Around a quarter (25%) of all cancer cases in women are breast cancer, making it the most frequent cancer in the world for women. Prior until recently, cervical cancer was the most frequent cancer among Indian women; however, the primary cause of cancer-related mortality is breast cancer, which is currently more common than cervical cancer. In rural India, cervical cancer is still more prevalent. [1,2] Breast cancer (BC) death and incidence rates adjusted for age are approximately 12.7 and 25.8 per 100,000 persons in India, respectively.[2] Right now, mortality rates are falling despite of rising incidence. Screening, early discovery, and better treatment may have impacted the decline.[3] The majority of female patients, in the imaging department, have a breast deformity that can be felt. The appropriate order and degree of imaging that are needed are still unclear.[4] Breast lumps have a relatively good predictive value for malignancy and are the most prevalent presenting symptom among women with breast cancer.[4] non-lump breast abnormalities such nipple retractions (7%) and breast discomfort (6%) as well as non-breast symptoms like back pain (1%) and weight loss (0.3%) are other less prevalent observations.[5]
Breast Symptomatology: Even with more aggressive treatment, the prognosis is not as excellent as in previous stages when over 50% of women with breast cancer are diagnosed in stages 3 and 4. Diseases may present later than expected for a variety of reasons, including ignorance, financial hardship, or lack of awareness. Early detection and diagnosis of BC are essential since they lower the province's death rate and raise the likelihood that patients will benefit from thorough medical care.[6] Beginning in the middle of the 1990s, developments in imaging technology fundamentally altered how women with detectable breast tumors were assessed. With the development of high-megahertz linear array transducers with improved near-field resolution, compound imaging, and harmonics, ultrasound technology applied to breast imaging significantly improved, resulting in improved characterization of the shape, margins, and internal echotexture of masses.[7] Mammography is necessary for women who have breast masses or lesions, but occasionally, especially in young women, heavy breast tissue limits the sensitivity of the scan. A suitable diagnostic method for identifying breast cancer under these circumstances is ultrasonic mammography. In addition to determining a breast's palpable mass, breast ultrasonography, also known as sonomammography, can remove cysts from solid masses and identify abnormalities in the peripheral view that mammography may miss.[8] The breast-imaging reporting and data system (BI-RADS) lexicon was created by the American College of Radiography as a common nomenclature to compile the results of several breast-imaging procedures, including MRI, USG, and MMG.[9] In our investigation, we also used the BI-RADS lexicon. In many instances, histopathological analysis is still the primary means of distinguishing benign from malignant lesions.[10]
Aims And Objectives
This was a hospital based prospective study conducted among 100 female patients with symptoms affecting the breast who underwent sonomammographic imaging, at Shri B.M Patil Medical College, Hospital and Research Centre, over a period of 2 years from September 2022 to April 2024, after obtaining clearance from institutional ethics committee and written informed consent from the study participants.
Inclusion Criteria: The study included female patients above 15 years of age who presented with breast masses and those willing for follow-up.
Exclusion Criteria
Female patients with breast masses who have: -
Study procedure: We scanned the patients using GE VOLUSON S8 BT18 and GE VERSANA PREMIER machines.
