Overdiagnosis of Papillary Thyroid Cancer
April 13, 2026From imaging to management: Enhancing the Breast Imaging Reporting and Data System with contrast-enhanced ultrasound for stratification of breast lesions
| Objectives | Selective vacuum-assisted biopsy (VAB) improves diagnostic accuracy for intermediate breast lesions (including B3, imaging-pathologic discordant, and high-risk lesions) while enabling complete resection. The authors evaluate the integration of contrast-enhanced ultrasound (CEUS) in the Breast Imaging Reporting and Data System (BI-RADS) to optimize selection of patients for VAB. |
| Authors |
Fen He, Li-juan Sun, Lu Li, Xiao-ying Yao, Pan Liu, Zhong Chen, Jie Tao Department of Ultrasound, The General Hospital of Western Theater Command, China |
| Journal |
Asian Journal of Surgery, 2026,[EPUB] DOI: 10.1016/j.asjsur.2026.01.153 |
| Methods |
Retrospective study analysis of 647 patients (from 2016 to 2023) who underwent conventional ultrasound, CEUS, core needle biopsy, and surgical excision. A triple-classification BI-RADS model was developed based on the original BI-RADS. Multivariate logistic regression analysis was conducted to develop a logistic regression model. CEUS was incorporated into BI-RADS to establish two models: the CEUS-adjusted BI-RADS model and the CEUS-BI-RADS scoring model. Overall accuracy, sensitivity, specificity, underdiagnosis rate of malignancies, overdiagnosis rate of benign lesions, and simulated secondary excision rate for intermediate lesions were compared across models. |
| Results |
Multivariate analysis showed that irregular shape, earlier enhancement, and iso-/hyperenhancement predicted intermediate lesions, whereas perfusion defects, irregular shape, earlier enhancement, and post-enhancement size enlargement predicted malignancy. The CEUS-adjusted BI-RADS model achieved an overall accuracy of 73.8 %, demonstrating sensitivities of 64.5 % (benign), 52.2 % (intermediate), and 93.0 % (malignant), with corresponding specificities of 83.9 %, 43.2 %, and 84.2 %. Compared to the original BI-RADS, it improved sensitivity for malignancies (87.8 %→93.0 %), reduced the overdiagnosis rate of benign lesions (25.1 %→13.3 %) and the simulated secondary resection of intermediate lesions (19.4 %→6.5 %), while maintaining the same underdiagnosis for malignant lesions (1.2 %→1.2 %). |
| Conclusions |
The integration of CEUS with BI-RADS demonstrates potential for improving classification of breast lesions before biopsy. Especially shows promise in distinguishing benign lesions, B3 lesions, imaging-pathologic discordant lesions, high-risk lesions, and malignant lesions prior to biopsy, providing a conceptual framework for optimizing clinical management efficiency. |
| Key points | CEUS-Adjusted BI-RADS Model (i. e. lesions initially classified as BIRADS 4C/5 with benign CEUS scores were and BI-RADS 3/4A/4B lesions with suspicious CEUS were upgraded by two categories) demonstrated lower overdiagnosis rate with similar sensitivity for malignancy.
In lesions larger than 2.5 cm, the CEUS-adjusted BI-RADS model demonstrated higher diagnostic performance. Simple combined BI-RADS-CEUS Scoring Model decreased the overdiagnosis rate but increased the false negatives. |
| Link (DOI) | https://doi.org/10.1016/j.asjsur.2026.01.153 |
| Ultrasound speciality | Ultrasound, BIRADS, Breast US, CEUS |
Short-Review by:
Prof. Dr. Jose Luis del Cura
Department of Radiology
Donostia University Hospital
Spain
Strengths:
The role of CEUS in breast imaging has not been clearly established. Moreover, the authors propose a specific application in a subgroup of lesions that pose a management problem: lesions of uncertain malignant potential on core needle biopsy. Surgical excision is recommended, but most of them are benign lesions. The potential role of CEUS in these lesions is an interesting field for investigation. The study is comprehensive and reviews all possible aspects of the problem.
Weaknesses:
Retrospective. Only in one centre. They study BIRADS 3-5 lesions but the authors do not explain how these categories were diagnosed. The patients were selected among those who met CNB eligibility criteria following initial screening; so, the results cannot be generalized to all breast screening populations. There is no specific statement about the analysis of CEUS to be blinded to the result of mammography and, obviously, they were not blinded to the US exam. It should be noted that misclassifying an intermediate lesion as malignant does not change initial clinical management. Clinical application of the results is not clear.
Personally thinking:
Retrospective. Only in one centre. They study BIRADS 3-5 lesions but the authors do not explain how these categories were diagnosed. The patients were selected among those who met CNB eligibility criteria following initial screening; so, the results cannot be generalized to all breast screening populations. There is no specific statement about the analysis of CEUS to be blinded to the result of mammography and, obviously, they were not blinded to the US exam. It should be noted that misclassifying an intermediate lesion as malignant does not change initial clinical management. Clinical application of the results is not clear.
