Multiparametric High-resolution 3-D Sonography With Color/Power-Doppler, Elastography and Contrast-enhanced Sonography for an Improved Detection and Characterization of Breast Tumors
Phase: NA
Conditions: Breast Cancer
Sponsor: Medical University of Vienna

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Multiparametric high-resolution sonography with Color/Power-Doppler, 
elastography and contrast-enhanced sonography for an improved 
detection and characterization of breast tumors. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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1. Introduction 
 
The value of mammography in breast cancer screening and diagnosis is 
unquestioned. Yet mammography has certain limitations, especially in women 
with dense breasts, with a considerable decrease in sensitivity and specificity 
(1). Ultrasound (US) is an established adjunct to mammography for further 
characterization of mammographically detected breast lesions, for lesion 
detection in women with dense breasts (ACR 3 and 4) (2), and due to the lack 
of ionising radiation is the method of choice in younger women.  
When using established criteria for the assessment of the probability of 
malignancy with  B-mode US (2, 3), it has a high diagnostic performance with 
sensitivities ranging from 94 to 95.4% and specificities ranging from 83 to 
87.4%) (4, 5). In B-mode breast US a malignant mass is typically round or 
irregularly shaped, vertically orientated to the skin, markedly hypoechoic and 
demonstrates a non circumscribed margin and posterior shadowing. Yet there 
are several benign or pre- cancerous lesions that demonstrate one or more of 
these characteristics, whereas malignant tumors do not always present with a 
typical morphology. In order to improve sonographic detection and especially 
characterization of breast lesions, other US examination modes and techniques 
apart from standard B-mode such as elastography, Color Doppler, contrast-
enhanced and 3D imaging have been developed and are currently under 
investigation. 
 Elastography measures the strain induced by probe compression on the 
breast. Based on the fact that breast cancer is in most cases stiffer than 
unaffected breast parenchyma, several studies have demonstrated an 
increase in specificity of conventional US by the addition of elastography 
(4-9). 
 One of the hallmarks of malignant tumors is tumor neoangiogenesis. 
Therefore studying the vascularization features of breast tumors by the 
means of Color and Power Doppler US helps to differentiate breast 
cancer from benign lesions (9-12).  
 Contrast-enhanced US assessing kinetic properties of breast tumors, 
especially with the use of second generation contrast agents, has been 

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investigated by several authors and shown promising results (13-19). 
Nevertheless different contrast agents and dosages have led to a certain 
degree of discordance among publications (16, 17). 
 3D imaging obtains reconstructions in the coronal plane and allows an 
improved depiction of the tumor interface, a valuable sonographic 
descriptor for differentiation of benign and malignant lesions (3, 20-22). 
 
Cho et al (9) have shown that the addition of elastography and Color Doppler 
to B-mode US can lead to a higher accuracy and sensitivity. Yet up to now there 
are no published studies evaluating the possible benefit of a multiparametric 
approach by adding elastography, Color Doppler, contrast-enhanced and 3D 
studies to B-mode US. 
 
1.1 State of the art 
 
2D B-mode ultrasound has been established as an adjunct to mammography 
for both screening and diagnostic purposes in women with dense breast 
parenchyma, for further characterization of clinically or mammographically 
detected lesions, for follow up and for guiding interventional procedures (2, 23). 
Elastography, Color Doppler and contrast-enhanced sonography are applied 
for an improved differentiation of benign from malignant lesions, whereas 3D 
ultrasound mainly offers better conspicuity of lesions and their interface with 
normal surrounding tissue.  
 
1.2 Clinical perspective and study aim 
 
In this prospective study we will perform multiparametric high resolution 
ultrasound in patients with known suspicious breast lesions (BI-RADS 4 and 5). 
We will acquire morphologic by conventional B-mode and 3D US and functional 
information about the lesions by examination of tumor vascularity and structure 
as expressed by means of stiffness. It can be expected that with this 
multiparametric US imaging an increased sensitivity and especially specificity 
of US of the breast can be achieved.  
 

