The purpose of this study was to assess the reliability of automated breast ultrasound (ABUS) examinations of suspicious breast masses in comparison to handheld breast ultrasound (HHUS) with regard to Breast Imaging Reporting and Data System (BI-RADS) category assessment, and to investigate the factors affecting discrepancies in categorization.
A total of 135 masses that were assessed as BI-RADS categories 4 and 5 on ABUS that underwent ultrasound (US)-guided core needle biopsy from May 2017 to December 2017 were included in this study. The BI-RADS categories were re-assessed using HHUS. Agreement of the BI-RADS categories was evaluated using kappa statistics, and the positive predictive value of each examination was calculated. Logistic regression analysis was performed to identify the mammography and US findings associated with discrepancies in the BI-RADS categorization.
The overall agreement between ABUS and HHUS in all cases was good (79.3%, kappa=0.61, P<0.001). Logistic regression analysis revealed that accompanying suspicious microcalcifications on mammography (odds ratio [OR], 4.63; 95% confidence interval [CI], 1.83 to 11.71; P=0.001) and an irregular shape on US (OR, 5.59; 95% CI, 1.43 to 21.83; P=0.013) were associated with discrepancies in the BI-RADS categorization.
The agreement between ABUS and HHUS examinations in the BI-RADS categorization of suspicious breast masses was good. The presence of suspicious microcalcifications on mammography and an irregular shape on US were factors associated with ABUS yielding a lower level of suspicion than HHUS in terms of the BI-RADS category assessment.
Early detection of breast malignancies significantly improves their clinical outcomes [
However, given that the introduction of ABUS was relatively recent, little is known regarding the clinical application of ABUS assessments of BI-RADS categories solely for solid breast masses, and whether such results are in concordance with those of HHUS. In clinical practice, a precise categorization of suspicious breast masses provides important information for the interpretation of biopsy results in accordance with imaging findings. Discordance in BI-RADS categorization depending on the type of US used could significantly affect the quality of patient care, and potentially lead to delayed cancer diagnoses or unnecessary procedures. In addition, the appropriate use of assessment categories often affects the validity of diagnostic performance audits.
Therefore, we aim to provide data that shed light on this possible issue by comparing diagnostic results obtained using ABUS and HHUS. The purpose of this study was to assess the reliability of ABUS examinations for suspicious breast masses by comparing the resulting BI-RADS category assessments to those made through HHUS examinations, and to investigate the factors affecting discrepancies in categorization.
This retrospective study was approved by the Institutional Review Board. The requirement for informed consent was waived. In our hospital, the breast US protocol had been changed from HHUS to ABUS. All patients were treated with ABUS unless there was a technical problem. A total of 189 masses in 185 patients who underwent ABUS and HHUS at a single large tertiary medical center from May 2017 to December 2017 were retrospectively reviewed. Then, 147 masses in 147 patients that were assessed as BI-RADS categories 4A, 4B, 4C, or 5 and underwent subsequent US-guided core needle biopsy were included in this study. In order to evaluate both mammography and US, we excluded 12 cases in 12 patients who did not also receive mammography. Patients who did not undergo HHUS imaging before a subsequent treatment, such as no further biopsy (n=32), excisional biopsy (n=6), and stereotactic biopsy (n=1), were excluded. Poor-quality ABUS images due to technical problems (n=3) were also excluded. Finally, 135 masses in 135 patients were included in this study.
