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Article

Comparison of Ultrasound Elastography,

Mammography, and Sonography in the
Diagnosis of Solid Breast Lesions

Hui Zhi, MD, Bing Ou, MD, Bao-Ming Luo, MD,

Xia Feng, MD, Yan-Ling Wen, MD, Hai-Yun Yang, MD

Objective. The purpose of this study was to evaluate the value of ultrasound elastography (UE) in dif-
ferentiating benign versus malignant lesions in the breast and compare it with conventional sonogra-
phy and mammography. Methods. From September 2004 to May 2005, 296 solid lesions from 232
consecutive patients were diagnosed as benign or malignant by mammography and sonography and
further analyzed with UE. The diagnostic results were compared with histopathologic findings. The
sensitivity, specificity, accuracy, positive and negative predictive values, and false-positive and -negative
rates were calculated for each modality and the combination of UE and sonography. Results. Of 296
lesions, 87 were histologically malignant, and 209 were benign. Ultrasound elastography was the most
specific (95.7%) and had the lowest false-positive rate (4.3%) of the 3 modalities. The accuracy
(88.2%) and positive predictive value (87.1%) of UE were higher than those of sonography (72.6%
and 52.5%, respectively). The sensitivity values, negative predictive values, and false negative rates of
the 3 modalities had no differences. A combination of UE and sonography had the best sensitivity
(89.7%) and accuracy (93.9%) and the lowest false-negative rate (9.2%). The specificity (95.7%) and
positive predictive value (89.7%) of the combination were better, and the false-positive rate (4.3%) of
the combination was lower than those of mammography and sonography. Conclusions. In a clinical
trial with Chinese women, UE was superior to sonography and equal or superior to mammography in
differentiating benign and malignant lesions in the breast. A combination of UE and sonography had
the best results in detecting cancer and potentially could reduce unnecessary biopsy. Ultrasound elas-
tography is a promising technique for evaluating breast lesions. Key words: breast carcinoma; mam-
mography; sonography; ultrasound elastography.

B
Abbreviations
ROI, region of interest; UE, ultrasound elastography
Received December 4, 2006, from the Department
of Ultrasound, Second Affiliated Hospital, Sun Yat-
Sen University, Guangzhou China. Revision request-
ed January 17, 2007. Revised manuscript accepted
for publication February 5, 2007.
Address correspondence to Bao-Ming Luo, MD,
Department of Ultrasound, Second Affiliated
Hospital of Sun Yat-Sen University, 107 Yanjiangxi
Rd, 510120 Guangzhou, China.
E-mail: baomingluo2005@126.com
reast cancer is the most common malignancy in
women and the second most common cause of
cancer-related mortality.1 The most current esti-
mates from the International Agency for Research
on Cancer for the global disease burden of breast cancer
are for 2002, and in that year, the agency estimated that
there were approximately 1.15 million newly diagnosed
cases and approximately 411,000 deaths.2 On the basis of
current estimates of an average annual increase in inci-
dence ranging from 0.5% to 3% per year, the number of
new cases projected to be diagnosed in 2010 is 1.4 to 1.5
million.2 Recent research on service screening programs
suggests that participation in modern, organized service

