63
J Gandhara Med Dent Sci
October - December 2026
ORIGINAL ARTICLE
:
:
ULTRASOUND STRAIN ELASTOGRAPHY IN THE DIAGNOSIS OF BREAST LESIONS
Tabassum Begum
1
,
Sumaira Noureen
1
,
Zubair Janan Orakzai
2
Laila Khan
1
,
Hina Baig
1
, Neelofar Azam
1
How to cite this article
Begum T, Noureen S, Orakzai ZJ,
Khan L, Baig H, Azam N. Ultrasound
Strain Elastography in the Diagnosis
of Breast Lesions. J Gandhara Med
Dent Sci. 2026;13(4):63-67.
Date of Submission:
23-06-2026
Date Revised:
07-09-2026
Date Acceptance:
10-09-2026
2
Associate Professor, , Department of
Radiology, Bacha Khan Medical
,
College, Mardan
Correspondence
1
Sumaira Noureen, Assistant Professor,
Department of Radiology, Bacha Khan
Medical College, Mardan
+92-333-9012455
sumairajvd@yahoo.com
ABSTRACT
OBJECTIVES
To determine the diagnostic performance of ultrasound strain elastography
for dierentiating benign and malignant breast lesions, using histopathology
as the reference standard.
METHODOLOGY
This prospective diagnostic-accuracy study was conducted in the Department
of Radiology, Bacha Khan Medical College and Mardan Medical Complex,
Mardan, from January to March 2026. Ninety-seven patients with suspected
breast
lesions
were
enrolled
by
non-probability
consecutive
sampling.
Conventional
ultrasonography
followed
by
strain
elastography
was
performed in all patients. BI-RADS category, elasticity score, and strain ratio
(cut-o
3.5)
were
compared
with
histopathology.
Data
were
analyzed
using
IBM SPSS Statistics version 25.
RESULTS
Strain
elastography
showed
a
sensitivity
of
94.9%,
specicity
of
86.2%,
positive predictive value of 82.2%, negative predictive value of 96.2%, and
overall accuracy of 89.7%. Elastography ndings were
strongly
associated
with
histopathological
diagnosis
(p
<
0.001).
BI-RADS
category,
elasticity
score, and strain ratio also showed strong to very strong correlations with
histopathology.
CONCLUSION
Ultrasound strain elastography demonstrated high diagnostic performance in
dierentiating benign from malignant breast lesions. Used as an adjunct to
conventional
ultrasonography
and
BI-RADS
assessment,
it
may
improve
diagnostic condence and help reduce unnecessary biopsy.
KEYWORDS:
Breast
Neoplasms,
Breast
Ultrasonography,
Elasticity
Imaging
Techniques,
Histopathology,
Predictive
Value
of
Tests,
Sensitivity
and Specicity, Strain Elastography
INTRODUCTION
Breast
lesions
are
common
clinical
and
radiological
findings,
and
accurate
characterization
is
essential
for
timely
diagnosis
and
appropriate
management.
1
Although most breast lesions are benign, distinguishing
benign from malignant disease remains a key diagnostic
challenge.
2
Early
and
accurate
diagnosis
of
breast
cancer
is
important
for
improving
clinical
outcomes.
3
Ultrasonography
is
a
widely
used
rst-line
imaging
modality for breast assessment, particularly in younger
women and those with dense breast tissue. It provides
information
on
lesion
morphology,
margins,
echotexture,
and
vascularity.
4
The
Breast
Imaging
Reporting
and
Data
System
(BI-RADS)
standardizes
reporting
and
guides
clinical
decision-making;
however,
conventional
ultrasonography
has
limited
specificity and may therefore contribute to unnecessary
biopsy of benign lesions.
5
Ultrasound elastography has
emerged as an adjunct imaging technique based on the
principle that
malignant tissue is generally stier than
benign
tissue.
Strain
elastography
assesses
tissue
deformation
under
applied
pressure
and
provides
qualitative and quantitative estimates of tissue stiness,
including
elasticity
score
and
strain
ratio.