All ABUS exams were performed using the same ABUS system (Invenia ABUS, Automated Breast Ultrasound System, GE Healthcare, Sunnyvale, CA, USA). The patients were placed in the supine position with a sponge beneath the shoulders to evenly spread the breast tissue during the examination. Three items of volume data were obtained from each breast: the anteroposterior volume, which covered the central part of the breast; the medial volume, which covered the inner and inferior parts; and the lateral volume, which covered the upper and outer parts. The nipple marker was placed according to each patient’s anatomy. In patients with larger breasts, additional views were taken to cover the entire breast tissue. The ABUS examinations were performed by two radiology technologists with extensive US training. The volume images were automatically transferred to a dedicated workstation. During the interpretation, multiplanar images in three different planes (axial, sagittal, and coronal) were used. A slice thickness of 0.5 mm was used to acquire volume data. Two breast radiologists (S.M.K. and M.J.) with 12 and 16 years’ experience in breast imaging, respectively, analyzed the 3D ABUS data on the dedicated ABUS workstation and reported the BI-RADS category assessment [
For suspicious breast masses that were assessed as BI-RADS categories 4 and 5 by ABUS, HHUS was performed prior to US-guided core biopsy. HHUS images were acquired using a linear transducer at 7-15 MHz bandwidth (iU22 Ultrasound System, Phillips Ultrasound, Bothel, WA, USA). All HHUS examinations were performed by two breast radiologists (S.M.K. and M.J.) with 16 and 12 years’ experience in breast imaging, respectively. Findings using the BI-RADS lexicon (i.e., image findings of shape, margin, echogenicity, posterior echogenicity, calcification, orientation, and size of the mass on HHUS) were recorded in the database during the biopsy. Because only suspicious lesions above category 4A were compared, the lesions were not judged as probably benign or benign.
For a comparative analysis, the BI-RADS category as determined by HHUS was re-assessed by two double-blinded radiologists (G.Y. and M.J.) with 4 and 12 years’ experience, respectively. The BI-RADS category assessment based on the HHUS examination was based on the static images taken during the biopsy. The radiologists were blinded to the Doppler and elastography images from the HHUS examination during the evaluation. If the mass required biopsy, it was judged to be category 4 or higher. When mammography was available at the time of interpretation, mammography findings were composited during the BI-RADS category assessment using both ABUS and HHUS. Patients’ medical records were reviewed for information including age, symptoms, mammography findings and density, final BI-RADS assessment categories, and the pathological results of the core needle biopsy or surgical excision. The lesion was categorized as either benign or malignant according to the core needle biopsy result. In cases of core needle biopsy followed by excision, the final result of excision was used as the reference.
The BI-RADS categories as determined by ABUS and HHUS were cross-tabulated. Kappa statistics were used to analyze the the agreement in BI-RADS grading between ABUS and HHUS. Kappa values of <0.20 were considered to indicate slight agreement; 0.21-0.40 fair agreement; 0.41-0.60 moderate agreement; 0.61-0.80 substantial agreement; and 0.81-1.00 excellent agreement [
This study analyzed 135 breast lesions in 135 patients (median age, 49 years; range, 35 to 82 years) who underwent both ABUS and HHUS followed by biopsy. Fifty-eight patients (43.0%) had symptoms (lump or nipple discharge), whereas 77 patients (57.0%) presented without clinical symptoms. The pathological analysis revealed 49 (36.3%) malignant lesions and 86 (63.7%) benign lesions. The average size of the masses was 18.6 mm (range, 4 to 66 mm). The characteristics of the study group are summarized in
The overall agreement between ABUS and HHUS in all cases was 79.3% (kappa=0.61; P<0.001), while the agreement in confirmed malignancies was 55.1% (kappa=0.39, P<0.001).