© 2007 by the American Institute of Ultrasound in Medicine • J Ultrasound Med 2007; 26:807–815 • 0278-4297/07/$3.50
26.6.jum.online.q 5/16/07 2:15 PM Page 808
Ultrasound Elastography in Solid Breast Lesions
screening may well reduce the risk of dying of
breast cancer by 40% or more.3 That is, early and
sensitive diagnosis represents a better prognosis.
Noninvasive diagnosis of breast cancer remains
a major clinical problem. Mammography and
sonography are currently the most sensitive
modalities for detecting breast cancer. Most
Chinese women have relatively small, dense
breasts,4 which is one of the various factors lead-
ing to false-negative findings on mammography.5
Practically, sonography is chosen as the primary
workup tool in the clinic in China. However, the
sonographic features for benign and malignant
lesions have been shown to override each other
substantially.6,7 These limitations of mammogra-
phy and sonography and the great desire not to
miss a malignant lesion in the early stage of dis-
ease lead to aggressive biopsy, but the biopsy
rate for cancer is only 10% to 30%.8,9 This means
that 70% to 90% of breast biopsies are per-
formed for benign diseases, which induce
unnecessary patient discomfort and anxiety in
addition to increasing costs to the patient.
Clearly, there is a great need for development of
additional reliable methods to complement the
existing diagnostic procedures to avoid unnec-
essary biopsy.
In the clinical examination, palpation is the
standard screening procedure for the detection
of breast, thyroid, prostate, and liver abnormali-
ties. That is done on the basis that cancer tissue
is harder than adjacent normal tissue. However,
palpation is not very accurate because of its poor
sensitivity as well as its limited accuracy in terms
of different locations of lesions. A better under-
standing of soft tissue elasticity, another charac-
teristic for delineating the properties of a lesion
in addition to morphologic characteristics that
can be detected with sonography and other
conventional radiologic modalities, and a sys-
tem for accurately and efficiently predicting it
are therefore needed. In the early 1990s, a tech-
nique called elastography was described by
Ophir et al.10 With this technique, the tissue is
compressed, and the tissue strain resulting from
this compression is imaged. Since its invention,
this concept has been proposed for elasticity
imaging of a wide range of different applica-
tions, including prostate,11 breast,12–15 thyroid,16
and intravascular ultrasound.17
808
The strain map of ultrasound elastography
(UE) is superimposed on a conventional B-mode
sonogram. The goal of this study was to evaluate
whether the new method of UE could improve
the differentiation and characterization of
benign and malignant breast lesions compared
with conventional sonography and mammogra-
phy and whether the combination of UE and
sonography could improve the accuracy of diag-
nosis of breast lesions significantly.
Materials and Methods
Patients
From September 2004 to May 2005, 232 patients
with 296 solid lesions in the breast were includ-
ed in the study. The mean age of the patients
was 42 years, with a range of 17 to 87 years. Final
diagnosis was confirmed by histopathologic
examination. Informed consent for diagnostic
procedures was obtained from each patient.
The study was approved by the Ethics
Committee of the hospital. All patients were
examined with mammography and sonogra-
phy, and those with solid lesions were further
analyzed with UE. All the examinations were
performed before any surgery, biopsy, or fine-
needle aspirations. Only the patients with all of
these examination findings available were
included in the study.
Study Design
Mammography was performed with a
Senographe 600T mammography system (GE
Healthcare, Milwaukee, WI). Standard medio-
lateral oblique and craniocaudal projections
were obtained. Additional projections, such as
coned-down compression and magnification
views, were considered when further help in
analysis was expected. Mammograms were
reviewed for masses, calcifications, architec-
tural distortion, and tubular ductal opacity. The
shape, margin, and density of masses were
noted. Two different radiologists with at least 5
years of experience in breast mammography
read the mammograms and made the diagnosis
of the lesions together.
In each patient, bilateral whole-breast sonog-
raphy was performed in the transverse and lon-
gitudinal planes with a EUB-8500 ultrasound
J Ultrasound Med 2007; 26:807–815
26.6.jum.online.q 5/16/07 2:15 PM Page 809