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2. Patients and Methods 
 
Over a period of 24  months 120 patients with breast lesions categorized as BI-
RADS 4 and 5 (3) will be included in this prospective study- that means patients 
with suspicious lesions, planned to undergo an image-guided biopsy or surgery. 
This number of patients is necessary for a hypothesized improvement of the 
AUC by 10% (from 0.8 to 0.9) with a type I error of 5% and a type II error of 
20%. The recruitment of patients will take place immediately after a breast 
clinical or imaging examination (mammography, ultrasound or MRI of the 
breast) demonstrating a suspicious breast lesion as described previously. All 
patients will be examined with multiparametric ultrasound. Contrast-enhanced 
examination will be conducted subsequently to the non contrast-enhanced one. 
The whole examination time will be approximately 30 minutes. Histopathology 
with either image-guided biopsy or surgery will be used as the standard of 
reference. Both in situ and invasive carcinomas will be regarded as a malignant 
(positive) result whereas benign and precursor lesions will be regarded as a 
benign (negative) result. In case of an image-guided biopsy, this will be 
performed immediately after the sonographic examination, whereas in the 
cases of planned surgery, this will be performed according to the planning of 
the respective Departments of Surgery or Gynecology.  
 
2.1 Inclusion criteria 
 
- 
Clinical, mammographic, MR-tomographic and/or ultrasonographic 
verification of a suspicious breast lesion (BIRADS 4 and 5) 
- 
Age > 18 years 
- 
Written informed consent 
- 
Histopathological verification of the lesions either by core biopsy or by 
surgical excision 
 
2.2 Exclusion criteria 
- 
Unstable or non-compliant patients 
- 
Pregnant or lactating patients or patients with suspected pregnancy 

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- 
Known contraindication to the intravenous administration of US contrast 
agents  
- 
Acute or chronic renal insufficiency 
- 
Pre- or post-transplant patients 
 
2.3 Imaging technique and evaluation 
 
All patients will be examined using a CE certified Siemens Accuson S3000 
ultrasound device, which is used for routine examinations in our department.  
 
2.3.1 B-mode 2D/3D examination 
 
2.3.1.1 Technique 
For the B-mode examinations an 18L6HD linear transducer will be used. The 
settings that will be used are the following: Dynamic Range 75 dB, Custom 
Tissue Imaging 1, ASC 3, High Dynamic Tissue Contrast Enhancement, Margin 
3, Persistence 3 and Space/Time encoding 3. For 3D imaging a data volume 
will be acquired and coronal plane images will be saved. 
 
2.3.1.2 Image evaluation 
Image evaluation of the B-mode ultrasound will be performed according to the 
revised ACR BI-RADS lexicon for ultrasound 5th edition, (3). Lesions will be 
evaluated for shape (oval, round or irregular), orientation (parallel or not), 
margin (circumscribed, microlobulated, indistinct, angular or spiculated), 
internal 
echogenicity 
(anechoic, 
hyperechoic, 
isoechoic, 
hypoechoic, 
heterogeneous or complex cystic and solid) and posterior acoustic features 
(none, enhancement, shadowing or combined pattern). Additionally on the 
coronal plane the presence or absence of retraction will be noted (22). The 
number and exact size of lesions in all 3 dimensions will be documented. Finally 
the likelihood of malignancy will be reported according to the ACR BI-RADS 
lexicon (3), with 4a = low suspicion for malignancy; 4b = moderate suspicion 
for malignancy; 4c = high suspicion for malignancy and 5 = highly suggestive 
of malignancy. 
 

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2.3.2 Elastography examination 
 
2.3.2.1 Technique 
For Acoustic Radiation Force Impulse (ARFI) elastography a 9L4 linear 
transducer and the “Virtual Touch IQ™” mode will be used, with following 
settings: Dynamic Range 65dB, Space/Time encoding 3, Spatial Compounding 
Off and Medium Dynamic Tissue Contrast Enhancement, whereas the velocity 
scale will be set from 0,5 to 10 m/sec. The images will be obtained by using a 
rectangular ROI including the lesion and at least 5 mm of normal surrounding 
tissue. Three 2 x 2 mm quantification ROIs will be placed in the lesion in order 
to measure the shear-wave velocity inside the lesion, whereas another equally 
big quantification ROI will be placed on fat tissue at the same depth to measure 
shear-wave velocity in fat tissue (24, 25). 
 
2.3.2.2 Image evaluation 
The shape (oval, round or irregular) and homogeneity (very, reasonably or not 
homogeneous) of the lesion as well as the elasticity ratio (lesion to fat elasticity) 
will be assessed, as has been proposed by Berg et al for shear-wave 
elastography (24). Using three ROIs placed in the lesion, the mean, maximum 
and minimum elasticity of the lesion (measured as shear-wave velocity in 
m/sec) as proposed by Berg et al and Bai et al (25)will be calculated (24). 
 
