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DIFFERNCES BETWEEN ULTRASONOGRAPHY AND OTHER
RADIOLOGICAL INSTRUMENTS
Fayzullayeva M.B, Sayfiddin Hoji Qadriddin
Tashkent medical academy
Summary:
Annotation.
Recent guidelines recommend the prioritized use of
ultrasonography as the main imaging method for women under the age of 45, with
mammography being considered when additional imaging is deemed necessary.
Key words:
ultrasonography, tomosynthesis, diagnosis, mammography
This study aims to evaluate
the effectiveness of ultrasonography and the value
of mammography in diagnosing breast cancer within this specific patient demographic.
The assessment involves a comprehensive review of the roles these imaging techniques
play in the diagnostic process for breast cancer within our healthcare unit
Methods and materials.
A retrospective analysis was conducted on all instances of breast cancer
diagnoses in patients aged 39 years or younger, spanning from June 2022 to June 2024.
The review encompassed a comprehensive examination of various factors, including
the presentation, clinical
findings,
imaging techniques
(ultrasonography,
mammography, magnetic resonance imaging (MRI), and histological data. The study
encompassed both invasive and intraductal carcinoma cases, excluding lobular
carcinoma in situ from consideration
Results.
During the study period, 3200 patients within this age group were
referred to the symptomatic breast clinic. Among them, 50 women were diagnosed
with either invasive cancer (n=38) or ductal carcinoma in situ (n=12). Mammography
was conducted on 28 patients and was primarily graded as uncertain, suspicious, or
malignant, with the majority falling into these categories. Unfortunately, malignancy
was overlooked in one patient during mammography evaluation.
All 50 patients underwent ultrasonography, which provided reports categorized
as uncertain, suspicious, or malignant, prompting a recommendation for diagnostic
core biopsy. Importantly, ultrasonography alone did not miss any instances of cancer.
Conclusions.
Within the scope of this study, ultrasonography emerged as a
dependable primary imaging modality for women under 45 years old, successfully
identifying all instances of cancer in this particular cohort. However, it is emphasized
that mammography and/or MRI continue to be crucial supplementary tools. These
additional imaging techniques play a vital role in accurately determining factors such
as multifocality and the extent of the disease. The study underscores the
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complementary nature of different imaging modalities in achieving a comprehensive
and precise assessment of breast cancer in this specific demographic
Keywords:
Primary imaging, Ultrasonography, Mammography, Women under
40 years
РАЗЛИЧИЯ МЕЖДУ УЛЬТРАЗВУКОВЫМ ИЗМЕРЕНИЕМ И
ДРУГИМИ РЕНТГЕНОЛОГИЧЕСКИМИ ИНСТРУМЕНТАМИ
Аннотация.
Согласно последним рекомендациям, основным методом
визуализации для женщин до 45 лет следует считать ультразвуковое
исследование, с маммографией в рассмотрении при необходимости
дополнительного исследования.
Ключевые
слова
:
ультрасонография,
томосинтез,
диагностика,
маммография.
Цель данного исследования
- оценить эффективность ультразвукового
метода и ценность маммографии в диагностике рака молочной железы (РМЖ) в
этой возрастной группе. Оценка включает всесторонний обзор роли этих
методов в диагностическом процессе рака груди в нашем медицинском
учреждении.
Методы и материалы.
Проведен ретроспективный анализ всех случаев
диагностирования РМЖ у пациенток в возрасте до 45 лет и младше в период с
июня 2022 года по июнь 2024 года. Обзор включал всестороннее изучение
различных факторов, включая представление, клинические данные, методы
визуализации (ультразвук, маммография, магнитно-резонансная томография
(МРТ) и гистологические данные. Исследование охватывало случаи как
инвазивного, так и интрадуктального рака, исключая лобулярный рак in situ из
рассмотрения.
Результаты.
В течение исследуемого периода 3200 пациенток данной
возрастной группы были направлены в симптоматическую клинику по борьбе с
раком груди. Среди них 50 женщин получили диагноз инвазивного рака (n=38)
или рака дуктальных карцином in situ (n=12). Маммография была проведена у 28
пациенток и в основном классифицирована как неопределенная, подозрительная
или злокачественная, с большинством попадающих в эти категории. К
сожалению, злокачественность была упущена у одной пациентки при оценке
маммографии.
Все 30 пациенток прошли ультразвуковое исследование, результаты
которого были классифицированы как неопределенные, подозрительные или
злокачественные,
что
послужило
основанием
для
рекомендации
диагностической биопсии. Важно отметить, что ультразвук в отдельности не
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упустил ни одного случая рака. Однако он не смог выявить множественные очаги
заболевания у одной пациентки.