scanner (Hitachi Medical Corporation, Tokyo,
Japan) equipped with a 7.5- to 13.0-MHz linear
array transducer. Sonographic features were
prospectively recorded in a computer database
and included anteroposterior-width ratio,
shape, margin, internal echogenicity, internal
echo texture, and posterior acoustic phenome-
na. With these features, 2 different sonogra-
phers with at least 5 years of experience in
breast sonography diagnosed the lesions as
benign or malignant together.
Ultrasound elastography was performed at
the same time as the sonographic examination.
Because the ultrasound scanner was equipped
with an elastography unit, the elasticity of a
lesion could be measured by a different color.
On the B-mode image, we displayed the target
lesion. Then we moved the region of interest
(ROI) around the lesion, making sure that the
target tissue occupied no more than one third
of the total area of the ROI. The probe was
moved inferior and superior to obtain the elas-
ticity images. Importantly, to obtain images
that were appropriate for analysis, we applied
the probe with only light pressure, with the
pressure indicator bar displayed as only 2 to 3.
The target lesion was scored as 1 to 5, using the
scoring system proposed by Itoh et al.14 If a
lesion was scored as 1 to 3, it would be benign;
if a lesion was scored as 4 to 5, it would be
malignant. A score of 1 indicated even strain
for the entire hypoechoic lesion (ie, the entire
lesion was evenly shaded in green). A score of
2 indicated strain in most of the hypoechoic
lesion with some areas of no strain (ie, the
hypoechoic lesion had a mosaic pattern of
green and blue). A score of 3 indicated strain at
the periphery of the hypoechoic lesion, with
sparing of the center of the lesion (ie, the
peripheral part of lesion was green, and the
central part was blue). A score of 4 indicated no
strain in the entire hypoechoic lesion (ie, the
entire lesion was blue, but its surrounding area
was not included). A score of 5 indicated no
strain in the entire hypoechoic lesion or in the
surrounding area (ie, both the entire hypoe-
choic lesion and its surrounding area were
blue). With the scoring system, 2 different
sonographers gave the diagnosis of the lesions
as benign or malignant together.
J Ultrasound Med 2007; 26:807–815
Zhi et al
Data Analysis
Interpretation of the various diagnostic proce-
dures was compared with the histologic findings
with regard to sensitivity, specificity, accuracy,
positive and negative predictive values, and
false-positive and -negative rates. Sensitivity,
specificity, negative and positive predictive val-
ues, and accuracy were evaluated as follows:
sensitivity = patients with suspected breast can-
cer/patients with histologically confirmed breast
cancer; specificity = patients with suspected
benign disease/patients with histologically con-
firmed benign disease; positive predictive value =
patients with histologically confirmed breast can-
cer/patients with suspected breast cancer; nega-
tive predictive value = patients with histologically
confirmed benign disease/patients with suspect-
ed benign disease; and accuracy = patients with
true-positive and -negative detected disease/all
patients with lesions (benign and malignant).
A result was classified as false-negative when a
diagnostic method classified histologically con-
firmed cancer as benign. A result was classified
as false-positive when a diagnostic method clas-
sified a histologically confirmed benign lesion as
cancer. We obtained the false-positive and -neg-
ative rates and compared the performance of all
diagnostic methods individually and the combi-
nation of sonography and UE for all patients.
Statistical Analysis
Statistical analysis was performed for all vari-
ables with the McNemar test and the Pearson χ2
test. P < .05 was considered statistically signifi-
cant. All the statistical analyses in this study were
carried out with SPSS for Windows software
(SPSS Inc, Chicago, IL).
Results
All patients underwent breast surgery, and all
abnormal lesions identified by mammography,
sonography, and UE were surgically removed. A
total of 296 breast lesions were examined histo-
logically. Histologic analysis showed that 209
(70.6%) of 296 lesions were benign and 87
(29.4%) of 296 lesions were malignant. The histo-
logic diagnoses are summarized in Table 1.
Lesion sizes ranged from 3.1 to 100.6 mm in
maximum diameter (mean, 16.5 mm; median,
809
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Ultrasound Elastography in Solid Breast Lesions

