Searching for a twinkling artefact in breast microcalcifications using B-flow ultrasonic non-doppler technology: a prospective study
Authors: Gazhonova V. E. , Popova A. Yu. , Mironova E. V. 
Published: April 2024

INTRODUCTION: The rapid rejuvenation of breast cancer in recent years has made it necessary to look for non-X-ray methods of imaging microcalcifications in women not yet covered by mammography screening. Developing technologies to see these microcalcifications on ultrasound is a promising goal, potentially reducing the number of unnecessary biopsies.

OBJECTIVE: Evaluation of factors influencing the ability of the B-flow technique to detect the presence of a flickering artifact in patients with microcalcifications detected by mammography.

MATERIALS AND METHODS: A prospective study of 57 patients with microcalcifications detected on mammograms was conducted. The Nondoppler technology of B-flow ultrasound examination was used for targeted ultrasound with the search for these areas during ultrasound. The possibilities of visualization of the twinkle artifact were evaluated for various microcalcifications in size, distribution, their number, and for pathological processes of different nature. Images in B-flow mode were found to be positive when a bright local flash occurred against a dark background in B-mode. Verification of diagnostic findings was performed by ultrasound-guided core- biopsy from areas with a twinkle artifact (in the presence of an imaging area during ultrasound) or with stereotactic biopsy (in the absence of visualization of the suspicious area with ultrasound with B-flow).

Statistics: The ANOVA test was used for triple pairwise comparisons between positive groups. The p<0.05 value was considered statistically significant.

RESULTS: According to the results of the study, out of 57 cases with microcalcifications, 34 (60%) recorded a twinkle artifact. The amount of microcalcifications with a visualized twinkle effect in B-flow was significantly higher in benign processes 34 (82.9%) out of 41, and less often in malignant 8 (50%) out of 16 (p=0.035). The effect of calcification morphology on the mammogram on their detection by ultrasound in the B-flow mode (p=0.035) was statistically significant. The most frequently manifested twinkle artifact were rounded, regular-shaped calcifications in 19 (95%) out of 20, which were found in granulomatous mastitis, fibrocystic changes, fibroadenomas, sclerosing adenosis, as well as polymorphic calcifications in 7 (63.6%) of 11. In the B-flow mode, it was not possible to obtain a twinkle artifact mainly with point small calcifications of 9 (69.2%) out of 13, and in all cases with linear or linear branching calcifications. In amorphous microcalcifications, the characteristics of background echogenicity and the presence or absence of a nodal component in the gray scale mode had a much greater influence on the appearance of the twinkle effect in the normal B-mode, whereas in the B-flow mode, these characteristics did not have a decisive effect on the appearance of a flickering artifact (p=0.8). The density of distribution of microcalcifications, the size of calcifications, the final pathomorphology, mammography characteristics, the background environment during ultrasound by the presence or absence of nodular formation and anechoic zones, did not affect the appearance of a bright flash in the B-flow mode.

DISCUSSION: The density of calcification distribution was not decisive for the appearance of a shimmering artifact in the B-flow mode. The flicker artifact is recorded both in grouped microcalcifications and in single ones. B-flow can help to detect calcifications that are not visible in the usual B-flow mode due to the lack of pronounced tissue contrast. But this artifact cannot be used to differentiate between benign and malignant processes.

CONCLUSION: The B-flow technique is promising for clarifying the twinkle artifact in the detected microcalcifications on the mammogram, which could potentially increase the incidence of ultrasound-guided trephine biopsies by detecting more areas with microcalcification accumulations.