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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 17  |  Issue : 1  |  Page : 103-109

Sonography, color doppler, and power doppler evaluation of palpable breast masses with pathological correlation


Department of Radiology, JNMC, DMIMS, Wardha, Maharashtra, India

Date of Submission27-Feb-2022
Date of Decision06-Mar-2022
Date of Acceptance16-Mar-2022
Date of Web Publication25-Jul-2022

Correspondence Address:
Dr. Soumya Jain
Department of Radiology, JNMC, DMIMS, Sawangi, Wardha, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_83_22

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  Abstract 


Background: The study was performed to analyze the accuracy of each of the techniques used in ultrasonography of breast in differentiating benign and malignant masses of the breast. The techniques under evaluation were B-mode, color Doppler, and power Doppler. Materials and Methods: It was a prospective, cross-sectional study involving 240 female patients who were clinically suspected to have a breast mass. The patients were referred to the Department of Radiodiagnosis, AVBRH, where they underwent ultrasonography with Aloka Hitachi USG Machine Arietta S70 with high-frequency linear probe (12–15 MHz) followed by Doppler assessment. Results: Of 240 patients that were included in the study, histologically, 73 (30.4%) patients were diagnosed with breast carcinoma, 167 (69.6%) were diagnosed with benign breast lesions. Gray scale ultrasonography had the highest accuracy with sensitivity of 90.4%, specificity of 92.8%, positive predictive value (PPV) of 84.6%, and negative predictive value (NPV) of 95.68%, followed by color Doppler having sensitivity of 89%, specificity of 87.1%, PPV of 87.69%, and NPV of 88.5%. Power Doppler had sensitivity of 82.19%, specificity of 89.22%, PPV of 76.9%, and NPV of 91.98%. The combined sensitivity and NPV of sonography, spectral color Doppler and power Doppler were found to be more, i.e., 91.78% and 95.97%, respectively. Conclusions: Breast malignancy is a very prevalent and common issue in India as well as in the rest of the world. Sonography has proven to be more accurate in differentiating benign from malignant masses of the breast. Color Doppler and power Doppler findings in conjunction with gray scale ultrasonography findings can help in early detection and give a better understanding of the type of lesion based on the tissue vascularity. This could also be used as an effective first-look screening tool to assess patients who are at high risk for breast carcinomas.

Keywords: Breast, carcinoma, central vascularity, Doppler, pulsatility index, power Doppler, resistive index


How to cite this article:
Jain S, Phatak SV. Sonography, color doppler, and power doppler evaluation of palpable breast masses with pathological correlation. J Datta Meghe Inst Med Sci Univ 2022;17:103-9

How to cite this URL:
Jain S, Phatak SV. Sonography, color doppler, and power doppler evaluation of palpable breast masses with pathological correlation. J Datta Meghe Inst Med Sci Univ [serial online] 2022 [cited 2022 Aug 18];17:103-9. Available from: http://www.journaldmims.com/text.asp?2022/17/1/103/352251




  Introduction Top


Breast disease constitutes among the most common disease in females of any age group. Diseases that affect the breasts – ranging from benign cysts to malignant lesions – often present themselves in the form of breast lumps.[1]

The breast is a modification of sweat glands and comprises fibroglandular and fatty tissues and hence can house various types of lesions.[2] Differentiating benign and inflammatory lesions from malignancies are very important especially in predisposed women in aspect of patient care and management. Excessive and unnecessary biopsies for benign breast lesions have an effect on the women undergoing them in the form of psychological, physical and financial terms, causing morbidity.[2],[3]

The National Institute of Cancer Prevention and Research stated that breast cancer encompasses for almost 27% of all cancers in women and is the most common cancer in India in females. The mortality rate in a woman with breast cancer is nearly 50% in India. The incidence rate starts to rise in the early 4th decade and peaks during the 7th and 8th decade.[4]

Malignant lesions are usually highly cellular and fall into the high-grade category. They are commonly hypervascular. Color Doppler is utilized in assessing the presence of vascularity, its distribution, and characterization in relation to malignant lesions.[5] Power Doppler is better than color Doppler when it comes to the detection of low flow volumes and is angle independent.[6]

Color Doppler and power Doppler in addition to ultrasonography have increased the diagnostic accuracy and improved the specificity in distinguishing between benign versus malignant nature of breast lesions. An increase in the efficacy of these techniques will help decrease the usage of biopsies, reducing the cost and anxiety associated with these procedures and minimizing unnecessary invasive procedures in otherwise healthy women.[6]

The aim of this prospective study was to determine and evaluate the efficacy of ultrasonography for the detection and characterization of various breast lesions and the usefulness of flow pattern and Doppler indices for distinguishing between malignant lesions and benign breast pathologies using pathological examination and diagnosis as reference.


