Characterisation of indeterminate focal breast lesions on grey-scale ultrasound: role of ultrasound elastography.

PURPOSE: This study was undertaken to evaluate the role of ultrasound (US) elastography in characterising focal breast lesions classified as indeterminate on B-mode US. MATERIALS AND METHODS: Eighty-four focal breast lesions, 64 benign and 20 malignant (mean diameter, 15.1 mm), detected but not characterised on B-mode US in 72 women, Breast Imaging Reporting and Data System (BI-RADS) US category 3 (n=56) or category 4 (n=28), were studied with US elastography and classified in consensus by two radiologists according to a five-point colour scale. Sensitivity, specificity and positive and negative predictive values (PPV and NPV) of US elastography compared with conventional US were calculated in relation to microhistology (n=67) and cytology (n=17), which were used as the reference standard. RESULTS: A total of 65/84 (77.4%) lesions were correctly classified as benign or malignant using US elastography, whereas the remaining 19/84 (22.6%) were incorrectly assessed. There were no statistically significant differences between US elastography and B-mode US with regard to sensitivity (70% vs. 68.4%), specificity (79.6% vs. 78.5%), PPV (51.8% vs. 48.1%) and NPV 89% vs. 89.5% (p>0.5). By contrast, a statistically significant difference was noted in the evaluation of BI-RADS 3 lesions, in which US elastography had 50% sensitivity, 86% specificity, 30% PPV and 93.5% NPV compared with BI-RADS 4 lesions (78.6%, 57.1%, 64.7% and 72.7%) (p<0.5). CONCLUSIONS: The high NPV of US elastography may help reduce the use of biopsy in BI-RADS 3 lesions, but its low PPV in BI-RADS 4 lesions does not allow avoidance of biopsy on the basis of the US elastographic score alone in this group of lesions

Usefulness of SonoVue in the identification of sentinel nodes in patients with breast cancer

Purpose Preoperative lymphoscintigraphy, introduced accordingly to sentinel lymph node biopsy (SLNB), is considered the gold standard for accurate axillary lymph node staging for breast cancer [4-9]. The technique, for the low radiation doses used (average absorbed doses of 0.5-1 mGy), is considered the almost devoid of carcinogenic potential. However lymphoscintigraphy has limitations such as the need of specialized medical and technician personnel and having to follow the strict and precise protectionist rules. Lymphatic imaging after intraparenchymal microbubble injection has been reported in animal models, and only few papers report human use. The aim of our study was to investigate the dynamics of intradermal injection of microbubbles as they travel to draining SLNs and to identify and localize SLNs before surgery in patients with breast cancer. Methods and Materials 14 consecutive consenting women (mean age 61 years, range 39-70), with primary breast cancer were subjected to periareolar intradermal injection of of 0.5 ml of SonoVue (Bracco Imaging, Milan, Italy), of the upper outer quadrant for the identification of the sentinel lymph node. A IU 22 scanner (Philips Ultrasound,Bothell,WA,USA), with a 3-9 MHz linear transducer and Pulse-inversion harmonic imaging tool were used to image the progression of CEUS (contrast enhancement ultra sound). After introduction of the contrast agent the patients were monitored ultrasonographically for 120 minutes, performing a dermal massage. Results In all patients were identified lymphatic pathways that were followed only for few centimeters from the injection site of microbubbles. In no patient was identified the sentinel node. Conclusion The echo scintigraphy with SonoVue in our experience does not seem to be a reproducible method for the study of the sentinel lymph node. The few studies in the literature seem to confirm the reduced reliability of the method that needs to be improved

High-frequency ultrasound in the study of male breast palpable masses

Purpose. To evaluate the role of high frequency colour- Doppler ultrasound in the study of diffuse or local breast nodules in males, and compare these results with those of mammography. Materials and methods. We studied 105 men aged between 12 and 82 years (mean age 42.3 years) with a palpable breast mass with or without pain. All patients underwent clinical and ultrasound examination. Seventyeight also underwent mammography, whereas 27 did not because of young age (under 25 years) (n=10), no clinical or sonographic suspicion of a malignant mass (n=16), and ulcerated neoplastic lesion (n=1). The final diagnosis derived from surgery in six patients and from three-year follow-up for 99 patients. Results. Eighty-nine patients had gynecomastia (85%), nine had adipomastia (8%), one had fibrolipoma (1%), five had carcinoma (5%) (invasive ductal carcinoma in four and bifocal ductal carcinoma and lobular carcinoma in one patient) and one had liposarcoma (1%). The clinical examination detected a bilateral (n=66) or unilateral (n=39) breast mass. Ultrasonography provided the correct diagnosis of diffuse nodular pathology in all cases and orientated diagnosis towards malignancy (6 cases) or benignity (1 case) of the lesions. No additional information was obtained from mammography, as compared to high-frequency ultrasonography. The integration of colour-Doppler in the examination was of little use as it demonstrated extensive vascularisation of most (5 cases) of the malignant lesions. Conclusions. Our results indicate that ultrasound allows the detection and characterization of palpable breast masses as well as correct local staging of neoplasms by identifying the degree of infiltration of the surrounding tissues

Computer-aided diagnosis in digital mammography: comparison of two commercial systems

Aim: Within this work, a comparative analysis of two commercial computer-aided detection or diagnosis (CAD) systems, CyclopusCAD® mammo (v. 6.0) produced by CyclopusCAD Ltd (Palermo, Italy) and SecondLook® (v. 6.1C) produced by iCAD Inc. (OH, USA) is performed by evaluating the results of both systems application on an unique set of mammographic digital images routinely acquired in a hospital structure. Materials & methods: The two CAD systems have been separately applied on a sample set of 126 mammographic digital cases, having been independently diagnosed by two senior radiologists. According to the human diagnosis, the cases in the sample reference set are divided into 61 negatives and 65 pathological cases (21 cases displaying both mass lesions and microcalcifications and 44 cases characterized only by mass lesions). The images in the pathological subset contain 123 human diagnosed mass lesions and 37 human diagnosed microcalcifications clusters. In the case of CyclopusCAD, the system offered the possibility to evaluate sensitivity at several threshold levels (working points); five different setting levels (high sensitivity, normal sensitivity, standard, normal specificity and high specificity) have been used. Results: At the standard threshold level, CyclopusCAD exhibits an overall sensitivity of 83.1 versus 66.2% for iCAD (p = 0.04) and an average number of false positives per image (FP/im) of 1.38 against 0.47 for iCAD (p < 0.01). Specifically, for the mass lesions, CyclopusCAD exhibits a sensitivity of 76.9% at a rate of 0.73 FP/im, while iCAD displays a sensitivity of 61.5% at 0.28 FP/im. For the microcalcifications, CyclopusCAD exhibits a sensitivity of 76.2% at a rate of 0.64 FP/image, while iCAD displays a sensitivity of 61.9% at 0.19 FP/im. The reported results have also been expressed in terms of free-response receiver operating characteristic curves, corresponding to five different thresholds in the case of CyclopusCAD and to one single threshold value for iCAD. Conclusion: The overall accuracies of the two systems are fairly comparable up to the uncertainty level of this analysis. CyclopusCAD may reach a higher sensitivity level for both masses and microcalcifications owing to the flexibility in the working point choice, with the price of a major number of FP/im