Table 1. Histologic Diagnoses of Benign and Malignant for mammography was significantly higher
Breast Lesions in 232 Patients than that of sonography (P < .05; Table 2).
Histopathologic Diagnosis n Combining UE and sonographic diagnostic
methods yielded the best results for detection of
Benign lesions (n = 209)
Fibroadenoma 125 cancer (Table 2). The highest results for accura-
Fibrocystic mastopathy 57 cy and sensitivity were seen for a combination
Papilloma 12 of the 2 methods (P < .05; Table 2). The specifici-
Chronic inflammation 7
Mucous adenoma 1
ty and positive predictive value of the combina-
Hyperplasia 6 tion were significantly higher than those of
Hematoma 1 mammography and sonography (P < .05; Table
Malignant lesions (n = 87) 2). The negative predictive value for the combi-
Invasive ductal carcinoma 66
Ductal carcinoma in situ 10 nation was significantly higher than that of
Cystosarcoma phyllodes 6 sonography (P < .05; Table 2).
Mucinous carcinoma 1 Mammographic findings were false-negative
Paget disease 1
in 24 of 87 cancers; sonographic findings were
Medullary carcinoma 1
Invasive lobular carcinoma 1 false-negative in 25 of 87 cancers; and 26 of 87
Papillocarcinoma 1 cancers were missed by UE. With regard to the
false-negative rate, no significant difference
between the 3 modalities was found. Most false-
negative findings on UE were found in early
13.3 mm; SD, 11.2 mm); in particular, the benign stages of invasive ductal carcinoma, which were
lesions were 3.1 to 100.6 mm (mean, 13.9 mm; all in stages 1 and 2, and noninvasive carcinoma
median, 11.7 mm; SD, 9.6 mm), and the malig- (Table 3). Six of the false-negative invasive ductal
nant lesions were 5.7 to 58.6 mm (mean, 23.1 carcinomas had somewhat large central necro-
mm; median, 20.2 mm; SD, 12.3 mm). sis, and 5 of the 6 cystosarcoma phyllodes had
With regard to sensitivity and negative predic- false-negative findings on UE (Table 3). Of 26
tive value, no significant difference between the cancers missed by UE, 18 were detected by
3 modalities was found (Table 2). The specifici- sonography. When the diagnoses from UE and
ty of UE was significantly higher than those of sonography were combined, the false-negative
mammography and sonography (P < .05; Table rate was 8 of 87 cancers, which was significantly
2). The specificity of mammography was signif- lower than that of any 1 of the 3 diagnostic meth-
icantly higher than that of sonography (P < .05; ods. The pathologic findings of the 8 missed can-
Table 2). The accuracy rates of UE and mam- cers included 5 invasive ductal carcinomas, 1
mography were significantly higher than that of papillocarcinoma, 1 ductal carcinoma in situ,
sonography (P < .05; Table 2). The positive pre- and 1 Paget disease. Four of the 8 were detected
dictive value for UE was significantly higher by mammography, and 4 were missed by all 3
than those of mammography and sonography modalities, including 2 invasive ductal carcino-
(P < .05; Table 2). The positive predictive value mas, 1 papillocarcinoma, and 1 Paget disease.