2.3.3 Color/Power Doppler US examination 
 
2.3.3.1 Technique 
For Color/Power Doppler US examination a 18L6HD linear transducer will be 
used. The examination settings for the Color Doppler US examination will be 
as following: Dynamic Range 70dB, Low Flow, Smooth 3, Space/Time 
encoding 5, Persistence 2, Filter 0 and a PRF of 488. The settings for the Power 
Doppler examination will be the following: Dynamic Range 70dB, Low Flow, 
Smooth 2, Space/Time encoding 5, Persistence 2, Filter 1 and a PRF of 488. A 
ROI slightly bigger than the lesion will be used and cine clips of at least 5 sec 
per case will be saved. 
 

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2.3.3.2 Image evaluation 
We will evaluate the number and distribution of vessels within and around the 
lesion according to the schemes proposed by Raza et al (12) and Moon et al 
(15). A score of 0-2 will be attributed as follows: 0= no visible vessels in the 
lesion; 1= one or two peripheral or central vessels; 2= three or more peripheral 
or central vessels or one or more penetrating vessels. Furthermore the 
morphology of the vessels will be assessed, as A= regular (uniform in caliber 
and course) or B= irregular (caliber irregularities, tortuous course) (26). 
 
2.3.4 Contrast-enhanced examination 
 
2.3.4.1Technique 
The contrast agent used will be a CE certified standard US contrast agent 
approved for breast diagnostics by the Austrian Federal Office for Safety in 
Health Care (27), injected intravenously as a bolus at a dose of 0.03 ml (0,24 
μl of sulphur hexafluoride microbubbles) per kg of body weight. Every injection 
will be followed by a flush with 5 ml of sodium chloride 9 mg/ml (0.9%) solution. 
The contrast-enhanced US examinations will be conducted using a 9L4 linear 
transducer and the following settings: Frame Rate 23 I/sec, Dynamic Range 
80dB, Margin 3, Persistence 3, Space/Time encoding 3, MI 0,06 and MIF 0,05. 
 
2.3.4.2 Image evaluation 
For the evaluation of contrast-enhanced examinations the number and 
distribution as well as the morphology of vessels will be reevaluated, similarly 
as in the pre- contrast studies (12, 15, 26). Furthermore the degree of 
enhancement will be characterized as minimal (no additional vessels), 
moderate (one or two additional vessels) or marked (three or more additional 
vessels), as proposed by Moon et al (15). Finally dynamic features, i.e. Time 
To Peak (TTP) enhancement  and the time until the elevated signal returns to 
baseline levels, will be noted (17). Any cases of prolonged (>5 min) 
enhancement will be recorded, as has been proposed by Jung et al (18). 
 
2.4 Evaluation of multiparametric ultrasonographic data 
 

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After evaluation of US data for clinical purposes two radiologists blinded to the 
findings of the other imaging modalities or the histopathological diagnosis, will 
evaluate the multiparametric US data acquired according to the above 
mentioned criteria. Results of multiparametric US will be compared to the 
results of B-mode ultrasound. 
 
2.5 Statistical evaluation 
 
A McNemar test will be applied to the B-mode ultrasound alone and B-mode 
ultrasound with additional ultrasonographic examinations positive and negative 
results to determine statistical independence. ROC analysis will be performed 
to estimate the overall performance of B-mode ultrasound and multiparametric 
ultrasound. Using the histopathological data the numbers of true-negative (TN), 
true-positive (TP), false-negative (FN) and false-positive (FP) results for B-
mode ultrasound and multiparametric US will be obtained and sensitivity, 
specificity, accuracy, positive predictive value (PPV) and negative predictive 
value (NVP) for both methods will be calculated. 
 
3. Timetable 
 
September 2015 
Obtaining IRB approval 
September 2015 to April 2017 
Multiparametric ultrasound examinations  
 
according to protocol  
May/June 2017 
Statistical evaluation 
July to September 2017 
Preparation and submission of manuscripts 
 
AMENDMENT TO THE STUDY PROTOCOL 
 
Treatment of early breast cancer is usually surgical, comprising breast-
conserving surgery for small, unifocal tumors, or mastectomy for larger or 
multicentric tumors. However, in women with locally aggressive disease or 
whose tumors display features that are predictive of early recurrence, 
neoadjuvant chemotherapy (NAC) is given to reduce the risk of recurrence. The 
early identification of chemotherapy responders and non-responders is crucial 