  Materials and Methods Top


It was a prospective, cross-sectional study involving 120 female patients who were clinically suspected to have a breast mass. The study was conducted between October 2019 and August 2021. The patients were referred to the Department of Radiodiagnosis, AVBRH, where they underwent ultrasonography with Aloka Hitachi USG Machine Arietta S70 with high-frequency linear (12–15 MHz) with color Doppler and power Doppler.

Inclusion

Female patients of all ages presented with clinically palpable breast lesions.

Exclusion

  • Postoperative patients
  • Individuals undergoing chemotherapy and radiotherapy
  • Unwilling patients to be a part of the study
  • Patients having already confirmed pathology report of breast mass.


Technique subsequent to a clinical history and physical examination, the procedure was explained to the patients and they were made to lie down comfortably on the patient's bed in the presence of a female attendant. The patient's arm should be relaxed and flexed behind her head, and the transducer pressure should be gentle but forceful. Medial lesions should be scanned in the supine position, while lateral lesions, such as the axilla, should be scanned in the contralateral oblique position. This eliminates any potential artifact caused by insufficient compression of the breast tissue. Coupling gel was applied and the probe was placed on the breast. The clinically abnormal area, i.e., region of interest was evaluated and ultrasound findings were dealt in detail and transverse, sagittal, and radial or antiradial planes. A systematic evaluation of the breast – from its peripheries to the nipple-areolar complex – was conducted. The retroareolar region was examined by moving the transducer in multiple planes to negate shadows of the nipple.

The lesions were assessed with regards to the shape, margin, echogenicity, posterior acoustic features, orientation, vascularity, Doppler indices, and vascularization patterns.


  Results Top


About 69.6% of 240 cases were benign and 30.4% were malignant lesions indicating that benign masses were more common than the malignant ones. The peak incidences of benign masses were found in 3rd decade while the most malignant masses were found in 4th decade. The mean age was 43 ± 16 years for cases with malignant masses. Fibroadenoma was the most common benign breast lesion (42.5%) followed by fibrocystic disease (13.4%) [Table 1] and [Figure 1].
Table 1: Distribution of various breast diseases presenting as lump

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Figure 1: Bar graph showing the distribution of various breast diseases presenting as a lump. (Pathologically correlated)

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Breast mass was the presenting symptom in 100% of the participants. Breast pain was also a common finding seen in 25% of the patients. Other findings include nipple discharge (8.5%) and superficial redness (7.9%) [Figure 2].
Figure 2: Graph showing the distribution of patients according to presenting symptoms

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Majority of breast masses (52%) were seen in the right breast, more frequently in upper lateral quadrant followed by lower lateral, upper medial, lower medial, and central.

Breast lump was the most common presenting symptom (100%), followed by pain (25%) and nipple discharge (8.7%). Redness was found in 7.9% of patients, fever in 6%, skin changes in 3.5%, and nipple retraction in 2.7%.

The 240 breast lesions were prospectively classified using solely B-mode grayscale US images. (a) Benign/BIRADS2 (133), (b) probably benign/BI-RADS 3 (29) or (c) suspicious suggestive of malignancy/BI-RADS 4 (11), (d) highly suggestive of malignancy/BIRADS 5 (67) [Table 2] and [Figure 3].
Table 2: USG BIRADS classification of breast masses

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Figure 3: Graph showing USG BIRADS classification of breast masses

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Color Doppler evaluation was done on all lesions. Of the 240 lesions, 114 were avascular on color Doppler whereas 126 showed vascularity. Out of the 114 avascular lesions, 8 (7%) of them were malignant lesions whereas 106 (93%) were benign. Seventy-six lesions were found to have hypervascularity on Doppler, out of which 62 (81.6%) were malignant whereas 14 (18.4%) benign lesions had hypervascularity suggesting hypervascularization is a good predictor of malignancy. Most of the benign lesions 63.4% (106 out of 167) were avascular, 28% (47) had hypovascularity whereas only 8% were hypervascular benign lesions [Table 4].
Table 4: Degree of vascularity of benign and malignant masses on color Doppler

