31 E-Strain Elastography as an Adjunct of Breast Ultrasound: Impact on Biopsy Decision-Making

Introduction

Breast ultrasound is routinely used for characterizing breast masses to determine the need for biopsy. Elastography offers a noninvasive assessment of tissue stiffness and is widely available, reproducible, and billable. This study examines whether E-strain elastography can aid clinicians in risk stratification and biopsy decision-making for breast lesions detected on ultrasound.

Materials and Methods

We performed a retrospective review of patients undergoing breast ultrasound with E-strain elastography ratio assessment between January 2, 2024, and March 12, 2025. Demographics, lesion size, BI-RADS category, E-strain ratio, and pathology were recorded. Malignant cases were further characterized by histology and receptor status. E-strain ratios were compared between benign and malignant lesions and across BI-RADS categories using unpaired ttests and linear regression.

Results

A total of 345 patients (340 female, 5 male; mean age, 53.4 years; range, 19-94) were included. Of 161 biopsied masses, 59 (36.6%) were malignant and 102 (63.4%) benign. Among malignant cases, 56 were invasive, predominantly ductal (n = 52), and 7 were lobular. The majority of lesions were BI-RADS 3 (n = 112; 32%) or BI-RADS 4 (n = 140; 41%). Mean E-strain ratio increased with BI-RADS level, from 1.56 in BI-RADS 3, 2.15 in BI-RADS 4, to 4.40 in BI-RADS 5. Malignant lesions had a significantly higher E-Strain ratio (3.51) than benign lesions (1.93), with a mean difference of 1.59 (P <.0001; 95% CI, 1.09-2.08). No significant correlation was found between Ki-67% and E-strain ratio (R2 = .011, P = .43).

Conclusion

Malignant breast lesions demonstrated significantly higher E-strain ratios than benign lesions, with progressive increases across BI-RADS categories. Routine incorporation of E-strain elastography may support biopsy decision-making for indeterminate breast lesions and help reduce unnecessary biopsies in clinical practice.