6
These
parameters
may
improve
lesion
characterization
when
conventional sonographic morphology is indeterminate.
Recent
studies
suggest
that
adding
elastography
to
conventional
ultrasonography
can
improve
diagnostic
discrimination
and
rene
BI-RADS
stratication,
particularly
for
borderline
or
indeterminate
lesions.
7,8
The
present
study
therefore
evaluated
the
diagnostic
performance
of
ultrasound
strain
elastography
in
dierentiating benign and malignant breast lesions and
assessed
the
association
of
elastography
parameters
with histopathological ndings.
METHODOLOGY
This
prospective
diagnostic-accuracy
study
was
conducted in the Department of Radiology, Bacha Khan
Medical College and Mardan Medical Complex (MTI),
Mardan, from January to March 2026. Ethical approval
was obtained from the institutional ethical review board
(Reference No. 936/BKMC; 14 January 2026), and the
study
was
conducted
in
accordance
with
institutional
http://doi.org/10.37762/jgmds.13-4.961
,
64
J Gandhara Med Dent Sci
October - December 2026
requirements
and
the
principles
of
the
Declaration
of
Helsinki.
Patients
with
clinically
or
radiologically
suspicious breast lesions who met the eligibility criteria
were
enrolled
using
a
non-probability
consecutive
sampling
technique.
A
total
of
97
patients
were
included.
The
sample
size
was
calculated
using
a
diagnostic-accuracy
approach
based
on
an
expected
sensitivity
of
approximately
85%,
a
95%
condence
level
(Z
=
1.96),
and
a
7%
margin
of
error;
the
calculated sample size was increased to 97 to allow for
potential data loss.
9
Adult patients with a breast lump or
suspicious
breast
lesion
who
underwent
ultrasonography
and
had
histopathological
verication
were
eligible.
Patients
with
previous
breast
surgery,
ongoing
treatment
for
breast
malignancy,
recurrent
lesions, or incomplete imaging or histopathological data
were
excluded.
On
conventional
ultrasonography,
BI-
RADS
categories
2-3
were
considered
benign/likely
benign,
and
categories
4-5
were
considered
suspicious/malignant
for
the
study
analysis.
Elastography
was
assessed
qualitatively
by
elasticity
score
(scores
1-3,
soft;
scores
4-5,
hard)
and
quantitatively
by
strain
ratio.
A
strain-ratio
cut-o
of
3.5 was used to classify lesions as benign or malignant.
Histopathological diagnosis was the reference standard.
Data
were
recorded
on
a
structured
proforma.
All
patients
underwent
B-mode
ultrasonography
followed
by
strain
elastography
using
standardized
imaging
procedures.
Recorded
variables
included
age,
lesion
size,
clinical
symptoms,
sonographic
shape,
margins,
echogenicity,
posterior
acoustic
shadowing,
BI-RADS
category,
elasticity
score,
and
strain
ratio.
Histopathological
ndings
from
biopsy
or
surgical
excision
were
subsequently
recorded.
Imaging
was
interpreted
by
qualied
radiologists
using
consistent
diagnostic
criteria.
Ultrasound
equipment
was
calibrated
before
data
collection,
and
data
entry
was
cross-checked
to
minimize
transcription
errors.
Data
were
analyzed
using
IBM
SPSS
Statistics
version
25.
Continuous variables are presented as mean standard
deviation
and
categorical
variables
as
frequency
and
percentage. Associations between imaging ndings and
histopathological diagnosis were assessed with the chi-
square
test,
with
Cramer's
V
used
as
an
eect-size
measure.
Sensitivity,
specicity,
positive
predictive
value, negative predictive
value,
likelihood ratios, and
overall
diagnostic
accuracy
were
calculated
with
95%
confidence intervals. Spearman's rho was used to assess
correlations
between
imaging
parameters
and
histopathology.
A
p-value
<
0.05
was
considered
statistically signicant.
