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Static and Dynamic Cumulative Maximum Intensity Display Mode for Subharmonic Breast Imaging

A Comparative Study With Mammographic and Conventional Ultrasound Techniques

Department of Radiology (J.K.D., F.F., S.F., C.W.P., T.B.F., D.A.M., L.M.L.) and Department of Radiologic Sciences, Jefferson School of Health Professions (T.B.F.), Thomas Jefferson University, Philadelphia, Pennsylvania USA; School of Biomedical Engineering, Science, and Health Systems, Drexel University, Philadelphia, Pennsylvania USA (J.K.D., S.F., L.M.L.); South Jersey Radiology Associates, Voorhees, New Jersey USA (C.W.P.); and GE Healthcare, Milwaukee, Wisconsin USA (A.L.H.).

Address correspondence to Flemming Forsberg, PhD, Department of Radiology, Division of Ultrasound, Thomas Jefferson University, Suite 763J, Main Building, 132 S 10th St, Philadelphia, PA 19107 USA. E-mail: flemming.forsberg{at}jefferson.edu

Objective. The purpose of this study was to test the efficacy of static and dynamic cumulative maximum intensity (CMI) subharmonic imaging (SHI) in breast ultrasound studies. Methods. Contrast-enhanced SHI was performed in 14 women using a modified LOGIQ 9 scanner (GE Healthcare, Milwaukee, WI) transmitting/receiving at 4.4/2.2 MHz. Following mammography, baseline scans of gray scale ultrasound and power Doppler imaging (PDI) were performed. Contrast-enhanced PDI and gray scale SHI were performed after contrast agent administration. Static CMI-SHI is a composite image summarizing blood flow over multiple frames using the maximum intensity projection technique. The dynamic CMI-SHI mode depicts the gradual inflow pattern of the contrast agent in blood vessels. Both CMI-SHI modes were set up using a new automated sum-absolute-difference–based block-matching algorithm to reduce noise and blurring and compensate for motion artifacts. Evaluation of the imaging modes for detecting breast cancer was done by an experienced radiologist, blinded to histopathologic findings. Sensitivity, specificity, and receiver operating characteristic (ROC) analyses were computed and compared for all ultrasound imaging modes and mammography. Results Of the 16 lesions, 4 were malignant. The area under the ROC curve (A_z) for the diagnosis of breast cancer was 0.64 for gray scale and PDI, 0.67 for contrast-enhanced PDI, 0.76 for mammography, 0.78 for SHI, and 0.75 for static CMI-SHI. For the dynamic CMI-SHI mode, the A_z increased to 0.90, and this was significantly better than mammography (P = .03). Conclusions. The new dynamic CMI-SHI mode produced the highest A_z for the diagnosis of breast cancer compared to conventional techniques and thus appears to improve diagnosis of breast cancer relative to conventional techniques, albeit based on a limited patient population.

Key Words: breast ultrasound • cumulative maximum intensity • dynamic imaging • image processing • motion compensation • subharmonic imaging

Abbreviations: A_z, area under the ROC curve • CMI, cumulative maximum intensity • MFI, MicroFlow Imaging • MVI, MicroVascular Imaging • PDI, power Doppler imaging • ROC, receiver operating characteristic • SAD, sum-absolute-difference • SHI, subharmonic imaging • SNR, signal-to-noise ratio