Table 2. Comparison of Sensitivity, Specificity, Accuracy, and Positive and Negative Predictive Values for
Mammography, B-Mode Sonography, and UE in the Differentiation of Benign From Malignant Breast Cancer
Imaging Modality Sensitivity, % (n) Specificity, % (n) Accuracy, % (n) PPV, % (n) NPV, % (n)
Mammography 72.4 (63/87) 87.1 (182/209)* 82.7 (245/296)* 70.0 (63/90)* 88.3 (182/206)
Sonography (B-mode) 71.2 (62/87) 73.2 (153/209) 72.6 (215/296) 52.5 (62/118) 86.0 (153/178)
UE 70.1 (61/87) 95.7 (200/209)*† 88.2 (261/296)* 87.1 (61/70)*† 88.5 (200/226)
Sonography (B-mode) + UE 89.7 (78/87)*†‡ 95.7 (200/209)*† 93.9 (278/296)*†‡ 89.7 (78/87)*† 95.7 (200/209)*
NPV indicates negative predictive value; and PPV, positive predictive value.
*P < .05 versus sonography.
†P < .05 versus mammography.
‡P < .05 versus UE.

810 J Ultrasound Med 2007; 26:807–815

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Zhi et al

The false-positive rates of mammography,
sonography, and UE were 12.9% (27/209), 26.8%
(56/209), and 4.3% (9/209), respectively. The
false-positive rate of UE was significantly lower
than that of mammography and sonography.
The histologic types of the false-positive find-
ings on UE are listed in Table 3. Among the false-
positive findings, 2 of fibroadenoma were with
calcifications, and 1 of fibrocystic mastopathy
was with dotted, organized remote hemorrhage.
When the diagnoses from UE and sonography
were combined, the false-positive was 9 of 209
benign lesions, which was the same as for UE
alone.
An illustration of a benign lesion and a malig-
nant lesion detected by UE that had almost the
same benign morphologic characteristics on
sonography is shown in Figure 1. An illustration
of a benign lesion and a malignant lesion detect-
ed by UE that had almost the same malignant
morphologic characteristics on sonography is
shown in Figure 2. An illustration of a benign
lesion detected by UE that was falsely diagnosed
as cancer by mammography is shown in Figure
3. An illustration of cancer detected by UE that
was missed by mammography is shown in
Figure 4.
from breast cancer and the extent of treatment
required is early detection through screening.
Ultrasound elastography is a new screening
modality in addition to sonography for detecting
and identifying lesions in the breast. It can pro-
vide the investigator with another characteristic,
stiffness, of the lesion. Through lightly compress-
ing of the target lesion, UE can noninvasively
determine strain and elasticity distributions
inside objects scanned and map the elasticity of
the lesion by using a standardized color scale,
with blue indicating regions with low elasticity
(harder tissue areas) and red indicating regions
with high elasticity (soft tissue).
Figure 1. Two lesions with almost the same benign morphologic
characteristics. A, Fibroadenoma in a 35-year-old woman. Right,
Sonographic image. A hypoechoic mass with a regular shape was
diagnosed as a benign lesion. Left, Ultrasound elastographic
image. The lesion had a mosaic pattern of green and blue, was
scored 1, and was diagnosed as a benign lesion. B, Invasive duc-
tal carcinoma in a 45-year-old woman. Right, Sonographic image.
A hypoechoic mass with a regular shape was diagnosed as a
benign lesion. Left, Ultrasound elastographic image. The entire
lesion was blue, was scored 4, and was diagnosed as a malignant
lesion.

A
Discussion

Breast cancer is the most common malignancy

among women worldwide.1 In the absence of a
known preventable cause of breast cancer, the
single most important factor in reducing death

Table 3. Analysis of False-Negative and -Positive

Diagnoses With UE
Histopathologic Diagnosis n B
False-negative (n = 26)
Invasive ductal carcinoma 12
Ductal carcinoma in situ 6
Cystosarcoma phyllodes 5
Mucinous carcinoma 1
Papillocarcinoma 1
Paget disease 1
False-positive (n = 9)
Fibroadenoma 3
Fibrocystic mastopathy 4
Papilloma 1
Hyperplasia 1

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Ultrasound Elastography in Solid Breast Lesions

To our knowledge, there are few reports about
UE for diagnosis of breast lesions, especially the
color-scaled UE that was evaluated in our study.
Itoh et al14 first used UE to detect breast lesions
and proposed the 5-point scoring system. They
had higher sensitivity of UE than that of con-
ventional sonography. Thomas et al15 evaluated
this new modality in 108 patients and found
that specificity was improved from 78% for
conventional sonography to 91.5% for UE.
Our results suggest that UE is a highly sensi-
tive, accurate means of identifying and assess-
ing solid lesions of the breast. Our results are in
agreement with those in a 1998 study by
Krouskop et al,18 which showed that various
breast tissues had differing elastic stiffness,
invasive carcinoma having the lowest elasticity,
followed by noninvasive carcinoma, fibrous tis-
sue in the breast, normal glandular breast tis-
sue, and breast fat tissue in that order. In our
study, we found that the specificity, accuracy,
and positive predict value for the combination
of sonography and UE were higher than those
of sonography, which is the first choice of
Figure 3. Fibroadenoma in a 39-year-old woman. A,
Mammogram showing a mass suspected to be a malignant
lesion. B, Right, Sonographic image. A hypoechoic mass with an
irregular shape was suspected to be a malignant lesion. Left,
Ultrasound elastographic image. The lesion had a mosaic pat-
tern of green and blue, was scored 2, and was diagnosed as a
benign lesion.
A

