Role of elasticity imaging/B-mode imaging ratio in the evaluation of solid breast lesions

SA Journal of Radiology ISSN: (Online) 2078-6778, (Print) 1027-202X Page 1 of 5 Original Research Role of elasticity imaging/B-mode imaging ratio in the evaluation of solid breast lesions Authors: Asif I. Tamboli1 Abhijit A. Gadpalliwar1 Raghav Agarwal1 Chaitali V. Ukirade1 Affiliations: 1 Department of Radiodiagnosis, Krishna Institute of Medical Sciences, Krishna Vishwa Vidyapeeth, Karad, India Corresponding author: Asif Tamboli, Dates: Received: 26 Mar. 2025 Accepted: 05 May 2025 Published: 23 July 2025 How to cite this article: Tamboli AI, Gadpalliwar AA, Agarwal R, Ukirade CV. Role of elasticity imaging/B-mode imaging ratio in the evaluation of solid breast lesions. S Afr J Rad. 2025;29(1), a3158. https:// doi.org/10.4102/sajr. v29i1.3158 Copyright: © 2025. The Authors. Licensee: AOSIS. This work is licensed under the Creative Commons Attribution License. Background: Ultrasound elastography, with the measurement of the lesional width ratio between elasticity imaging (EI) and B-mode image (BI) (EI/BI), provides a non-invasive method for breast cancer (BC) characterisation. Evidence from a limited number of researchers supporting the efficacy of this ratio in avoiding unnecessary biopsies warrants further exploration. Objectives: To assess the role of the EI/BI ratio in the evaluation of solid breast lesions and correlate the findings with histopathological results. Method: The study enrolled 54 female patients with clinically palpable breast lesions, nonpalpable breast lesions (seen on mammography or ultrasound) and high-risk female participants with a positive family history of BC. Using ultrasound elastography, the EI/BI ratio was calculated and correlated with the histology using the Chi-square test and Cramer’s V test. Results: The mean age was 41.9 ± 11.8 years, and 59.2% had fibroadenomas. The EI/BI ratio was ≥ 1 in 16 (29.6%) cases, where malignancy was confirmed on histology in all cases. Thirty-eight cases were benign as per the EI/BI ratio (< 1), of which 2 were found to be malignant. A significant correlation was seen between the EI/BI ratio and histopathology findings (p < 0.001). The specificity, sensitivity, positive and negative predictive values and diagnostic accuracy of the EI/BI ratio were 100%, 88.9%, 94.7%, 100% and 96.3%, respectively. Conclusion: The EI/BI ratio is effective in differentiating between benign and malignant solid breast lesions, with a statistically significant correlation with histopathology. Contribution: The study validates the use of EI/BI ratio by radiologists to effectively differentiate between benign and malignant breast lesions in patients. Keywords: breast neoplasm; elasticity imaging techniques; ultrasound elastography; histopathology; EI/BI ratio. Introduction Breast cancer (BC) is the most common malignancy among women with an annual global incidence of 2.1 million, causing the highest number of cancer-related deaths in women.1 It is also the most predominant cancer among Indian female participants with prevalence and mortality rates as high as 25.8 and 12.7 per 100 000 women, respectively.2,3 Hence, screening and early detection are important for improving outcomes and survival in such patients.1 Mammography and ultrasound are the commonly employed diagnostic modalities for BC because of their high sensitivity.4 Nontheless, there is a likelihood that mammography may yield false-negative results when performed on dense breasts and ultrasound lacks specificity because solid lesions may be benign.5 To overcome this, the Breast Imaging-Reporting and Data System (BIRADS) was introduced by the American College of Radiology. However, the BIRADS criteria may also generate false positive results leading to unnecessary biopsies.6,7 Read online: Scan this QR code with your smart phone or mobile device to read online. A more accurate, non-invasive method used for BC evaluation is ultrasound elastography.4 It assesses the relative tissue stiffness by measuring the displacement (strain) in response to a mechanically applied force.8 A real-time analysis of the returning radiofrequency signals is acquired using the standard B-mode image (BI) algorithm and the compression elasticity imaging (EI) algorithm.9 The breast is the only organ where tumour size differs between BI and EI, with malignant lesions appearing larger in the latter, because of the invasive nature of BC.10 This allows diagnostic characterisation by measuring the ratio of the maximum diameter of the lesion on EI to that on BI (EI/BI = width ratio).11 This ratio has shown high sensitivity (99%) and specificity (87%) http://www.sajr.org.za Open Access Page 2 of 5 for values > 1 suggesting malignancy and < 1 implying benignity.12 The EI/BI ratio has also shown significant correlation with tumour grades.10 There is limited literary evidence that explores the use of ultrasound elastography in the potential diagnosis of BC. This research is therefore aimed at assessing the role of the EI/BI ratio in the evaluation of solid breast lesions and correlation of the findings with histopathological results in a tertiary care hospital in Karad, India. Research methods and design Original Research The lesion width was measured in the same location on the BI and EI. The EI/BI ratio (width ratio) was then calculated by dividing the maximal horizontal length of the lesion measured on the EI by the corresponding length measured on the BI. If an echogenic ring was present around the lesion on BI, it was not included in the measurement. An EI/BI ratio ≥ 1 was considered as malignant while < 1 as benign.10,12 Histopathological examination was conducted on biopsied samples from these lesions. The EI/BI ratio was correlated with the histopathology findings, extracted from the patient’s medical records. Study design and participants Statistical analysis A prospective, observational, analytical study was conducted at a tertiary care hospital in India, between 01 June 2024 and 31 December 2024. Female patients with clinically palpable and non-palpable breast lesions (seen on mammography or ultrasound) and high-risk female participants with a positive family history of BC, who were scheduled for breast ultrasound, were included after obtaining written informed consent. Patients with cystic breast lesions, recurrent BC following chemotherapy or radiotherapy, and pregnant women, were excluded. Data were compiled and analysed using Microsoft Excel and statistical software R version 3.6.3. Continuous variables were presented as mean ± standard deviation (s.d.) while categorical variables were presented as number (%). The Chisquare test was used to evaluate the association between attributes; a p value of ≤ 0.05 was considered statistically significant. Strength of association was measured by Cramer’s V/odds ratio. The sample size was calculated using Buderer’s formula (Equation 1)13: n = (Z21−α/2 × SN × [1− SN]) / (L2 × Prevalence) [Eqn 1] where, n = required sample size, (...truncated)