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in order to allow chemotherapy scheme modifications or changes to surgery or 
hormonal therapy, and thus provide optimal patient outcomes. Yet tumor 
response to NAC can be very different, resulting in fibrosis, concentric 
shrinking, fragmentation or change in the density of malignant tissue. All of 
these may affect the evaluation of residual tumor size (28).  
Evaluation of tumor response to NAC is routinely done by using solely 
morphologic criteria (size reduction in mammography or B-mode ultrasound 
(US)), with US being more accurate than mammography in the evaluation of 
residual tumor size after NAC (28), showing a moderate correlation with the 
final histopathologic tumor size (29).  
However, the potentials of a multiparametric (mp) US have not yet been 
explored. We hypothesize that a functional imaging of the breast using high-
resolution mp US allows an improved monitoring of therapy-induced changes 
before morphologic changes are visible (e.g. tumor-shrinkage). Our approach 
focuses on the assessment of specific imaging biomarkers, which help to 
differentiate treatment responders from non-responders immediately after 
onset of NAC. The aim of this study-phase is to acquire mp US data with 
CP/PD, elastography and CEUS for an improved assessment of early treatment 
response. 
For this reason, 40 patients with breast cancer undergoing NAC will be imaged 
before, during and after NAC/pre-surgery with mp US imaging of the breast. 
This number of patients is necessary for a hypothesized improvement of the 
AUC by 20% (from 0.7 to 0.9) with a type I error of 5% and a type II error of 
20%. The participants to this part of the study will be recruited among the 
patients, already taking part in the first part of the study and planned to receive 
a NAC, according to the recommendations of the interdisciplinary tumor board. 
Due to different underlying biochemical processes of the different US 
modalities, it can be assumed that the single modalities may have different time 
frames for the early detection of therapy-induced changes- yet literature data 
on this subject are sparse. To monitor therapy response, the patients will 
receive a baseline mp US examination (as already planned in the study 
protocol) and an additional mp US examinations on the 3rd day after the 1st 
cycle, in order to evaluate possible initial changes in tumor morphologic and 
functional parameters, induced by NAC, which might allow for an early 

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prediction of histologic response. Patients will be examined again in the week 
after the 2nd, 4th and 6th (last) cycles of NAC. In cases where 8 NAC cycles 
will be necessary, a further examination will be planned after the 8th cycle. 
The image analysis will be conducted as described in the original study 
protocol. 
Qualitative and quantitative imaging parameters will be correlated with 
histopathological tumor grade, microvascular density as an indicator of tumor-
neoangiogenesis, hormone receptor status and other newer factors such as 
HER2-neu proliferative indices and gene expression profile before and after 
NAC. 
For the assessment of treatment response, functional imaging data of the 
baseline examination and of the examinations after the 1st, 2nd, 4th and 6th 
(+/- 8th) cycle will be compared for therapy-induced changes of both lesion 
morphology and functional capabilities by two experienced radiologists 
independently.  
The statistical evaluation will be performed as described in the original study 
protocol. 
 
CHANGES IN THE STUDY PROTOCOL 
- Additional mp US examinations after the first, second, fourth and sixth (and 
after the eighth, if 8 NAC cycles are necessary) cycle of NAC. 
- Correlation of qualitative and quantitative imaging parameters with 
histopathological tumor grade, microvascular density, hormone receptor status, 
HER2-neu, proliferative indices and gene expression profile before and after 
NAC. 
 
 

