Clinically and mammographically occult breast lesions: detection and classification with high-resolution sonography

With recent significant advances in ultrasound technology, the potential of high-resolution sonography to improve the sensitivity of cancer diagnosis in women with dense breasts has become a matter of interest for breast imagers. To determine how often physician-performed high-resolution sonography can detect nonpalpable breast cancers that are not revealed by mammography, 8,970 women with breast density grades 2 through 4 underwent high-resolution sonography as an adjunct to mammography. All sonographically detected, clinically and mammographically occult breast lesions that were not simple cysts were prospectively classified into benign, indeterminate, or malignant categories. Diagnoses were confirmed by ultrasound-guided fine-needle aspiration, core-needle biopsy, or surgical biopsy. In 8,103 women with normal findings at mammography and physical examination, 32 cancers and 330 benign lesions were detected in 273 patients with sonography only. Eight additional cancers were found in 867 patients with a malignant (n = 5) or a benign (n = 3) palpable or mammographically detected index lesion. The overall prevalence of cancers detected with screening sonography was 0.41%, and the proportion of sonographically detected cancers to the total number of nonpalpable cancers was 22%. The mean size of invasive cancers detected only by sonography was 9.1 mm, and was not statistically different from the mean size of invasive cancers detected by mammography. The sensitivity of prospective sonographic classification for malignancy was 100%, and the specificity was 31%. In conclusion, the use of high-resolution sonography as an adjunct to mammography in women with dense breasts may lead to detection of a significant number of otherwise occult cancers that are no different in size from nonpalpable mammographically detected cancers. Prospective classification of these lesions based on sonographic characteristics resulted in an acceptable benign-to-malignant biopsy rate of 6.3:1.