The PPV of BI-RADS category 4A lesions based on ABUS and HHUS was 15 of 95 (15.79%) and nine of 83 (10.84%), respectively. The PPV of BI-RADS category 4B lesions based on ABUS and HHUS was nine of 15 (60%) and seven of 18 (38.89%), respectively. The PPV of BI-RADS category 4C lesions based on ABUS and HHUS was eight of eight (100%) and 15 of 16 (93.75%), respectively. For BI-RADS category 5 lesions based on ABUS and HHUS, the PPVs were both 100%. The PPVs for each category did not differ significantly between ABUS and HHUS. In the logistic regression analysis of the likelihood of a lower BI-RADS category being assigned based on ABUS than based on HHUS, microcalcifications on mammography (odds ratio [OR], 4.63; 95% confidence interval [CI], 1.83 to 11.71; P=0.001) and an irregular shape on US were found to be statistically significant predictors (OR, 5.59; 95% CI, 1.43 to 21.83; P=0.013) (
In this study, the overall agreement in BI-RADS categorization between ABUS and HHUS was good. The presence of microcalcifications on mammography and an irregular shape on US were associated with a lower BI-RADS category being assigned based on ABUS than based on HHUS. Our study documented good overall interobserver agreement in BI-RADS categorization between ABUS and HHUS. In accordance with this result, a recent prospective study involving 1,886 patients reported excellent overall agreement (99.8%) between HHUS and ABUS, with a kappa value of 0.994 [
To our knowledge, this study is the first to compare the reliability of suspicion of malignancy between HHUS and ABUS in suspicious breast masses. Both ABUS and HHUS are US modalities that provide relatively fast, radiation-free images. Nonetheless, the interpretation of the images acquired using these two different imaging techniques can vary depending on the reader’s experience. An increasing number of studies have attempted to validate the reliability of ABUS, and have reported comparable overall results between ABUS and HHUS [
Our study has several limitations. First, the enrolled study population was restricted to patients who underwent HHUS-guided biopsy after ABUS examinations, with a retrospective selection of cases. Thus, the HHUS interpretations might have been biased in that all cases were first assessed by ABUS and recommended for biopsy. Second, this study included a relatively small sample and might have only represented part of the general population. Third, our study used only static HHUS images, without elastography or Doppler images. In practice, including this additional information in the analysis of HHUS imaging findings is likely to improve the overall diagnostic performance [
In conclusion, BI-RADS categorization showed good agreement between ABUS and HHUS examinations in cases of suspicious breast masses. The presence of suspicious microcalcifications on mammography and an irregular shape on US were factors associated with a lower BI-RADS category being assigned by ABUS than by HHUS. Improved awareness of microcalcifications, which were found to be associated with a lower BI-RADS category being assigned by ABUS, might be beneficial for radiologists by promoting a better understanding of suspicion of malignancy based on imaging findings, with implications for further clinical decision-making.
Conceptualization: Jang M, Yun G. Data acquisition: Jang M, Yun G. Data analysis or interpretation: Jang M, Ahn HS. Drafting of the manuscript: Yun G. Critical revision of the manuscript: Kim SM, Yun BL. Approval of the final version of the manuscript: all authors.
No potential conflict of interest relevant to this article was reported.
A, B. Craniocaudal and mediolateral mammography images indicate grouped fine pleomorphic microcalcifications in the 3H direction of the left breast. C, D. On automated breast ultrasound imaging, a subtle, indistinct, irregular, hypoechoic mass with microcalcifications in the corresponding location was noted, which was classified as Breast Imaging Reporting and Data System category 4B. E. On handheld breast ultrasound imaging, a relatively more prominent, spiculated, irregular, heterogeneous, echoic mass was found in the same location, which was classified as Breast Imaging Reporting and Data System category 5.
Characteristics of the study group
Characteristic | Value |
---|---|
Age (yr) | 49.0±9.7 (35-82) |
Tumor size (mm) | 18.6±11.5 (4-66) |
Clinical findings | |
No symptom | 77 (57.0) |
Lump | 54 (40.0) |
Nipple discharge | 4 (3.0) |
Values are presented as mean±SD (range) or number (%).
