A Prospective Multicenter Study on the Additive Value of Contrast-Enhanced Ultrasound for Biopsy Decision of Ultrasound BI-RADS 4 Breast Lesions

Objective: The main aim of this study was to determine whether the use of contrast-enhanced ultrasound (CEUS) could improve the categorization of suspicious breast lesions based on the Breast Imaging Reporting and Data System (BI -RADS), thereby reducing the number of benign breast lesions referred for biopsy. Methods: This prospective study, conducted between January 2017 and December 2018, enrolled consenting patients from eight teaching hospitals in China, who had been diagnosed with solid breast lesions classi fied as BIRADS 4 using conventional ultrasound. CEUS was performed within 1 wk of diagnosis for reclassi fication of breast lesions. Histopathological results obtained from core needle biopsies or surgical excision samples served as the reference standard. The simulated biopsy rate and cancer-to-biopsy yield were used to compare the accuracy of CEUS and conventional ultrasound (US). Results: Among the 1490 lesions diagnosed as BI -RADS 4 with conventional ultrasound, 486 malignant and 1004 benign lesions were con firmed based on histology. Following CEUS, 2, 395, and 211 lesions were reclassi fied as CEUS-based BI -RADS 2, 3, and 5, respectively, while 882 (59%) remained as BI -RADS 4. The actual cancer-tobiopsy yield based on US was 32.6%, which increased to 43.4% when CEUS-based BI -RADS 4A was used as the cut-off point to recommend biopsy. The simulated biopsy rate decreased to 73.4%. Overall, in this preselected BIRADS 4 population, only 2.5% (12/486) of malignant lesions would have been miscategorized as BI -RADS 3 using CEUS-based reclassi fication. The diagnostic accuracy, sensitivity, and speci ficity of contrast-enhanced ultrasound reclassi fication were 57.65%, 97.53%, and 38.35%, respectively. Conclusion: Our collective findings indicate that CEUS is a valuable tool in further triage of BI -RADS category 4 lesions and facilitates a reduction in the number of biopsies while increasing the cancer-to-biopsy yield.