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Operator Dependence of Physician-performed Whole-Breast US: Lesion Detection and Characterization¹

¹ From Breast Imaging Consultant, American Radiology Services, Johns Hopkins Green Spring, 10755 Falls Rd, Suite 440, Lutherville, MD 21093 (W.A.B.); Center for Statistical Sciences, Brown University, Providence, RI (J.D.B., J.B.C.); and Department of Radiology, Northwestern University School of Medicine, Chicago, Ill (E.B.M.). Received October 19, 2005; revision requested December 9; revision received January 20, 2006; final version accepted February 8. Supported by a grant from the Avon Foundation. Address correspondence to W.A.B. (e-mail: wendieberg{at}hotmail.com).

View larger version (153K): [in this window] [in a new window] [Download PPT slide]   Figure 1a: (a) Radial and (b) transverse US images (L12–5-MHz transducer; HDI 5000, ATL/Philips) show a mass (denoted by calipers in b) classified as an irregular, hypoechoic, solid mass with calcifications, assessed as BI-RADS category 4A by five observers; 4B by one observer; 4C by one observer; and 5 by one observer, all with recommendation for biopsy. Three observers described this as BI-RADS category 3, with recommendation for short-interval follow-up. The observer in b classified this as a complicated cyst. Because of the consensus recommendation for biopsy, its suspicious appearance on multiple images, and some uncertainty about this correlating with a prior biopsy site, US-guided core biopsy was performed, which showed a collagen plug with clip (arrow) from prior stereotactic biopsy.

View larger version (177K): [in this window] [in a new window] [Download PPT slide]   Figure 1b: (a) Radial and (b) transverse US images (L12–5-MHz transducer; HDI 5000, ATL/Philips) show a mass (denoted by calipers in b) classified as an irregular, hypoechoic, solid mass with calcifications, assessed as BI-RADS category 4A by five observers; 4B by one observer; 4C by one observer; and 5 by one observer, all with recommendation for biopsy. Three observers described this as BI-RADS category 3, with recommendation for short-interval follow-up. The observer in b classified this as a complicated cyst. Because of the consensus recommendation for biopsy, its suspicious appearance on multiple images, and some uncertainty about this correlating with a prior biopsy site, US-guided core biopsy was performed, which showed a collagen plug with clip (arrow) from prior stereotactic biopsy.

View larger version (10K): [in this window] [in a new window] [Download PPT slide]   Figure 2: Scatterplot of empirically observed detection rate against each lesion's mean diameter for each of 88 lesions in 22 breasts evaluated at US by 11 experienced breast radiologists. Solid line displays best fit from a nonlinear model describing the dependent relationship of detection rate on lesion diameter. Lesions larger than 13 mm were excluded for convergence of the best-fit model but were otherwise included in analyses. Lesion detection increased 12% per millimeter with increasing lesion diameter between 3 and 13 mm.

View larger version (96K): [in this window] [in a new window] [Download PPT slide]   Figure 3: Transverse US image (L13–6.5-MHz transducer; Hi Vision 8500, Hitachi Medical Systems America) shows 31-mm (maximum diameter) oval, circumscribed hypoechoic mass (denoted by calipers) detected at US by 10 (91%) of 11 investigators. This patient had multiple, bilateral similar masses and had undergone biopsy of this palpable fibroadenoma. The one observer who overlooked this lesion scanned this participant at the end of 12 hours of scanning, which suggests that fatigue played a role in overlooking it.

View larger version (186K): [in this window] [in a new window] [Download PPT slide]   Figure 4a: Radial US images (L12–5-MHz transducer; HDI 5000, ATL/Philips) show a serpiginous fibroadenoma (denoted by calipers) that was difficult for observers to consistently measure. Measurement of lesion size was generally highly reliable, with an ICC of 0.80 for the largest horizontal lesion diameter. (a) The largest diameter by one observer was 27 mm, and (b) the smallest measurement of the same diameter was 9 mm.

View larger version (176K): [in this window] [in a new window] [Download PPT slide]   Figure 4b: Radial US images (L12–5-MHz transducer; HDI 5000, ATL/Philips) show a serpiginous fibroadenoma (denoted by calipers) that was difficult for observers to consistently measure. Measurement of lesion size was generally highly reliable, with an ICC of 0.80 for the largest horizontal lesion diameter. (a) The largest diameter by one observer was 27 mm, and (b) the smallest measurement of the same diameter was 9 mm.

View larger version (183K): [in this window] [in a new window] [Download PPT slide]   Figure 5a: Radial US images (L12–5-MHz transducer; HDI 5000, ATL/Philips) show discrepancy in lesion characterization and resultant management by two observers. This 9 x 6-mm lesion (denoted by calipers) was thought to be (a) a low-suspicion hypoechoic solid mass by one observer, with recommendation for biopsy, and (b) a benign anechoic cyst by the other 10 observers. Proper adjustment of gain, dynamic range, and focal zone settings is critical to proper US distinction of cystic and solid lesions. In a, the gain is too high. Spatial compounding was used by observers for both a and b: Posterior enhancement is not well seen.

View larger version (183K): [in this window] [in a new window] [Download PPT slide]   Figure 5b: Radial US images (L12–5-MHz transducer; HDI 5000, ATL/Philips) show discrepancy in lesion characterization and resultant management by two observers. This 9 x 6-mm lesion (denoted by calipers) was thought to be (a) a low-suspicion hypoechoic solid mass by one observer, with recommendation for biopsy, and (b) a benign anechoic cyst by the other 10 observers. Proper adjustment of gain, dynamic range, and focal zone settings is critical to proper US distinction of cystic and solid lesions. In a, the gain is too high. Spatial compounding was used by observers for both a and b: Posterior enhancement is not well seen.