND METHODS: All 110 participants received an ABVS examinationcompared with HHUS which was set up as a standard tool. The scans were interpretedby specialists blinded to the results of breast imaging and medical history. CohenKappa value was used to interpret agreement between diagnostic tools. RESULTS: On the basis of the Breast Imaging Reporting and Data System (BI-RADS)classification, of the 110 cases, an agreement was achieved in 102 cases (92.7%).Kappa value (K) was 0.885 representing almost perfect agreement. CONCLUSION: We concluded that ABVS is comparable to HHUS as an adjunctivetool to mammography for screening of breast cancer

Automated breast ultrasound: basic principles and emerging clinical applications.

Automated breast ultrasound (ABUS) is a recently introduced ultrasonography technique, developed with the purpose to standardize breast ultrasonography and overcome some limitations of handheld ultrasound (HHUS), such as operator dependence and the considerable amount of medical time necessary to perform and interpret HHUS. This new ultrasonography technique separates the moment of image acquisition (that may be performed also by a technician) from that of its interpretation, increasing reproducibility, reducing operator-dependence and physician time. Moreover, multiplanar reconstructions, especially the coronal view, introduce new diagnostic information. ABUS, with those advantages, has the potential to be used as an adjunctive tool to screening mammography, especially in the dense breast, where mammography has a relatively low sensitivity. Women's awareness of risks related to breast density is a hot topic, especially in the USA where legislative breast density notification laws increase the demand for supplemental ultrasound screening. Therefore, ABUS might have the potential to respond to this need. The purpose of this article is to present a summary of current state-of-the-art of ABUS technology and applications, with an emphasis on breast cancer screening. This article discusses also how to overcome some ABUS limitations, in order to be familiar with the new technique.

Imaging Performance of a Handheld Ultrasound System With Real-Time Computer-Aided Detection of Lumbar Spine Anatomy: A Feasibility Study.

The aim of this study was to evaluate the imaging performance of a handheld ultrasound system and the accuracy of an automated lumbar spine computer-aided detection (CAD) algorithm in the spines of human subjects. This study was approved by the institutional review board of the University of Virginia. The authors designed a handheld ultrasound system with enhanced bone image quality and fully automated CAD of lumbar spine anatomy. The imaging performance was evaluated by imaging the lumbar spines of 68 volunteers with body mass index between 18.5 and 48 kg/m. The accuracy, sensitivity, and specificity of the lumbar spine CAD algorithm were assessed by comparing the algorithm's results to ground-truth segmentations of neuraxial anatomy provided by radiologists. The lumbar spine CAD algorithm detected the epidural space with a sensitivity of 94.2% (95% confidence interval [CI], 85.1%-98.1%) and a specificity of 85.5% (95% CI, 81.7%-88.6%) and measured its depth with an error of approximately ±0.5 cm compared with measurements obtained manually from the 2-dimensional ultrasound images. The spine midline was detected with a sensitivity of 93.9% (95% CI, 85.8%-97.7%) and specificity of 91.3% (95% CI, 83.6%-96.9%), and its lateral position within the ultrasound image was measured with an error of approximately ±0.3 cm. The bone enhancement imaging mode produced images with 5.1- to 10-fold enhanced bone contrast when compared with a comparable handheld ultrasound imaging system. The results of this study demonstrate the feasibility of CAD for assisting with real-time interpretation of ultrasound images of the lumbar spine at the bedside.

Agreement Between an Automated Volume Breast Scanner and Handheld Ultrasound for Diagnostic Breast Examinations.

To compare the agreement and interobserver variability of diagnostic handheld ultrasound (US) and a single volume on an automated breast volume scanner (ABVS) and to determine whether there was a significant difference if the ABVS was used by a sonographer or mammographic technologist. Ninety patients scheduled for diagnostic US examinations were randomized to either handheld US or the ABVS first. The AVBS was randomized between a sonographer and a mammographic technologist performing the study. The studies were blinded, randomized, and read by 2 radiologists. The lesion with the highest Breast Imaging Reporting and Data System (BI-RADS) score was used in the analysis. Final diagnoses were made by core biopsy or follow-up for 2 years. Lesions included 9 malignant and 81 benign. The 90 patients had a mean age ± SD of 53.1 ± 16.3 years. The κ value for agreement between the ABVS and handheld US was 0.831 (95% confidence interval, 0.744-0.925), whereas the global agreement for a 7-point BI-RADS score was 0.488 (0.372-0.560). The agreement between the ABVS and handheld US was nearly the same when the ABVS was used by a mammographic technologist (κ = 0.858 [0.723-0.963]) or sonographer (κ = 0.803 [0.596-1.000]; P = .47). The areas under the receiver operating characteristic curves for characterization by the ABVS were 0.91 (0.84-0.96) for reader 1 and 0.91 (0.83-0.96) for reader 2; those for handheld US were 0.91 (0.84-0.96) for reader 1 and 0.83 (0.74-0.90) for reader 2, with no statistical difference. The agreement based on pathologic images was κ = 0.831 (0.718-0.944); for handheld US, κ = 0.795 (0.623-0.967); and for the AVBS, κ = 0.869 (0.725-1.000). Performing a single-view diagnostic ABVS examination has good agreement with a handheld diagnostic US workup. There is no difference if the ABVS is used by a sonographer or mammographic technologist.