Cross-tabulation of Breast Imaging Reporting and Data System categorization by automated versus handheld breast ultrasound
ABUS category | HHUS category |
||||
---|---|---|---|---|---|
4A | 4B | 4C | 5 | Total | |
All cases (n=135) | |||||
4a | 81 | 9 | 4 | 1 | 95 |
4b | 1 | 9 | 4 | 1 | 15 |
4c | 1 | 0 | 4 | 3 | 8 |
5 | 0 | 0 | 4 | 13 | 17 |
Total | 83 | 18 | 16 | 18 | 135 |
Malignancy (n=49) | |||||
4A | 7 | 4 | 3 | 1 | 15 |
4B | 1 | 3 | 4 | 1 | 9 |
4C | 1 | 0 | 4 | 3 | 8 |
5 | 0 | 0 | 4 | 13 | 17 |
Total | 9 | 7 | 15 | 18 | 49 |
ABUS, automated breast ultrasound; HHUS, handheld breast ultrasound.
Odds ratios of mammographic and ultrasonographic findings for a lower Breast Imaging Reporting and Data System categorization being assigned by automated than by handheld breast ultrasound
Total | Lower grade on ABUS, n (%) | Univariable analysis |
Multivariable analysis |
|||
---|---|---|---|---|---|---|
OR (95% CI) | P-value | OR (95% CI) | P-value | |||
Mammographic finding | ||||||
Density | ||||||
B | 23 | 4 (17.4) | 1 | - | ||
C | 68 | 11 (16.2) | 0.87 (0.26-2.89) | 0.816 | - | - |
D | 44 | 8 (18.2) | 1.01 (0.28-3.57) | 0.989 | - | - |
Microcalcifications | ||||||
None | 102 | 11 (10.8) | 1 | - | ||
Present | 33 | 12 (36.4) | 4.63 (1.83-11.71) | 0.001 | - | - |
Ultrasonographic finding | ||||||
Size (cm) | ||||||
<1 | 32 | 5 (15.6) | 1 | - | ||
>1 and ≤2 | 61 | 7 (11.5) | 0.69 (0.21-2.27) | 0.539 | - | - |
>2 and ≤5 | 39 | 11 (28.2) | 2.02 (0.64-6.33) | 0.229 | - | - |
>5 | 3 | 0 | 0.71 (0.03-1.588) | 0.832 | - | - |
Shape | ||||||
Oval, round | 46 | 2 (4.3) | 1 | 1 | ||
Irregular | 89 | 21 (23.6) | 5.59 (1.43-21.83) | 0.013 | 3.75 (0.78-17.97) | 0.099 |
Orientation | ||||||
Parallel | 124 | 20 (16.1) | 1 | - | ||
Nonparallel | 11 | 3 (27.3) | 2.10 (0.55-7.95) | 0.275 | - | - |
Margin | ||||||
Circumscribed | 51 | 5 (9.8) | 1 | - | ||
Irregular | 71 | 14 (19.7) | 2.13 (0.74-6.12) | 0.160 | - | - |
Indistinct | 13 | 4 (30.8) | 4.00 (0.96-16.70) | 0.057 | - | - |
Echo pattern | ||||||
Isoechoic | 16 | 1 (6.3) | 1 | - | ||
Complex solid and cystic | 7 | 2 (28.6) | 4.70 (0.49-44.38) | 0.177 | - | - |
Hypoechoic | 94 | 16 (17.0) | 2.17 (0.37-12.60) | 0.387 | - | - |
Heterogeneous | 18 | 4 (22.2) | 3.21 (0.44-23.27) | 0.249 | - | - |
Posterior echogenicity | ||||||
None | 105 | 18 (17.1) | 1 | - | ||
Enhancement | 16 | 2 (12.5) | 0.82 (0.19-3.42) | 0.780 | - | - |
Shadowing | 11 | 3 (27.3) | 1.95 (0.51-7.45) | 0.330 | - | - |
Combined | 3 | 0 | 0.68 (0.03-13.64) | 0.798 | - | - |
Calcification | ||||||
None | 115 | 14 (12.2) | 1 | 1 | ||
Present | 20 | 9 (45.0) | 5.78 (2.08-16.04) | 0.001 | 5.37 (1.75-16.46) | 0.003 |