Figure 2. Two lesions with almost the same malignant mor-

phologic characteristics. A, Papilloma in a 49-year-old woman.
Right, Sonographic image. A hypoechoic mass with an irregular
shape was diagnosed as a malignant lesion. Left, Ultrasound
elastographic image. The lesion had a mosaic pattern of green
and blue, was scored 3, and was diagnosed as a benign lesion.
B, Invasive ductal carcinoma in a 42-year-old woman. Right,
Sonographic image. A hypoechoic mass with an irregular shape
was diagnosed as a malignant lesion. Left, Ultrasound elasto-
graphic image. The entire lesion was blue, was scored 4, and
was diagnosed as a malignant lesion.

B B

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26.6.jum.online.q 5/16/07 2:15 PM Page 813
modality for screening the breasts of Chinese
woman. Most Chinese women have relatively
small, dense breasts,4 and the median age of
these patients with breast cancer is 47 years,
which is 8 years younger than in Western
women,19 which limits the use of mammogra-
phy. Bird et al20 stated that breast cancer was
less likely to be detected by mammography in
Figure 4. Invasive ductal carcinoma in a 55-year-old woman.
A, Mammogram showing several masses suspected to be
benign lesions. B, Right, Sonographic image. A hypoechoic mass
with a round shape was suspected to be a benign lesion. Left,
Ultrasound elastographic image. Both the entire hypoechoic
lesion and its surrounding area were blue. The blue area on UE
was larger than the lesion area on sonography. It was scored 5
and was diagnosed as a malignant lesion.
A
B lower than those for mammography and
J Ultrasound Med 2007; 26:807–815
Zhi et al
women with dense breasts and in women
younger than 50 years. One of the various fac-
tors leading to false-negative findings on mam-
mography is the effect of breast density.5
Furthermore, breast density on mammography
is also associated with an increased risk of
breast cancer.21 Meanwhile, dense glandular
tissue usually has a hyperechoic appearance
on sonography, and mostly breast cancers are
hypoechoic; carcinomas in this setting are eas-
ily detected on sonography. In our study, we
found that UE was better than sonography for
detecting breast cancer in Chinese patients.
Compared with mammography, the specificity
of UE was higher, but there was no significant
difference between the sensitivity, accuracy,
and positive and negative predictive values of
UE and mammography. However, mammogra-
phy uses ionizing radiation, which itself is a
potential carcinogen,22 and this limits the age
and frequency with which it can be used.23
Conversely, there is no such risk to patients
when using UE. In addition, UE and sonogra-
phy are much less expensive than mammogra-
phy in China.
There is an overlap of the elasticity between
benign and malignant lesions in the breast,13
which limits the use of UE. In our study, 26 of
87 cancers were missed by UE. Most false-neg-
ative findings on UE were found in early stages
of invasive ductal carcinoma, which were all in
stages 1 and 2, and in noninvasive carcinoma,
and some invasive soft tissue carcinomas such
as cystosarcoma phyllodes6 had large central
necrosis (the lesions with large central necrosis
all had false-negative findings). Consequently,
large-scale necrosis may impair the diagnostic
assessment in UE.15 Nine of 209 benign lesions
were misdiagnosed by UE. That rate was much
sonography, which would decrease unneces-
sary biopsies considerably. Among the false-
positive diagnoses, 3 had calcifications, which
might affect the diagnosis on UE, and 1 had a
dotted remote hemorrhage that had already
been organized, which may have increased the
hardness of the lesion. Therefore, when using
UE, one should pay attention to all the factors
that would affect the stiffness of lesions and
cause misleading results.
813
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Ultrasound Elastography in Solid Breast Lesions