RESULTS
The
mean
age
of
the
97 participants
was
46.0
13.2
years. More than half were older than 45 years (54.6%),
32.0% were aged 30-45 years, and 13.4% were younger
than
30
years.
A
family
history
of
breast
cancer
was
present in 18.6%. Mean lesion size was 2.85 0.82 cm,
pain was reported by 41.2%, and 54.6% of lesions were
in the left breast.
Table 1: Demographic and Clinical Characteristics (n = 97)
Variable
Value
Age
(years)
46.0 13.2
Age (years)
< 30 years
13 (13.4%)
< 30 years
3045 years
31 (32.0%)
3045 years
> 45 years
53 (54.6%)
> 45 years
Family history of
breast cancer
No
79 (81.4%)
Yes
18 (18.6%)
Lesion size (cm)
2.85 0.82
Pain
No
57 (58.8%)
Yes
40 (41.2%)
Side of breast
Left
53 (54.6%)
Right
44 (45.4%)
Ultrasound
features
were
signicantly
associated
with
histopathological diagnosis. Irregular shape (
χ
= 25.63,
p < 0.001; Cramer's V = 0.51) and ill-dened margins
(
χ
=
33.35,
p
<
0.001;
V
=
0.59)
showed
large
associations
with
malignancy.
Posterior
acoustic
shadowing
(
χ
=
16.67,
p
<
0.001;
V
=
0.42)
and
a
hypoechoic
pattern
(
χ
=
9.14,
p
=
0.003;
V
=
0.31)
showed moderate associations. BI-RADS category was
very
strongly
associated
with
histopathology
(
χ
=
71.72, p < 0.001; V = 0.86).
Table 2: Association of Ultrasound Findings with Histopathology
(n = 97)
Variable
Benign
(n=58)
Malignan
t (n=39)
χ
²
p-
value
Cramer's
V
Irregular
Shape
25.63
<0.001
0.51
(Large)
Regular
45 (81.8%)
10 (18.2%)
Irregular
13 (31.0%)
29 (69.0%)
Ill-defined
Margins
33.35
<0.001
0.59
(Large)
Well-dened
dened
45 (86.5%)
07 (13.5%)
Ill-defined
13 (28.9%)
32 (71.1%)
Posterior
Shadowing
16.67
<0.001
0.42
(Moderate)
Absent
46 (75.4%)
15 (24.6%)
Present
12 (33.3%)
24 (66.7%)
Hypoechoic
Pattern
9.14
0.003
0.31
(Moderate)
No
36 (75.0%)
12 (25.0%)
Yes
22 (44.9%)
27 (55.1%)
BI-RADS
Category
71.72
<0.001
0.86 (Very
Large)
2
31 (100%)
0 (0%)
3
22 (88.0%)
03 (12.0%)
4
5(31.3%)
11 (68.8%)
5
0 (0%)
25 (100%)
BI-RADS
≥4
66.93
<0.001
0.83 (Very
Large)
23
53 (94.6%)
03 (5.4%)
45
05 (12.2%)
36 (87.8%)
Ultrasound Strain Elastography in the Diagnosis of Breast Lesions
65
J Gandhara Med Dent Sci
October - December 2026
Elastography
ndings
were
also
strongly
associated
with histopathological diagnosis. An elasticity score of
4-5
was
associated
with
malignancy
(
χ
=
63.06,
p
<
0.001; Cramer's V = 0.81), as was a strain ratio > 3.5 (
χ²
= 61.64, p < 0.001; V = 0.80). The odds of malignancy
were
markedly
higher
for
hard
lesions
(OR
=
100.8,
95% CI 23.6-430.5) and for lesions with a strain ratio >
3.5 (OR = 115.6, 95% CI 23.2-576.6).