Заключение.
В рамках данного исследования ультразвуковой метод
проявил себя как надежный основной метод визуализации для женщин младше
45 лет, успешно выявляя все случаи рака в этой конкретной группе. Однако
подчеркивается, что маммография и/или МРТ остаются ключевыми
дополнительными инструментами. Эти дополнительные методы визуализации
играют важную роль в точном определении факторов, таких как
множественность очагов и степень распространения заболевания.
Ключевые
слова:
первичная диагностика, рентгеновская маммография, ультразвуковая
диагностика, молодые женщины.
Annotation.
The guidelines from 2022 recommend adopting ultrasonography as
the primary imaging method for patients below the age of 45 with clinically benign or
uncertain breast lesions [4,11]. Mammography is suggested as an option if additional
imaging is deemed necessary. There are specific situations outlined in the guidelines
where mammography is supported, such as in cases of clinically suspicious lesions,
patients aged 35–39 years with normal ultrasonography and a clinically indeterminate
lesion, and when additional diagnostic information is needed for indeterminate (B3)
lesions [1,5,7]. Ultrasonography demonstrates greater sensitivity and specificity than
mammography in women under 35 years of age, making it the preferred imaging
investigation in this patient group. Moreover, this superiority of ultrasonography over
mammography has been confirmed in studies involving women up to the age of 40–45
years [2,3].
Advancements in technology, particularly the use of high-frequency
ultrasonography probes, have significantly improved sensitivity, achieving rates of up
to 100% when applied to patients below the age of 45 [6,8,9,12]. This technological
progress has demonstrated that ultrasonography is capable of detecting occult
malignancies, even in the dense breast tissue characteristic of younger women.
In contrast, mammography in this age group is associated with high recall rates,
elevated rates of additional imaging, and relatively low rates of cancer detection [20].
The purpose of this study was to evaluate the effectiveness of ultrasonography and
delineate the role of mammography in patients under 40 years of age. The focus was
on reviewing the diagnostic accuracy of these imaging modalities within this specific
age group in our healthcare unit [10,13,14].
Methods and materials.
The Somerset Cancer Register at the hospital served as
the data source for this retrospective study, providing details on eligible patients.
Between June 1, 2022, and June 30, 2024, a total of 3200 patients under the age of 45
were referred to the breast department at the University Hospital of North
Staffordshire. Within this group, 1,736 mammography and 1948 ultrasonography scans
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were conducted. Diagnoses were confirmed by reviewing histopathology reports, and
eligibility and demographic/presentation details were verified through medical record
reviews. Cancer cases included various types of invasive carcinoma and ductal
carcinoma in situ, with exclusion of lobular carcinoma in situ cases. Patients with
indeterminate (B3) or suspicious of malignancy (B4) imaging features but subsequent
benign pathology were excluded.
All imaging was part of the triple assessment process, with clinical breast
examinations performed by a breast surgeon in the majority of cases before imaging.
In 2022, the 'one-stop' symptomatic clinic transitioned to a radiology-led approach,
where imaging reports were available to the clinician on the same day as the patient's
consultation with the breast surgeon. Immediate ultrasonography-guided biopsy and
needle core biopsy of abnormal axillary lymph nodes were conducted for patients with
indeterminate or suspicious findings. Standard practice dictated mammography for all
patients aged 35 and over, along with 'targeted' ultrasonography for areas of clinical
concern. Patients under 35 underwent ultrasonography as the primary imaging
modality. Mammography was performed in all patients, regardless of age, with
ultrasonic or clinically suspicious or malignant findings. It was also conducted in
patients with clinically indeterminate (B3) lesions if ultrasonography was normal.
From May 2011, following national guidelines, ultrasonography became the
primary imaging modality for patients below the age of 45. Magnetic resonance
imaging (MRI) was employed in cases of lobular cancer, multifocal disease, or
discrepancies between imaging modalities or clinical findings.
During the study period, breast ultrasonography used an Aplio 500 (Toshiba,
Crawley, UK) with a 7–15 MHz probe. Suspicious or malignant breast masses (B4 and
B5) prompted whole breast and axillary ultrasonography, along with conventional
mammography.