The ipsilateral arm was abducted, the patient was positioned in a contralateral posterior oblique position, and the hand was placed beneath the head to flatten and thin the breast. The degree of posterior obliquity was varied to thin and flatten the portion of the breast undergoing sonographic evaluation. If a breast mass could only be felt when the patient is upright, then we occasionally performed US examination with the patient seated. A 9 MHz linear transducer was employed. We adjusted the depth of the initial US survey of the breast region of interest to allow visualization of the pectoralis muscle at the posterior edge of the field of view. We changed the initial gain settings to depict fat as a mid-level gray at all levels. During real-time scanning, time gain compensation was changed either manually or automatically based on convenience. We considered the background tissue surrounding the lesion to help with precise lesion correlation across several modalities. Similarly, while scanning a palpable abnormality, we paid special attention to the area of clinical concern to guarantee that we scanned the correct location. We touched the palpable anomaly with a finger, and the transducer was positioned immediately over the area. We changed the depth or field of view as necessary once we discovered a lesion or when looking we were looking for a subtle finding. When a mass was identified and the US settings are optimized, US "sweeps" were used to scan the lesion in numerous planes across its whole length. Pictures of the lesion were taken from both the radial and antiradial viewpoints, and they were labeled with the centimeters away from the nipple as well as the "right" or "left" clock face position. Both with and without calipers, photos were taken to enable margin assessment on still images. Three dimensions should be used to evaluate lesion size: the longest horizontal diameter should be reported first, then the anteroposterior diameter, and finally the orthogonal horizontal. Complementary Color and Power Doppler was performed to improve sensitivity in detecting malignant breast lesions. Sufficient care was to taken to eliminate artefacts. By comparing a lesion's strain to that of the surrounding normal tissue, strain ratios were calculated, and strain elastography was done. Elastography and B-mode US characteristics were carefully correlated. The social sciences statistical program (Version 25) was used to do statistical analysis after the obtained data was entered into an Excel sheet from Microsoft. Tables, and percentages were produced using the data distribution. Lastly, the relationship between the histological diagnosis and the SMG was examined using a Chi-square test. A cutoff point of p<0.05 was used for significance.
Statistical Methods
Data was entered in MS Excel and analyzed using SPSS software. Results were resented as tables.
|
Age |
Benign (HPR) |
Malignant (HPR) |
Total |
|
< 20 |
5 |
0 |
5 |
|
(%) |
6.1% |
0.0% |
4.2% |
|
20 - 29 |
30 |
2 |
32 |
|
(%) |
36.6% |
5.5% |
27.1% |
|
30 - 39 |
26 |
1 |
27 |
|
(%) |
31.7% |
2.8% |
22.9% |
|
40 - 49 |
15 |
6 |
21 |
|
(%) |
18.3% |
16.7% |
