Objective: This study is focused on ultrasound multimodality examination, which refers to the combined use of three ultrasound examination modalities, ultrasound (US), acoustic radiation force impulse (ARFI) imaging, and contrast-enhanced ultrasound (CEUS). The purpose of this study is to analyze the value of applying ultrasound multimodality examination in the differential diagnosis of benign and malignant breast non-mass-like lesions (NMLs).
Methods: Cases of breast NMLs were analyzed retrospectively, and the nature of all the lesions was verified by pathological examination. Based on the gray-scale ultrasound image characteristics, the cases were classified into types Ⅰ to Ⅴ, and type Ⅰ and type Ⅱ were further classified into 4 subtypes, Ⅰa, Ⅰb, Ⅱa, and Ⅱb, according to whether there was also calcification, and the proportion of malignant cases in each subtype was statistically analyzed. Logistic regression models of US, US+ARFI, US+CEUS, and US+ARFI+CEUS for the diagnosis of malignant cases were established, ROC curves were drawn, the area under the curve (AUC) was calculated, and comparisons were made accordingly. The detection rate of malignant NMLs without calcification (atypical malignant NMLs) by the combination examination of US, ARFI, and CEUS was analyzed.
Results: A total of 407 cases were included in the study. All subjects were female, aged 22 to 81 years, with the average age being (47.0±11.0) years. There were 220 benign cases and 187 malignant cases. Ranked from the highest to the lowest, the malignancy proportion of the different types was Ⅰb>Ⅱb>Ⅲ>Ⅴ>Ⅰa>Ⅱa>Ⅳ. The malignant proportion of the low echo area with calcification was significantly higher than that of the lesions without calcification. The AUC (95% confidence interval [CI]) for diagnosing malignant cases with the logistic regression models of US, US+ARFI, US+CEUS, and US+ARFI+CEUS were 0.895 (0.862-0.927), 0.908 (0.878-0.937), 0.921 (0.893-0.948), and 0.927 (0.902-0.952), respectively. Comparison of the AUC of the 4 regression models showed significant differences (P<0.001). The detection rate of US for NMLs without calcification was 80.7%. When US was used in combination with ARFI and CEUS, 86.4% of the malignant NMLs lesions without calcification could be detected if the lesion CEUS score was 4 or 5 points or if shear-wave velocity (SWV)≥4.28 m/s.
Conclusion: Breast NMLs with calcification show high risks of malignancy, and a pathological examination is always recommended for a conclusive diagnosis. Ultrasound multimodality examination can improve the diagnostic accuracy of breast NML without calcification.
目的: 本研究的超声多模态检查是指高频超声（ultrasound, US）、声辐射力脉冲成像（acoustic radiation force impulse, ARFI）、超声造影（contrast-enhanced ultrasound, CEUS）这三种超声检查方式联合使用。本研究拟分析超声多模态检查对乳腺非肿块型病变（non-mass-like lesions, NMLs）良恶性的鉴别诊断价值。
方法: 回顾性分析乳腺非肿块型的病例，病灶性质均经病理检查证实。依据灰阶超声图像特征，将病例分为Ⅰ～Ⅴ类型，并根据是否伴有钙化，将其中Ⅰ型及Ⅱ型又分为Ⅰa型、Ⅰb型和Ⅱa型、Ⅱb型，统计分析各分型恶性比例。建立US、US+ARFI、US+CEUS、US+ARFI+CEUS的logistic诊断恶性病例的回归模型，绘制受试者工作特征（ROC）曲线，计算曲线下面积（area under the curve, AUC），并进行比较。分析US、ARFI与CEUS串联实验对不伴钙化的恶性NMLs（不典型恶性NMLs）的检出率。
结果: 最终纳入研究病例407例，均为女性，年龄22～81岁，平均年龄（47.0±11.0）岁。其中良性病例220例，恶性病例187例。恶性占比从高到低分别为Ⅰb型>Ⅱb型>Ⅲ型>Ⅴ型>Ⅰa型>Ⅱa型>Ⅳ型，伴有钙化的低回声区恶性比例明显高于不伴钙化的病灶。US、US+ARFI、US+CEUS、US+ARFI+CEUS的logistic回归模型诊断恶性病例的AUC及95%置信区间（CI）分别为0.895（0.862～0.927）、0.908（0.878～0.937）、0.921（0.893～0.948）、0.927（0.902～0.952）。4个回归模型的AUC相比，差异有统计学意义（P<0.001）。US对不伴钙化的NMLs的检出率为80.7%，若US与CEUS、ARFI联合，当病灶CEUS评分为4分或5分或ARFI中的剪切波速度（shear-wave velocity, SWV）≥4.28 m/s时判断为恶性，此时可以检出86.4%的不伴钙化的恶性NMLs病灶。
结论: 伴有钙化的乳腺NMLs恶性风险高，均建议行病理学检查明确诊断；不伴钙化的乳腺NMLs可以联合多模态超声检查，有助于提高诊断效能。
Keywords: Acoustic radiation force impulse; Breast lesions; Contrast-enhanced ultrasound; Non-mass-like; Ultrasound.
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