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October 28, 2026Beyond single cut-off values in ultrasound: limitations and implications for context aware radiology reporting
| Objectives |
Quantitative ultrasound frequently relies on single cut-off values to dichotomize continuous measurements into “normal” and “abnormal.” Although embedded in workflows and guidelines, their biological plausibility and their external validity may be limited in heterogeneous clinical populations and across different technical settings. This narrative review evaluates the conceptual foundations, clinical implications, and relevance of single cut-off values for contemporary radiology reporting. |
| Authors |
Schöpper I, Dohna M, Bansmann PM. Department of Diagnostic and Interventional Radiology, Hospital Porz am Rhein, Cologne, Germany. Department of Diagnostic and Interventional Radiology, Paediatric Radiology, University Hospital Bonn, Bonn, Germany |
| Journal |
Insights Imaging. 2026 Aug 17;17(1):204. doi: 10.1186/s13244-026-02371-9. |
| Methods |
Critical review of studies, consensus statements, and international guidelines published between 1991 and February 2026, predominantly via PubMed/MEDLINE, with emphasis on recent and clinically relevant evidence. Research on diagnostic accuracy, population-based studies, and methodological investigations was qualitatively synthesized to assess the biological, technical, and clinical limitations of fixed cut-off values in ultrasound. Studies and documents were prioritized if they fulfilled at least one of the following criteria: (1) they addressed methodological limitations of dichotomizing continuous biomarkers; (2) they provided empirical evidence for variability, overlap, or uncertainty of quantitative ultrasound measurements; (3) they represented consensus statements or guidelines relevant to clinical ultrasound reporting; (4) they illustrated clinically relevant examples in which fixed thresholds are widely used; or (5) they discussed probabilistic, percentile-based, multivariable, or longitudinal interpretation strategies. As this article was not designed as a systematic review, no formal meta-analysis or PRISMA flowchart was included. |
| Results |
Most quantitative ultrasound parameters reflect continuous biological processes influenced by patient characteristics, technical factors, and operator variability. Dichotomization may lead to information loss, misclassification, and reduced generalizability, particularly near decision boundaries (“gray zones”). Evidence from vascular ultrasound, elastography, and organ volumetry supports continuous risk gradients rather than discrete biological thresholds. Technical and operator-related variability further limits universal transferability across vendors and clinical settings. Reliance on single cut-off values in ultrasound largely reflects historical and methodological convention rather than biological discontinuities. Context aware interpretation strategies, including percentile-based references, multivariable risk models, probabilistic reporting, and longitudinal assessment, may better reflect biological variability and diagnostic uncertainty. |
| Conclusions |
Single cut-off values remain widely used in quantitative ultrasound, despite uncertainty about their biological validity, diagnostic reliability, and generalizability in clinical practice. Fixed ultrasound thresholds remain clinically useful but may lead to misclassification when biological variability, technical factors, and clinical context are not accounted for. Many ultrasound-derived parameters are continuous, context-dependent biomarkers whose meaning cannot be fully captured by rigid dichotomization, particularly near decision boundaries where measurement uncertainty and variability are greatest. Evidence supports more nuanced interpretative frameworks. Approaches such as percentile-based references, multivariable risk models, probabilistic reporting, and longitudinal assessment preserve quantitative information while better reflecting uncertainty and interindividual variability. The article recommends: to report uncertainty explicitly near boundaries (“gray zones”), instead of a deterministic “normal/abnormal” label; prefer contextual reference frameworks when available; to integrate pre-test probability and indication, and to use trends for monitoring whenever possible. |
| Key points |
Quantitative ultrasound findings should be interpreted as context-dependent measurements rather than absolute diagnostic boundaries. Thresholds should evolve from rigid decision boundaries toward context-sensitive reference points helping communicate diagnostic uncertainty more transparently. Despite ongoing standardization and AI-assisted optimization, individualized clinical judgment remains essential to integrate imaging findings into meaningful patient care. |
| Link (DOI) | https://dx.doi.org/10.1186/s13244-026-02371-9 |
| Ultrasound speciality |
Continuous biomarkers, Cut-off values, Quantitative ultrasound, Ultrasound variability |
Short-Review by:
Prof. Dr. Jose Luis del Cura
Department of Radiology
Donostia University Hospital
Spain
Strengths:
Approximately 200 publications screened. Diverse publication types included: original observational and diagnostic studies, reviews and meta-analyses, methodological/statistical papers, consensus statements, guidelines and reporting/scientific statements.
Includes very common and enlightening practical examples.
Integrates methodological, biological, and clinical perspectives on cut-off values in quantitative ultrasound and links these concepts to contemporary reporting frameworks.
Provides a conceptual framework that support more context-aware and clinically meaningful ultrasound reporting.
Weaknesses:
Narrative review.: provides a concept-driven synthesis rather than a systematic screening and appraisal process. No meta-analysis or structured risk-of-bias assessment was performed.
Not a systematic review. Study selection was not exhaustive and may be affected by personal opinions of the authors and a selection bias is probable.
The focus is on adult ultrasound and selected exams with established cut-offs. International guidelines and consensus documents are used, but local implementation varies across institutions and vendors.
Personally thinking:
Interesting observation regarding the use of continuous variables and measurements as if they were dichotomous in ultrasound.
This is common practice in ultrasound, especially among less experienced operators and in routine examinations where a non-conforming measurement can trigger a cascade of additional tests.
The article, using common and illustrative examples, aptly emphasizes the need to interpret ultrasound measurements within a clinical context and to remember the need to consider patient and equipment factors.
The recommendations included for the reports are very useful.