17.8% |
|
50 - 59 |
5 |
9 |
14 |
|
(%) |
6.1% |
25% |
11.9% |
|
60 - 69 |
1 |
10 |
11 |
|
(%) |
1.2% |
27.8% |
9.3% |
|
70+ |
0 |
8 |
8 |
|
(%) |
0.0% |
22.2% |
6.8% |
|
Total |
82 |
36 |
118 |
|
(%) |
100.0% |
100.0% |
100.0% |
|
P value = 0.000 (<0.005)* Age with HPR Findings – Correlation |
|||
|
|
Benign (HPR) |
Malignant (HPR) |
Total |
|
< 12.00 |
72 |
7 |
79 |
|
(%) |
87.8% |
19.4% |
66.9% |
|
12.00 - 23.99 |
6 |
10 |
16 |
|
(%) |
7.3% |
27.8% |
13.6% |
|
24.00 - 35.99 |
2 |
8 |
10 |
|
(%) |
2.4% |
22.2% |
8.5% |
|
36.00 - 47.99 |
1 |
6 |
7 |
|
(%) |
1.2% |
16.7% |
5.9% |
|
48.00 - 59.99 |
1 |
4 |
5 |
|
(%) |
1.2% |
11.1% |
4.2% |
|
60.00+ |
0 |
1 |
1 |
|
(%) |
0.0% |
2.8% |
0.8% |
|
Total |
82 |
36 |
118 |
|
(%) |
100.0% |
100.0% |
100.0% |
|
P value = 0.000 (<0.005)* Duration of Symptoms with HPR Findings - Correlation |
|||
|
Table 1 |
|||
|
|
Benign (HPR) |
Malignant (HPR) |
Total |
||
|
Irregular |
10 |
31 |
41 |
||
|
(%) |
12.2% |
86.1% |
34.7% |
||
|
Oval |
62 |
1 |
63 |
||
|
(%) |
75.6% |
2.8% |
53.4% |
||
|
Round |
10 |
4 |
14 |
||
|
(%) |
12.2% |
11.1% |
11.9% |
||
|
Total |
82 |
36 |
118 |
||
|
(%) |
100.0% |
100.0% |
100.0% |
||
|
P value = 0.000 (<0.005)* Shape with HPR Findings - Correlation |
|||||
|
|
Benign (HPR) |
Malignant (HPR) |
Total |
||
|
Circumscribed |
69 |
6 |
75 |
||
|
(%) |
84.1% |
16.7% |
63.6% |
||
|
Indistinct |
12 |
6 |
18 |
||
|
(%) |
14.6% |
16.7% |
15.3% |
||
|
Microlobulated |
0 |
7 |
7 |
||
|
(%) |
0.0% |
19.4% |
5.9% |
||
|
Spiculated |
1 |
9 |
10 |
||
|
(%) |
1.2% |
25.0% |
8.5% |
||
|
Angular |
0 |
8 |
8 |
||
|
(%) |
0.0% |
22.2% |
6.8% |
||
|
Total |
82 |
36 |
118 |
||
|
(%) |
100.0% |
100.0% |
100.0% |
||
|
P value = 0.000 (<0.005)* Margin with HPR Findings - Correlation |
|||||
|
Table 2 |
|||||
|
|
Benign (HPR) |
Malignant (HPR) |
Total |
|
Not parallel |
6 |
27 |
33 |
|
(%) |
7.3% |
75.0% |
28.0% |
|
Parallel |
76 |
9 |
85 |
|
(%) |
92.7% |
25.0% |
72.0% |
|
Total |
82 |
36 |
118 |
|
(%) |
100.0% |
100.0% |
100.0% |
|
P value = 0.000 (<0.005)* Orientation with HPR Findings - Correlation |
|||
|
|
Benign (HPR) |
Malignant (HPR) |
Total |
|
Combined |
9 |
1 |
10 |
|
(%) |
11.0% |
2.8% |
8.5% |
|
Enhancement |
30 |
9 |
39 |
|
(%) |
36.6% |
25.0% |
33.1% |
|
None |
40 |
11 |
51 |
|
(%) |
48.8% |
30.6% |
43.2% |
|
Shadowing |
3 |
15 |
18 |
|
(%) |
3.7% |
41.7% |
15.3% |
|
Total |
82 |
36 |
118 |
|
(%) |
100.0% |
100.0% |
100.0% |
|
P value = 0.000 (<0.005)* Posterior Acoustic Features with HPR Findings - Correlation |
|||
|
|
Benign (HPR) |
Malignant (HPR) |
Total |
|
In mass |
11 |
14 |
25 |
|
(%) |
13.4% |
38.9% |
21.2% |
|
Intraductal |
0 |
2 |
2 |
|
(%) |
0.0% |
5.6% |
1.7% |
|
None |
70 |
20 |
90 |
|
(%) |
85.4% |
55.6% |
76.3% |
|
Outside Mass |
1 |
0 |
1 |
|
(%) |
1.2% |
0.0% |
0.8% |
|
Total |
82 |
36 |
118 |
|
(%) |
100.0% |
100.0% |
100.0% |
|
P value = 0.001 (<0.005)* Calcifications with HPR Findings - Correlation |
|||
|
Table 3 |
|||
|
|
Benign (HPR) |
Malignant (HPR) |
Total |
|
Absent |
65 |
2 |
67 |
|
(%) |
79.3% |
5.6% |
56.8% |
|
Internal Vascularity |
11 |
34 |
45 |
|
(%) |
13.4% |
94.4% |
38.1% |
|
Vessels in Rim |
6 |
0 |
6 |
|
(%) |