Table 3: Association
of
Elastography
Findings
with
Histopathology (n = 97)
Elastogra
phy
Parameter
Benign
(n=58)
Malign
ant
(n=39)
χ
²
p-
value
Crame
r's V
Odds
Ratio
(95%
CI)
Elasticity Score
Score 1-3
(Soft)
55
(90.2%)
06 (9.8%)
Score
4-5
(Hard)
3(8.3%)
33 (91.7%)
63.06
<0.001
0.81
(Very
Large)
100.8
(23.6-
430.5)
Strain Ratio (Cut-o = 3.5)
≤3.5
(Benign)
50
(96.2%)
02 (3.8%)
>3.5
(Malignant)
8 (17.8
%)
37
(82.2%)
61.64
<0.001
0.80
(Very
Large)
115.6
(23.2-
576.6)
Using
a
strain-ratio
cut-o
of
3.5,
strain
elastography
achieved
a
sensitivity
of
94.9%,
specicity
of
86.2%,
positive predictive value of 82.2%, negative predictive
value
of
96.2%,
and
overall
diagnostic
accuracy
of
89.7%. The positive likelihood ratio was 6.87, and the
negative
likelihood
ratio
was
0.06,
supporting
useful
rule-in and strong rule-out performance, respectively.
Table
4:
Diagnostic
Accuracy of
Strain
Elastography
(cut-o
=
3.5; n = 97)
Parameter
Value (%)
95% Condence
Interval
Sensitivity
94.9%
82.7% 99.4%
Specificity
86.2%
74.6% 93.9%
Positive Predictive Value
(PPV)
82.2%
67.9% 92.0%
Negative Predictive Value
(NPV)
96.2%
86.8% 99.5%
Accuracy
89.7%
81.7% 94.9%
LR+
6.87
3.84 12.29
LR−
0.06
0.02 0.23
BI-RADS
category
correlated
very
strongly
with
histopathology
(Spearman
r
=
0.822,
p
<
0.001).
Elasticity score (r = 0.784, p < 0.001) and strain ratio (r
=
0.817,
p
<
0.001)
also
showed
very
strong
positive
correlations
with
histopathological
diagnosis.
Correlations
among
BI-RADS
category,
elasticity
score, and strain ratio were strong to very strong.
Table 5: Correlation analysis (Spearman’s rho;
n=97)
Variable Pair
R-Value
p-value
Interpretation
BI-RADS
vs
Histopathology
0.822
<0.001
Very strong
Elasticity
Score
vs
Histopathology
0.784
<0.001
Very strong
Strain
Ratio
vs
Histopathology
0.817
<0.001
Very strong
Elasticity
Score
vs
BI-RADS
0.724
<0.001
Very strong
Strain
Ratio
vs
BI-
RADS
0.624
<0.001
Strong
Strain
Ratio
vs
Elasticity Score
0.698
<0.001
Strong
DISCUSSION
This
study
demonstrated
strong
diagnostic
utility
of
ultrasound
strain
elastography
for
differentiating
benign
from
malignant
breast
lesions.
Both
the
qualitative
elasticity
score
and
quantitative
strain
ratio
were
closely
associated
with
histopathology,
while
the
strain-ratio
model
showed
high
sensitivity,
specicity,
and
overall
accuracy.
These
ndings
are
consistent
with
evidence
that
adding
strain
or
shear-wave
elastography to conventional ultrasonography can
improve lesion stratication and rene BI-RADS-
based
decision-making,
particularly
for
indeterminate
lesions.
Tang
et
al.,
Gu
et
al.,
and
Mumtaz
et
al.
similarly
reported
improved
diagnostic characterization when elastography was
incorporated
into
breast
ultrasonography.
10,11,12
Conventional
ultrasound
features,
including
irregular
shape,
ill-defined
margins,
posterior
acoustic
shadowing,
and
hypoechogenicity,
were
significantly associated with malignancy, and BI-
RADS
showed
a
particularly
strong
relationship
with
histopathology.
This
supports
the
role
of
grayscale
ultrasonography
as
the
basis
of
breast
lesion assessment while highlighting the additional
value
of
elastography
when
morphology
alone
is
insucient. Studies by Zhi et al. and Yang et al.
have
shown
improved
discrimination
when
elastography is incorporated into BI-RADS-based
assessment,
while
Bayoumi
et
al.
reported
added
diagnostic
value
of
strain
elastography
in
BI-
RADS 4 lesions.