Diagnostic Performance of Automated Breast Volume Scanning (ABVS) Compared to Handheld Ultrasonography With Breast MRI as the Gold Standard

This study aimed to compare the diagnostic value of automated breast volume scanning (ABVS) to that of handheld ultrasonography (HHUS) using breast magnetic resonance imaging (MRI) as the gold standard. Twenty-eight patients with 39 examined breasts with at least one lesion visible in breast MRI underwent HHUS and ABVS. Detection rate, localization, maximum diameter, and Breast Imaging Reporting and Data System classification were compared. Sensitivity, specificity, diagnostic accuracy, positive predictive value, and negative predictive value were calculated for HHUS and ABVS. Lesion localization and maximum diameters based on HHUS and ABVS were compared to size measurement in MRI. Breast Imaging Reporting and Data System categories based on each method were compared to the MRI diagnosis (malignant or benign) or, if available (21 cases), with the histologic diagnosis. MRI detected 72 lesions, ABVS 59 lesions, and HHUS 54 lesions. Malignancy was proven histopathologically in 15 cases. There was no significant difference between ABVS and HHUS in terms of sensitivity (93.3% vs. 100%), specificity (83.3% vs. 83.3%), diagnostic accuracy (87.2% vs. 89.7%), positive predictive value (77.8% vs. 78.9%), and negative predictive value (95.2% vs. 100%). Agreement regarding lesion localization (same quadrant) was 94.3% for ABVS and MRI and 91.2% for HHUS and MRI. Lesion size compared to MRI lesion size was assessed correctly (+/- 3 mm) in 79.4% (HHUS) and 80% (ABVS). The correlation of size measurement was slightly higher for ABVS-MRI (r = 0.89) than for HHUS-MRI (r = 0.82) with P < .001. ABVS can be used as an alternative to HHUS. ABVS has the advantage of operator independence and better reproducibility although it is limited in evaluating axillary lymph nodes and lacks Doppler or elastrography capabilities, which sometimes provide important supplementary information in HHUS.

Analysis of false-negative readings of automated breast ultrasound studies.

To assess the reasons for false-negative readings of automated breast ultrasound (ABUS) studies. Between 2012 and 2015, 1,890 ABUS studies were performed at our tertiary medical center. Those for which false-negative results were documented in the initial ABUS report against the corresponding hand-held ultrasound (HHUS) scan were reviewed by three specialized breast radiologists. Key images of specific lesions were marked on the ABUS and HHUS scans and compared for quality (equal, better with HHUS, better with ABUS). Readers were also asked to identify the reasons for the differences in image quality between the scans: poor visibility, lesion location, or fibroglandular tissue shadowing. Twenty-two ABUS studies met the study criteria. Two of the three readers found that most lesions were better demonstrated with HHUS. Overall agreement among the readers was moderate (kappa 0.36, SD 0.15, p = 0.002). Highest agreement was found for better image quality for HHUS than ABUS (kappa 0.4, SD 1.3, p = 0.0007). Of the four biopsy-proven carcinomas, three were found by all three readers to be better depicted with HHUS; two were located peripherally and were not seen by ABUS. For all readers, the most common reason for false-negative readings was poor visibility, followed by peripheral lesion location and shadowing obscuring the lesion. Several factors may make reading ABUS images difficult. Resolution can be diminished by imperfect transducer-breast contact, and fibrotic breasts can cause artifacts such as marked shadowing. Peripheral lesions may be missed because of blind spots. Reader training and experience may play an important role in managing these issues. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:245-251, 2017.