Imaging reports were provided by two consultant radiologists and two consultant
radiographers specializing in breast disease, and all breast symptomatic imaging was
single read/autonomously reported. Reports were summarized using the American
College of Radiology's Breast Imaging Reporting and Data System (BI-RADS)/Royal
College of Radiologists Breast Group classification. Sonography interpretations
followed guidelines reported by Stavros et al., with representative images illustrating
benign (B2), indeterminate (B3), suspicious (B4), and malignant (B5) lesions. Figures
1–4 provide examples of these lesions.
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Figure 1. Local characterisation of a benign (B2) lesion. A well defined, solid,
homogenous lesion (arrow) with posterior acoustic enhancement.
Figure 2. Local characterisation of an indeterminate (B3) lesion. A small solid
lesion with indistinct borders (arrow).
Figure 3. Local characterisation of a suspicious (B4) lesion. An irregular solid
lesion infiltrating the breast parenchyma (arrow).
All biopsies in this study were conducted under ultrasonography guidance,
utilizing a 14G tru-cut needle mounted on a Pro-Mag™ Ultra (Canada) automated gun
with a standard 25mm throw. The procedure involved infiltration with 3–5ml of 1%
lignocaine and was performed by a consultant radiologist or consultant radiographer
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with specialized training in breast intervention. The operator's discretion determined
the acquisition of one to three core samples during the procedure.
Results from all needle core biopsies underwent thorough review at the
multidisciplinary team meeting. The pathological analysis of both core biopsies and
excised lymph nodes adhered to the National Health Service Breast Screening
Programme and the Royal College of Pathologists tissue pathways guidelines for non-
operative diagnostic procedures and reporting. The diagnosis of multicentric disease
was based on positive histology derived from core biopsies conducted in different
quadrants of the breast. The postoperative surgical specimen was considered the 'gold
standard' for determining tumor size, grade, type, and lymph node status. The study
sought ethical approval from the ethics committee, and it was determined that, as there
was no change in practice (mammography still being undertaken in addition to
ultrasonography), formal ethics approval was not required.
Results.
Between June 2022 and June 2024, a total of 3200 women under the age
of 45 attended the symptomatic breast clinic. Out of these, 2,331 were referred for
ultrasonography assessment, resulting in 3200 ultrasonography examinations.
Additionally, 829 patients underwent mammography, generating 1736 mammograms.
Among these patients, 328 (18,9%) were referred for diagnostic biopsy, leading to a
total of 372 biopsies. Following histological analysis, 30 patients were identified with
either invasive (n=38) or in situ (n=12) breast disease [table 2 and 3]. Consequently,
the rate of malignancy was 9.1% in those patients undergoing diagnostic biopsy and
1.3% in those referred for imaging. The average age of these patients was 36 years,
with a range from 27.5 to 39.8 years (Table 1). Among the 38 patients with invasive
disease, a total of 35 tumors were identified, with the majority (91.4%) being ductal
carcinomas of no special type. The median tumor size on histopathological assessment
was 32.3 mm, ranging from 10 to 120 mm.
Table 1.
Symptoms of breast cancer
Symptoms
Number of patients
abs
%
Breast lump
25
83.3%
Nipple distortion
2
6.7%
Axillary lump
1
3.3%
Axillary pain and breast lump
1
3.3%
Advanced disease
1
3.3%
Table 2
Classification histological system of patients
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Histology
abs
%
Invasive
ductal
carcinoma
20
66.7
Medullary
carcinoma
7
23.3
cancer in situ
1
3.3
Invasive lobular
carcinoma
2
6.7
Table 3
Classification grade system of patients
Grade
abs
%
Grade 3
16
53.4
Grade 2
11
36.6
Grade 1
3
10.0
Table 4
Classification BIRADS system of patients
Breast Imaging Reporting and Data
System
Number of patients
BI-RADS 1
8 (28.6%)
BI-RADS 2
8 (28.6%)
BI-RADS 3
6 (21.4%)
BI-RADS 4
6 (21.4%)
BI-RADS 5
2 (6.6 %)
Among the 30 patients identified with malignant disease, the majority (n=25,
83.3%) presented with a breast lump. Two patients (6.7%) presented with nipple
distortion, while one patient (3.3%) each presented with an axillary lump, axillary pain
and breast lump, and advanced disease. Detailed patient demographics, presentation,
and disease status are summarized in Table 1.
Ultrasonography successfully identified all patients with malignant disease.
Within these 30 patients, ultrasonography detected 34 abnormalities on imaging: 5
(14.7%) graded as BI-RADS 3, 12 (35.3%) as BI-RADS 4, and 17 (50.0%) as BI-
RADS 5. Of the five lesions classified as BI-RADS 3, two were confirmed as
fibroadenomas upon definitive histopathology following core biopsy. It is noteworthy
that both lesions occurred in patients who also had malignant lesions.