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Further spectral analysis was done on all vascular lesions of the breast to find out if the resistive and pulsatility indices were helpful in diagnosing malignant lesions. The resistive index (RI) range in benign lesions was 0.56–0.8 and the mean value calculated of RI for benign lesions was 0.650 ± 0.05. RI range in malignant lesions was 0.65–0.92 and the mean RI calculated was 0.77 ± 0.07 for malignant lesions. This difference turned out to be significant (P < 0.001). The pulsatility index (PI) range for benign lesions was 1.05–1.6 and the mean value calculated of PI for benign lesions was 1.21 ± 0.12. PI range of malignant lesions was 1.1–1.8 and the mean PI calculated was 1.55 ± 0.18 [Table 5].
Table 5: Comparison of resistive index values in benign and malignant breast lesions among vascular lesions

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Vascularization pattern was central in 82.1% of malignant lesions and 10.7% of benign lesions suggesting that the central vascularity pattern improved the diagnostic accuracy of malignant lesions. In our study, 3 out of 8 color Doppler avascular malignant lesions showed vascularity on power Doppler attributed to very small-caliber vessels which are low flow and picked up on power Doppler [Table 6] and [Figure 4].
Table 6: Distribution of lesions based on pattern of vascularization in power Doppler

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Figure 4: Graph showing the distribution of lesions based on the pattern of vascularization in power Doppler

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  Discussion Top


This prospective study evaluated 240 individuals with complaints of a palpable breast mass. The study focused on the usefulness of ultrasound, color Doppler, and power Doppler using cumulative correlation with histopathology to reduce the number of breast biopsies.

Our study sample comprised only female patients. The mean age for cases with malignant masses was 43.07 ± 16 years, similar to the study done by Parveen, et al.[7] In our study, there were a total of 69.6% benign and 30.4% malignant cases indicating the benign masses were more common than the malignant ones. The peak incidence of benign masses was found in 3rd decade while most malignant masses were found in 4th decade. These findings are similar to the study by Olu-Eddo and Ugiagbe[8] in Nigeria who found that benign breast lesions constituted 70% of breast lumps and occurred predominantly in young females with a peak incidence in the 3rd decade.

69.6% of breast masses were benign and 30.4% were malignant similar to a study conducted by Yaðtu et al. in which benign masses were 68.4% and malignant masses were 31.6%.[9] In our study, fibroadenoma was the most common benign breast lesion (42.5%) followed by fibrocystic disease (13.4%). Ali et al. also reported similar findings in 2005.[10]

Breast mass was the presenting symptom in 100% of the participants. This correlates well with the inclusion criteria that included all patients referred for the evaluation of breast masses. Breast pain was also a common finding seen in 25% of the patients. Other presenting symptoms included nipple discharge (8.5%) and superficial redness (7.9%).

The majority of breast masses (52%) were found in the right breast in our analysis, which was consistent with Reddy and Khaladkar[11] findings, but differed from Rimsten's[12] observation that the prevalence of breast lesions is higher in the left breast than in the right.

The most common site of breast cancer in this study was the upper lateral quadrant (48.4%). This finding was comparable to studies done by Rimsten[12] and Reddy and Khaladkar.[11]

In our study, 74 out of 240 cases were found to have an irregular shape, out of which 63 (85.1%) turned out to be malignant on histopathology giving a sensitivity of 86.3% for predicting the malignant nature of lesion. The orientation of lesion was assessed and 79.4% (58) out of 84 nonparallel lesions were malignant on tissue diagnosis. Noncircumscribed margin has a sensitivity of 91.7% in predicting the malignant nature of lesion which was the same as laid out in a study by Reinikainen et al.[13] and Chen et al.[14] 62.8% (105) benign and (64) 87.6% malignant lesions were hypoechoic suggesting that echogenicity is not a reliable predictor of malignancy.

Out of 240 masses, 73 (30.4%) were malignant, according to histologic findings. Noncircumscribed margin (85.9%), irregular form (85.14%), and nonparallel orientation are all sonographic BI-RADS features that have a high predictive value for malignancy (73.4%). Circumscribed margin (96.3%), parallel orientation (90.6%), and oval form are all sonographic BI-RADS features that are highly predictive of benign lesions (93.9%). This was in line with the study done by Stavros et al.,[15] Hong et al.,[16] Ibrahim et al.,[17] and Gokalp et al.[18]

Some features were not reliable in differentiating between benign and malignant lesions such as echogenicity of lesion and its posterior acoustic features.

