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Using ultrasound to examine lumps and suspicious areas of the breast may be an effective alternative to biopsy for women under 40, researchers reported at Radiological Society of North America (RSNA 2009).

In two analyses, targeted ultrasound correctly distinguished between cancerous and benign lesions in the majority of cases, Constance Lehman, MD, of the University of Washington, and colleagues reported at RSNA 2009.

"Ultrasound is a valuable tool in evaluating focal signs in women under 40," Lehman said. "The high sensitivity supports use of ultrasound over surgical excision."

She said that a targeted ultrasound is typically performed for women under 40 with palpable masses. However, little data exists on outcomes, and there are lingering questions about the need for concurrent mammography and the safety of ultrasound surveillance compared with biopsy. So to determine imaging accuracy and malignancy outcomes, the researchers conducted a retrospective review of all breast ultrasound examinations performed at their facility between 2002 and 2006 in two separate studies.

In the first study, the researchers evaluated the accuracy of ultrasound as a primary diagnostic modality in women younger than 30 who had breast lumps. They also evaluated whether ultrasound surveillance had advantages over tissue sampling.

"We wanted to know, is it safe to follow a patient with ultrasound rather than perform surgery?" Lehman said.

Patients received either 24 months of imaging surveillance or biopsy. A total of 1,091 lesions were examined in 830 women. The researchers found that in two-thirds of patients, the lesions were identified as benign using ultrasound, and none were cancerous -- a 100% sensitivity.

A total of 17% of patients were classified as moderate risk for cancer via the ultrasound and were recommended for ultrasound surveillance. The remaining 20% were classified as high-risk, and were referred for biopsy.

Lehman said there were only three cases of cancer in the 164 women who had been referred for biopsy. The test's specificity, she said, was 79.3%. She added that 33% of those who were recommended for close surveillance wound up having a biopsy, most often because they requested it. None of their lesions were malignant.

"Patients often want tissue sampling anyway," Lehman said. "But if we have confidence in our imaging tools, we can give women more security that they can be surveilled [with imaging] rather than having an intervention."

For the second study, the researchers looked at data on women ages 30 to 39, evaluating 1,327 palpable masses in 1,032 patients. In this age group, they found that 98% of examined lumps were benign, which is "reassuring for women," but still calls attention to the 2% malignancy rate in this young age group, Lehman said.

Again, all masses were correctly detected by ultrasound, making for a 100% sensitivity, but the specificity of the diagnostic test was still lower at 89%. Lehman noted that its specificity precludes ultrasound from being a useful screening tool.

"Ultrasound is a fantastic tool in the diagnostic setting," she said. "But we have not found it to have the performance we need to use it as a screening tool."

The findings are "timely with the U.S. Preventive Services Task Force (USPSTF) recommendations that women don't perform self-examinations," Lehman said. "Women will identify certain areas" that are potentially cancerous via such exams.

Fewer than 2% of women under 40 who present with palpable masses or localized pain actually have cancer, she said, but this figure is not something to which to turn a blind eye.

"Dr. Lehman's study shows that we can be comfortable in starting out diagnostic workup with ultrasound in these women," said Joseph Tashjian, MD, of St. Paul Radiology in St. Paul, Minn. "We have had the same experience as Dr. Lehman with ultrasound. We find it very reliably answers the question as to whether the lesion is cancer or normal breast tissue."

Source: RSNA

Discuss more about RSNA 2009 in our RSNA Conference Group