13,14,15
The very large eect sizes
Ultrasound Strain Elastography in the Diagnosis of Breast Lesions
66
J Gandhara Med Dent Sci
October - December 2026
and high odds ratios observed for elasticity score
and
strain
ratio
indicate
that
lesion
stiness
was
strongly
associated
with
malignant
pathology.
Shahzad
et
al.
similarly
found
that
elastography-
derived
measures
improved
dierentiation
between
benign
and
malignant
breast
lesions,
particularly
when
interpreted
alongside
BI-
RADS.
16
These
ndings
support
the
use
of
elastography
as
an
adjunct
rather
than
a
replacement
for
conventional
ultrasonography.
The
high
negative
predictive
value
(96.2%)
and
low negative likelihood ratio (0.06) are clinically
important
because
they
indicate
good
rule-out
performance.
This
may
be
particularly
useful
for
reducing
unnecessary
invasive
procedures
in
sonographically
suspicious
but
elastographically
soft lesions. Other studies have
likewise reported
that
elastography
can
improve
specicity
and
rene
management
of
low-
to
intermediate-
suspicion
breast
lesions.
12,13,15,17
The
correlation
analysis further demonstrated consistency between
BI-RADS,
elasticity
score,
strain
ratio,
and
histopathological
diagnosis.
Similar
relationships
between
elastographic
stiness
and
pathological
characteristics have been reported by Frimpong et
al.
18
In
addition,
studies
addressing
automated
three-dimensional
elastography
and
interobserver
reliability
suggest
increasing
technical
maturity
and
reproducibility
of
elastography-based
breast
assessment.
9,19
Emerging
quantitative
and
machine-learning approaches may further improve
standardization and prediction.
14,20,21
LIMITATIONS
The
study
was
conducted
within
a
single
institutional setting and included a relatively small
sample, which may limit external generalizability.
Strain
elastography
is
also
operator-dependent.
Larger
multicenter
studies
using
standardized
acquisition
and
interpretation
protocols
are
required to validate the diagnostic thresholds and
performance estimates reported here.
CONCLUSION
Ultrasound
strain
elastography
showed
high
diagnostic
performance
for
dierentiating
benign
and malignant breast lesions. Both elasticity score
and
strain
ratio
were
closely
associated
with
histopathology,
and
the
strain-ratio
model
demonstrated
high
sensitivity,
specicity,
and
negative
predictive
value.
As
an
adjunct
to
conventional
ultrasonography
and
BI-RADS
assessment,
strain
elastography
may
improve
diagnostic
condence
and
help
reduce
unnecessary biopsy.
CONFLICT OF INTEREST:
None
FUNDING
SOURCES:
None
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Tabassum Begum -
Concept
&
Design;
Data
Acquisition;
Data
Analysis/Interpretation;
Drafting
Manuscript;
Critical
Revision; Supervision; Final Approval
Sumaira Noureen -
Concept & Design; Data Acquisition; Data
Analysis/Interpretation;
Drafting
Manuscript;
Critical
Revision; Supervision; Final Approval
Zubair Janan Orakzai -
Concept &
Design; Data Acquisition;
Data
Analysis/Interpretation;
Drafting
Manuscript;
Critical
Revision; Supervision; Final Approval
Laila
Khan
-
Concept
&
Design;
Data
Acquisition;
Data
Analysis/Interpretation;
Drafting
Manuscript;
Critical
Revision; Supervision; Final Approval
Hina
Baig
-
Concept
&
Design;
Data
Acquisition;
Data
Analysis/Interpretation;
Drafting
Manuscript;
Critical
Revision; Supervision; Final Approval
Neelofar
Azam
-
Concept
&
Design;
Data
Acquisition;
Data
Analysis/Interpretation;
Drafting
Manuscript;
Critical
Revision; Supervision; Final Approval
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Ultrasound Strain Elastography in the Diagnosis of Breast Lesions