7.3% |
0.0% |
5.1% |
|
Total |
82 |
36 |
118 |
|
(%) |
100.0% |
100.0% |
100.0% |
|
P value = 0.000 (<0.005)* Vascularity with HPR Findings - Correlation |
|||
|
|
Benign (HPR) |
Malignant (HPR) |
Total |
|
Hard |
2 |
24 |
26 |
|
(%) |
2.4% |
66.7% |
22.0% |
|
Intermediate |
7 |
11 |
18 |
|
(%) |
8.5% |
30.6% |
15.3% |
|
Soft |
73 |
1 |
74 |
|
(%) |
89.0% |
2.8% |
62.7% |
|
Total |
82 |
36 |
118 |
|
(%) |
100.0% |
100.0% |
100.0% |
|
P value = 0.000 (<0.005)* Elasticity with HPR Findings - Correlation |
|||
|
Region |
Benign (HPR) |
Malignant (HPR) |
Total |
|
Axillary |
7 |
16 |
23 |
|
(%) |
8.5% |
44.4% |
19.5% |
|
None |
75 |
20 |
95 |
|
(%) |
91.5% |
55.6% |
80.5% |
|
Total |
82 |
36 |
118 |
|
(%) |
100.0% |
100.0% |
100.0% |
|
P value = 0.000 (<0.005)*, Lymph Nodal Involvement with HPR Findings - Correlation |
|||
|
Table 4 |
|||
|
SMG Findings |
Benign (HPR) |
Malignant (HPR) |
Total |
|
Benign (SMG) |
80 |
0 |
80 |
|
(%) |
97.6 |
0.0 |
67.8% |
|
Malignant (SMG) |
2 |
36 |
38 |
|
(%) |
2.4 |
100 |
32.2% |
|
Total |
82 |
36 |
118 |
|
(%) |
100.0% |
100.0% |
100.0% |
|
P value = 0.000 (<0.005)*, SMG findings with HPR findings - Correlation |
|||
|
BIRADS |
Benign (HPR) |
Malignant (HPR) |
Total |
|
BIRADS 2 |
53 |
0 |
53 |
|
(%) |
64.6% |
0.0% |
44.9% |
|
BIRADS 3 |
10 |
0 |
10 |
|
(%) |
12.2% |
0.0% |
8.5% |
|
BIRADS 4a |
16 |
2 |
18 |
|
(%) |
19.5% |
5.6% |
15.3% |
|
BIRADS 4b |
2 |
5 |
7 |
|
(%) |
2.4% |
13.9% |
5.9% |
|
BIRADS 4c |
0 |
3 |
3 |
|
(%) |
0.0% |
8.3% |
2.5% |
|
BIRADS 5 |
1 |
24 |
25 |
|
(%) |
1.2% |
66.7% |
21.2% |
|
BIRADS 6 |
0 |
2 |
2 |
|
(%) |
0.0% |
5.6% |
1.7% |
|
Total |
82 |
36 |
118 |
|
(%) |
100.0% |
100.0% |
100.0% |
|
P value = 0.000 (<0.005)* ACR US - BIRADS with HPR findings - Correlation |
|||
|
Table 5 |
|||
SMG revealed a heterogenous breast composition with an oval-shaped, circumscribed, heterogenous lesion in parallel orientation, showing no significant posterior acoustic features in the 1 o’clock position of the right breast measuring about 1.4 x 1.6 x 0.8 cm. Adjacent duct ectasia was noted. The lesion showed no significant vascularity on Color Doppler Interrogation and was graded as soft on strain elastography. There was no evidence of calcifications, architectural distortion, skin changes or edema.
A diagnosis of an ACR BIRADS 2 lesion with features favoring a Fibroadenoma was made.
Histopathology returned a positive result for Fibroadenoma.
Image 2
SMG revealed a homogenous - fibroglandular breast composition with a large irregular-shaped, microlobulated, hypoechoic lesion in a not parallel orientation, showing posterior acoustic enhancement and architectural distortion measuring about 3.2 x 3 x 3.2 cm in the 8 to 10 o’clock position of the right breast. The lesion showed internal vascularity on Color Doppler Interrogation and were graded as intermediate on strain elastography. There was no evidence of skin changes, duct changes or edema.
A diagnosis of an ACR BIRADS 5 lesion with features favoring Breast Carcinoma was made.
Histopathology returned a positive result for Mucinous Breast Carcinoma Type B.
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