Ultrasound elastography is superimposed on
conventional sonography. There have been
marked advances in the quality of ultrasound
imaging over the past 2 decades, and the ability
to differentiate benign and malignant features of
solid masses with the use of ultrasound has
improved. This was achieved because of techno-
logical improvements. When we combined the 2
modalities together, we got the best results for
detection of breast cancer. The sensitivity, speci-
ficity, accuracy, and positive predictive value
improved to 89.7%, 95.7%, 93.9%, and 89.7%,
respectively, which were much higher than those
of mammography and sonography. In addition,
the negative predictive value improved to 95.7%,
which was higher than that of sonography, and
the false-negative rate dropped to 8 of 87 cancers,
which was much lower than those of mammog-
raphy (24/87) and sonography (25/87). This
combination includes detection of 2 features of a
lesion, morphologic characteristics and hard-
ness, which reflect the properties of the lesion.
Shape, margin, internal echogenicity, echo tex-
ture distribution, posterior echo, and a bilateral
reflection sign have been shown to be valuable in
the differential diagnosis of benign and malig-
nant breast tumors.24 Conversely, malignant tis-
sue usually is harder than normal breast tissue.
Therefore, the 2 elements, morphologic charac-
teristics and hardness, can reflect whether the
lesion is benign or malignant. This combination,
however, did not affect the false-positive rate,
which was the same as that for UE alone.
Although there are many limits for the use of
mammography in Chinese woman, every modal-
ity has its own advantages. Mammography is use-
ful for detecting early breast cancer, especially
carcinoma in situ.25 Carcinoma in situ can be
identified on mammography by the presence of
suspicious microcalcifications. These microcal-
cifications are more frequent in intraductal than
in infiltrating cancers,26 which can be easily
detected by mammography. Because the hard-
ness of carcinoma in situ is lower than that of
infiltrating cancer, a little harder than benign tis-
sues, it is not easy to differentiate carcinoma in
situ, which our results show. Most false-negative
findings on UE were found in early stages of inva-
sive ductal carcinomas and noninvasive carcino-
mas. In the 26 carcinomas misdiagnosed by UE,
814
9 could be diagnosed by mammography, includ-
ing 4 invasive ductal carcinomas, 4 ductal carci-
nomas in situ, and 1 mucinous carcinoma.
When using UE to screen a lesion, there are
many things to pay attention to. The first is that
the area of the target lesion occupied in the ROI
should be less than one third. The echo signals
acquired with the ultrasound scanner are cap-
tured on an external computer and used to cal-
culate the tissue strain with the combined
autocorrelation method.27 This is a qualitative
elasticity measurement that is relative to the
average strain inside the ROI. To compare the tar-
get lesion elasticity with that of normal breast tis-
sue, both tissue types should be present in the
ROI.28 The second thing is that light pressure on
the target lesion should be applied with the
probe by hand. There is a pressure indicator on
the machine, and the pressure scale should be
between 2 and 3. If the pressure scale is greater
than 3, it means that the pressure is too high,
which causes nonlinear properties of tissue elas-
ticity and leads to misdiagnosis.
In conclusion, UE is superior to conventional
sonography and is superior or equal to mam-
mography in differentiating benign and malig-
nant lesions in the breast. By combining UE and
sonography, the detection accuracy can be
improved greatly, and the combination poten-
tially could reduce unnecessary biopsy. This
combination was the optimal screening modali-
ty in our study. Ultrasound elastography is a
promising technique for differentiation of breast
lesions.
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