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Twenty-eight out of the thirty patients with malignant breast disease also
underwent mammography; one patient refused due to pain, and another presented with
advanced fungating cancer. In total, 32 lesions were identified through mammography:
1 (3.1%) graded as BI-RADS 2, 9 (28.1%) as BI-RADS 3, 8 (25.0%) as BI-RADS 4,
and 14 (43.8%) as BI-RADS 5. The patient graded as BI-RADS 2 was subsequently
proven to have invasive breast cancer upon histopathological assessment following
core biopsy, performed due to a BI-RADS 3 score on ultrasonography. Among the nine
lesions graded as BI-RADS 3, one was confirmed as a fibroadenoma upon definitive
histopathology following core biopsy.
In patients presenting with a breast lump, ultrasonography demonstrated greater
reliability than mammography in identifying likely malignant disease. Of the 25
patients in this subgroup, 88% were graded as BI-RADS 4 or 5 on ultrasonography,
while 66.7% (16 of 24, with one patient not undergoing mammography due to pain)
received similar grading on mammography. The difference, although not statistically
significant (p=0.0955, Fisher’s exact test), suggests a trend favoring ultrasonography.
MRI was performed on 12 patients, primarily due to discrepancies in imaging
findings, discrepancies between imaging and clinical findings, or the presence of
multifocal disease. In the study population, MRI exhibited higher accuracy than both
ultrasonography and mammography in detecting multifocal disease and accurately
measuring tumor size. Notably, the study did not find a high false positive rate
associated with MRI, contrary to some reports.
Discussion.
This study underscores the high accuracy of ultrasonography in
identifying suspicious lesions in women under 40 with symptomatic breast disease.
Numerous studies have consistently shown that ultrasonography outperforms
mammography in terms of both specificity and sensitivity in women up to the age of
40–45. Technological advancements, particularly the use of high-frequency probes,
have significantly improved sensitivities, reaching up to 100% in this age group. This
improvement has been especially crucial in detecting occult malignancy within the
inherently dense breast tissue of younger women. The differentiation between cystic
and solid masses has seen notable enhancements, enabling the reliable characterization
of these solid masses as either benign or suggestive of malignancy.
In this study, the majority of symptomatic patients presented with a breast lump
or nodularity, and 86.7% presented with a breast lump, aligning with findings in other
reported series. Ultrasonography performed exceptionally well in this setting, with
sensitivities and specificities surpassing those of mammography in younger women.
Notably, in the age group with the most contention (36–40 years), ultrasonography
exhibited a sensitivity of 84.6% and a specificity of 91.9%, compared to 69.2%
sensitivity and 83.3% specificity for mammography. This superior performance of
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ultrasonography is attributed to the predominantly dense breast tissue in younger
women, favoring the use of ultrasonography.
The sensitivity of ultrasonography is not age-dependent, in contrast to
mammography. While diagnostic mammography sensitivity was reported to be 85.7%
in women younger than 40, it was slightly lower in those aged 35–39 at 82.5%.
Specificity was lower in women presenting with a lump compared to those without,
reflecting the challenges in interpretation, especially in denser breasts. The positive
predictive value of mammography was reported at 14.6% for all women under 40,
improving to 18.6% for the subgroup aged 35–39. Ultrasonography, as demonstrated
in this study, was extremely reliable in identifying malignancy in this patient
population.
However, despite the exceptional reliability of ultrasonography in identifying
malignancy, it showed less reliability in identifying multifocal disease compared to
MRI. Preoperative MRI, in particular, has demonstrated superiority over both
ultrasonography and mammography in detecting additional suspicious findings,
especially in the ipsilateral breast. This series affirms that the correlation between
additional MRI findings and proven ipsilateral cancers was particularly strong in
patients aged 39 years or younger, possibly owing to MRI's efficacy in imaging dense
breast tissue.
Conclusions.
The accurate diagnosis of breast cancer in younger women poses
challenges due to factors such as inherently dense breast tissue, shorter tumor doubling
times, and the absence of routine screening for baseline imaging. This small study
suggests that ultrasonography serves as a sensitive and safe primary imaging modality
in this specific population. However, the study emphasizes that mammography and/or
MRI remain essential complementary tools, especially for identifying multifocal
disease. The combined use of these imaging modalities contributes to a more
comprehensive and accurate assessment in the diagnosis of breast cancer in younger
women.
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