On US, out of the 78 lesions which were categorized as BIRADS 4/5, 67 (85.59%) turned out to be malignant on histopathology. Four malignant lesions were given BIRADS 3, i.e., indeterminate and 2 were given BIRADS 2 on US. Out of 73 histopathologically proven malignant lesions, 2 were categorized as BIRADS 2 on US, 4 as BIRADS 3, and 5 as BIRADS 4.

The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy of US in detecting malignancy turned out to be 90.41%, 92.81%, 84.62%, 95.68%, and 92%, respectively [Table 3].
Table 3: The association between histopathological diagnosis and USG diagnosis

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Angiogenesis, or the development of aberrant new blood vessels, is linked to the progression of breast cancer. Through preexisting microvessels in normal breast tissue, cancer cells induce the formation of aberrant new vessels.

Based on a variety of criteria, Doppler sonography can detect neovascularity. Tumors are neovascular, which means they have more blood vessels supporting them. These tumors are frequently surrounded by vessels, which are known as a pattern of the peripheral net of vessels. Due to the absence of normal capillary beds in tumors, the sinusoidal gaps act as arteriovenous connections. This causes blood flow to flow at a faster rate than usual and resistance to be lower than usual. The flow pattern (peripheral vs. central blood flow), PI, and RI of pulsed Doppler waveforms can assist identify benign from malignant lesions.

Our study proved that malignant lesions have more vascularity as compared to benign ones which were in line with the study done by Davoudi et al.[5] Similar findings were also found in a recent study done by Al Hialy et al.,[20] Stanzani et al.,[21] and Waqar, et al [Table 7].[22]
Table 7: Comparison of validity of USG, color Doppler spectral, and power Doppler

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Seventy-six lesions were found to have hypervascularity on Doppler, out of which 62 (81.6%) were malignant whereas 14 (18.4%) benign lesions had hypervascularity. The findings were similar to the study done by Cosgrove et al.,[23] Gupta et al.,[19] and Keshavarz et al.[24]

Out of the 50 hypovascular lesions, 47 (94%) were benign whereas 3 (6%) were malignant.

It was concluded that 89% (65 out of 73) malignant lesions had vascularity; out of which 85% (62) were hypervascular suggesting hypervascularity is an important predictor of malignancy. Similar findings were seen in a study done by Stanzani et al.[21]

Most of the benign lesions 63.4% (106 out of 167) were avascular, 28% (47) had hypovascularity whereas only 8% were hypervascular benign lesions. Similar findings were found in a study done by Gupta et al.,[19] Davoudi et al.,[5] and Al Hialy et al.[20] The positive and NPVs of vascularity for detecting malignancy were 81.5% and 93%, respectively.

Blood flow is increased in tumors, which increases velocity and lowers resistance from normal tissue. The blood flow pattern in central and peripheral blood flow, as well as the RI, can help differentiate benign from malignant lesions using the waveform in pulse Doppler. The peripheral and central blood flow patterns are the same in benign lesions with a low RI. The central and peripheral blood flow patterns in malignant lesions are distinct. The central blood flow pattern is characterized by a high RI, a high systolic velocity, and a sharp systolic peak. The difference in waveform pattern is a good predictor of malignant lesions.

Further spectral analysis was done on all vascular lesions of breast to find out if the resistive and pulsatility indices were helpful in diagnosing malignant lesions. The RI range in benign lesions was 0.56–0.8 and the mean value calculated for RI in benign lesions was 0.650 ± 0.05. RI range in malignant lesions was 0.65–0.92 and the mean RI calculated was 0.77 ± 0.07. This difference turned out to be significant (P < 0.001). The PI range in benign lesions was 1.05–1.6 and the mean value calculated for PI in benign lesions was 1.21 ± 0.12. PI range in malignant lesions was 1.1–1.8 and the mean PI calculated was 1.55 ± 0.18.