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4. Literature 
 
1. Carney PA, Miglioretti DL, Yankaskas BC, et al. Individual and combined effects of 
age, breast density, and hormone replacement therapy use on the accuracy of screening 
mammography. Ann Intern Med 2003;138:168-175. 
2. Stavros AT. Breast ultrasound. Philadelphia: Lippincott, Williams and Wilkins; 
2004. 
3. Mendelson EB, Böhm-Vélez M, Berg WA, et al. ACR BI-RADS® Ultrasound.  ACR 
BI-RADS® Atlas, Breast Imaging Reporting and Data System. Reston, VA: American 
College of Radiology, 2013. 
4. Thomas A, Kummel S, Fritzsche F, et al. Real-time sonoelastography performed in 
addition to B-mode ultrasound and mammography: improved differentiation of breast 
lesions? Acad Radiol 2006;13:1496-1504. 
5. Scaperrotta G, Ferranti C, Costa C, et al. Role of sonoelastography in non-palpable 
breast lesions. Eur Radiol 2008;18:2381-2389. 
6. Itoh A, Ueno E, Tohno E, et al. Breast disease: clinical application of US 
elastography for diagnosis. Radiology 2006;239:341-350. 
7. Garra BS, Cespedes EI, Ophir J, et al. Elastography of breast lesions: initial clinical 
results. Radiology 1997;202:79-86. 
8. Gheonea IA, Donoiu L, Camen D, et al. Sonoelastography of breast lesions: a 
prospective study of 215 cases with histopathological correlation. Rom J Morphol 
Embryol 2011;52:1209-1214. 
9. Cho N, Jang M, Lyou CY, et al. Distinguishing benign from malignant masses at 
breast US: combined US elastography and color doppler US--influence on radiologist 
accuracy. Radiology 2012;262:80-90. 
10. Delorme S AH, Knopp MV, Zuna I, Junkermann I, von Fournier D, van Kaick G. 
Breast cancer: assessment of vascularity by Color Doppler. Eur Radiol 1993 3:253-257. 
11. del Cura JL, Elizagaray E, Zabala R, et al. The use of unenhanced Doppler 
sonography in the evaluation of solid breast lesions. AJR Am J Roentgenol 
2005;184:1788-1794. 
12. Raza S, Baum JK. Solid breast lesions: evaluation with power Doppler US. 
Radiology 1997;203:164-168. 
13. Huber S, Helbich T, Kettenbach J, et al. Effects of a microbubble contrast agent on 
breast tumors: computer-assisted quantitative assessment with color Doppler US--early 
experience. Radiology 1998;208:485-489. 
14. Kedar RP, Cosgrove D, McCready VR, et al. Microbubble contrast agent for color 
Doppler US: effect on breast masses. Work in progress. Radiology 1996;198:679-686. 
15. Moon WK, Im JG, Noh DY, et al. Nonpalpable breast lesions: evaluation with 
power Doppler US and a microbubble contrast agent-initial experience. Radiology 
2000;217:240-246. 
16. Wenhua D, Lijia L, Hui W, et al. The clinical significance of real-time contrast-
enhanced ultrasonography in the differential diagnosis of breast tumor. Cell Biochem 
Biophys 2012;63:117-120. 
17. Balleyguier C, Opolon P, Mathieu MC, et al. New potential and applications of 
contrast-enhanced ultrasound of the breast: Own investigations and review of the 
literature. Eur J Radiol 2009;69:14-23. 
18. Jung EM, Jungius KP, Rupp N, et al. Contrast enhanced harmonic ultrasound for 
differentiating breast tumors - first results. Clin Hemorheol Microcirc 2005;33:109-
120. 

V6 28/08/16 
19. Caproni N, Marchisio F, Pecchi A, et al. Contrast-enhanced ultrasound in the 
characterisation of breast masses: utility of quantitative analysis in comparison with 
MRI. Eur Radiol 2010;20:1384-1395. 
20. Rotten D, Levaillant JM, Zerat L. Analysis of normal breast tissue and of solid 
breast masses using three-dimensional ultrasound mammography. Ultrasound Obstet 
Gynecol 1999;14:114-124. 
21. Weismann CF, Datz L. Diagnostic algorithm: how to make use of new 2D, 3D and 
4D ultrasound technologies in breast imaging. Eur J Radiol 2007;64:250-257. 
22. Kotsianos D, Wirth S, Fischer T, et al. [3D ultrasound (3D US) in the diagnosis of 
focal breast lesions]. Radiologe 2005;45:237-244. 
23. Performance and practice guidelines for breast ultrasound.: The American Society 
of Breast Surgeons; 2010. 
24. Berg WA, Cosgrove DO, Dore CJ, et al. Shear-wave elastography improves the 
specificity of breast US: the BE1 multinational study of 939 masses. Radiology 
2012;262:435-449. 
25. Bai M, Du L, Gu J, et al. Virtual touch tissue quantification using acoustic radiation 
force impulse technology: initial clinical experience with solid breast masses. J 
Ultrasound Med 2012;31:289-294. 
26. Ozdemir A, Kilic K, Ozdemir H, et al. Contrast-enhanced power Doppler 
sonography in breast lesions: effect on differential diagnosis after mammography and 
gray scale sonography. J Ultrasound Med 2004;23:183-195; quiz 196-187. 
27. Bundesamt für Sicherheit im Gesundheitswesen. BASG-Brief - 141201_SonoVue. 
28. Keune JD, Jeffe DB, Schootman M, et al. Accuracy of ultrasonography and 
mammography in predicting pathologic response after neoadjuvant chemotherapy for 
breast cancer. Am J Surg 2010;199:477-484. 
29. Roubidoux MA, LeCarpentier GL, Fowlkes JB, et al. Sonographic evaluation of 
early-stage breast cancers that undergo neoadjuvant chemotherapy. J Ultrasound Med 
2005;24:885-895.