Previous research has found that a high RI increases the risk of cancer in a breast mass, owing to the existence of stenosis, occlusions, and arteriovenous shunts, as well as a lack of smooth muscle. However, different RI values have been employed as cut-off criteria in investigations to distinguish between benign and malignant breast tumors. Our study showed that 57 (87.6%) out of 65 malignant lesions had a RI of more than 0.72 and a PI of more than 1.36 giving a sensitivity of 89.06%, specificity of 87.1%, positive and NPV of 87.69% and 88.52%, respectively, with a diagnostic accuracy of 88.1% in diagnosing malignant lesions whereas only 6 out of 61 benign lesions had a high RI, suggesting that RI >0.72 and PI >1.36 are a reliable cut off point to differentiate malignant from benign breast lesions. This RI and PI cut-off value allowed a significant discrimination between the benign and malignant lesions (P < 0.001).

Power Doppler ultrasound (PDUS) is angle independent and free of aliasing artifacts because it measures the amplitude of blood flow. The lack of uniform interpretation guidelines limits the utility of PDUS, which has shown tremendous promise in predicting malignancy. As a result, we intended to see if a lesion's vascular pattern may be utilized to predict malignancy and if a lesion's vascular pattern corresponds with its BI-RADS category. Although other components of PDUS imaging may have been utilized, it appears that assessing vascular patterns takes less time. Our study revealed that the peripheral net pattern of vascularization around the margins of tumor was suggestive of a typically benign lesion.

Vascular morphology was central in 82% of malignant lesions and 10% of benign lesions suggesting that the central vascularity pattern improved the diagnostic accuracy of malignant lesions. Similar findings were seen in a study done by Kook et al.[25] and Reinikainen et al. in 2001[13] on power Doppler sonography. In the study done by Sirous et al. in 2015,[26] 81% of malignant lesions showed a central vascularization pattern, similar to our study.

In our study, 3 out of 8 color Doppler avascular malignant lesions showed vascularity on power Doppler attributed to very small-caliber vessels which are low flow and picked up on power Doppler. The same fact was highlighted by Tozaki and Fukuma[27] and Gupta et al.[19] proving that the power Doppler assessment of breast masses increases pick-up rate of malignancy. The same seen in a study done by Watanabe et al [Figure 5], [Figure 6], [Figure 7], [Figure 8].[28]
Figure 5: A 26-year-old female with invasive intraductal carcinoma shows an irregular-shaped hypoechoic lesion with noncircumscribed margins and vertical extension On color Doppler, the lesion appears hypervascular compared to adjacent normal breast parenchyma. On spectral analysis, the intratumoral vessel showed RI of 0.7and PI of 1.3. On power Doppler, the lesion shows central vascularity predominantly. RI: Resistive index, PI: Pulsatility index

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Figure 6: A 35-year-old female with fibroadenoma shows a well-defined oval-shaped hypoechoic lesion with well-circumscribed margins and parallel orientation. On color Doppler, the lesion appears hypovascular compared to adjacent normal breast parenchyma. On spectral analysis, the intratumoral vessel showed RI of 0.53and PI of 0.71 On Power Doppler, the lesion was found to have peripheral/capsular vascularity predominantly. RI: Resistive index, PI: Pulsatility index

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Figure 7: 52-year-old female with invasive ductal carcinoma of the breast shows an irregular-shaped hypoechoic lesion with noncircumscribed and spiculated margins with vertical extension. On color Doppler, the lesion appears hypervascular compared to adjacent normal breast parenchyma. On spectral analysis, the intratumoral vessel showed RI of 0.73 and PI of 1.38. RI: Resistive index, PI: Pulsatility index

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Figure 8: 50-year-old female with invasive ductal carcinoma of the breast shows an irregular-shaped hypoechoic lesion with noncircumscribed and spiculated margins with vertical extension. On power Doppler, the lesion was found to have central vascularity predominantly

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  Conclusions Top


Ultrasonography is an effective tool for the assessment of breast lesions. Three most reliable grayscale criteria, i.e., shape, margin, and orientation of lesion as mentioned above should be used by practitioners to distinguish between malignant and benign palpable lesions of the breast, which can lead to a reduction in number of biopsies.

Doppler holds a good potential in the field of breast imaging. It is a rapid, simple, and noninvasive investigation complementing breast ultrasound examination. It increases confidence in the diagnosis of malignant lesions. Doppler has a significant role to play in imaging of young patients having dense breast and the malignant lesion can be easily missed during routine mammography. The combination of US, color, and power Doppler can help more efficiently assess lesions and guide biopsies to increase the identification rate of breast cancer.

Color Doppler and power Doppler help us gain qualitative as well as quantitative information on lesions thus helping in better diagnosis of lesion on imaging.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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