Breast cancer has emerged as the most prevalent malignancy among women globally and continues to be a major public health burden [1]. In 2020, an estimated 2.3 million new cases and 685,000 deaths were recorded worldwide [2]. In India, breast cancer accounted for 13.5% of all cancer cases and 10.6% of all cancer-related deaths, surpassing cervical cancer as the leading cause of female cancer mortality [3]. Risk factors for breast cancer include genetic predisposition (e.g., BRCA1/2 mutations), early menarche, late menopause, nulliparity, reduced breastfeeding, lifestyle factors, and environmental exposures [4,5]. Importantly, early detection significantly improves prognosis, emphasizing the role of effective screening and diagnostic tools [6]. The triple assessment approach-clinical evaluation, imaging, and cytology/histopathology-is the gold standard for breast lesion diagnosis [7]. Mammography remains the most widely used imaging modality, particularly effective for microcalcifications and architectural distortions [8]. However, its sensitivity decreases in dense breast tissue and in younger women [9]. Sono-mammography addresses these limitations by enabling real-time evaluation, distinguishing cystic from solid lesions, and offering better visualization in dense parenchyma [10,11]. FNAC has long been established as a simple, cost-effective, and minimally invasive technique to provide cytological confirmation of breast lesions [12]. When combined with imaging findings, FNAC enhances diagnostic accuracy, reduces false positives, and assists in therapeutic planning [13]. Several studies have compared mammography, sono-mammography, and FNAC individually and in combination [14-18]. Most conclude that combined imaging modalities yield higher diagnostic accuracy compared to either technique alone [19,20]. However, local population-specific variations necessitate further evaluation. The present study aimed to evaluate breast lesions using mammography and sono-mammography, categorize them according to BI-RADS, and correlate imaging findings with FNAC results. The study also aimed to calculate sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and overall diagnostic accuracy of each modality.

STUDY DESIGN AND SETTING A prospective descriptive study was carried out at the Department of Radiodiagnosis, Meenakshi Hospital, Thanjavur, between October 2022 and January 2024. STUDY POPULATION A total of 62 female patients, aged between 35 and 75 years (mean: 50.9 ± 9.8 years), referred for evaluation of breast lesions, were included. Inclusion Criteria • Women above 35 years with symptomatic breast lesions (pain, lump, nipple discharge). • Asymptomatic women above 35 years undergoing screening. Exclusion Criteria • Male patients with breast lesions. • Patients with previously confirmed carcinoma. • Patients with fungating or painful breast masses. Clinical Assessment All patients provided informed consent. A structured proforma was used to collect demographic details, clinical history (menstrual, obstetric, lactational), and family history of breast cancer. Imaging • Mammography: Performed using PHILIPS Mammodiagnost, with standard CC and MLO projections. Lesions were assessed for shape, margins, density, and calcifications, and categorized by BI-RADS [21]. • Sono-mammography: Performed on GE Voluson E8 Expert with 7.5-12 MHz linear probe. Lesions were analyzed for shape, margins, echogenicity, orientation, posterior features, and vascularity, followed by BI-RADS classification [22]. Cytology FNAC was performed with a 22-gauge needle and 10 ml syringe. Smears were stained and classified as benign or malignant. Statistical Analysis Data were analyzed with SPSS v26. Categorical data were presented as percentages and continuous variables as mean ± SD. Sensitivity, specificity, PPV, NPV, and diagnostic accuracy were calculated. A p-value <0.05 was considered significant.

A total of 62 female patients aged between 35 and 75 years (mean: 50.9 ± 9.8 years) were studied. The majority presented with a palpable breast lump, and FNAC was used as the gold standard for cytological confirmation. The findings from mammography, sono-mammography and combined modalities are summarized below. CLINICAL PROFILE The most frequent presenting complaint was a palpable lump (55%), followed by screening cases (29%), mastalgia (13%), and nipple discharge (3%). Table 1: Distribution of patients based on indication of mammography Indication Number Percentage Screening 18 29% Pain 8 13% Lump 34 55% Nipple discharge 2 3% Mammographic Findings Breast composition showed that heterogeneously dense tissue was most common (47%). Lesions were predominantly located in the upper outer quadrant (40%). Table 2: Breast composition and lesion location Breast Density Number % Lesion Location Number % Predominantly fatty 2 3 Upper outer quadrant 25 40 Scattered fibroglandular 24 39 Upper inner quadrant 15 24 Heterogeneously dense 29 47 Central 10 16 Extremely dense 7 11 Lower quadrants 12 20 Bi-Rads Classification Lesions were classified using BI-RADS categories. Mammography reported 24% benign, 40% probably benign, 23% suspicious, and 13% malignant, while sono-mammography reported 27%, 42%, 18%, and 13%, respectively. Table 3: BI-RADS classification by modality BI-RADS Category Mammography (%) Sono-mammography (%) Benign (BI-RADS 2) 24 27 Probably benign (BI-RADS 3) 40 42 Suspicious (BI-RADS 4) 23 18 Malignant (BI-RADS 5) 13 13 Fnac Correlation FNAC confirmed 42 lesions (68%) as benign and 20 lesions (32%) as malignant. Table 4: FNAC correlation FNAC Result Number Percentage Benign 42 68% Malignant 20 32% Diagnostic Performance When compared with FNAC, mammography had a sensitivity of 90.48% and specificity of 90%, while sono-mammography achieved 95.23% sensitivity and 85% specificity. The combined approach yielded the best results, with 97.62% sensitivity, 85% specificity, and 93.55% accuracy. Table 5: Diagnostic performance of modalities compared with FNAC Modality Sensitivity Specificity PPV NPV Accuracy Mammography 90.48% 90% 95% 81.8% 90.32% Sono-mammography 95.23% 85% 93% 89.5% 91.93% Combined modalities 97.62% 85% 93.2% 94.4% 93.55%

This study confirms that mammography and sono-mammography are highly effective in evaluating breast lesions, but their combined use significantly improves diagnostic accuracy. The results demonstrated sensitivities of 90.48% for mammography, 95.23% for sono-mammography, and 97.62% for the combined approach. The higher accuracy of combined imaging is consistent with prior studies [7,8,9]. Mammography remains the gold standard for early detection, especially for microcalcifications and subtle architectural distortions [10]. However, its sensitivity is reduced in women with dense breasts [11]. Our findings that 47% of patients had heterogeneously dense breasts explain why some lesions were missed on mammography. Sono-mammography provided better lesion characterization in dense breasts and was particularly useful in differentiating cystic from solid lesions. Hypoechoic irregular lesions with posterior shadowing and internal vascularity strongly correlated with malignancy, aligning with findings from Mujagić et al. [15] and Chala et al. [19]. FNAC correlation confirmed malignancy in 32% of cases. Features like spiculated margins, irregular shape, suspicious calcifications (mammography), and non-parallel hypoechoic lesions (sono-mammography) had strong predictive value for malignancy. Compared with similar studies by Tiwari et al. [21] and Ismail et al. [23], our results demonstrated slightly higher sensitivity, possibly due to strict BI-RADS categorization and combined interpretation of imaging findings. This study emphasizes the complementary nature of the two imaging modalities. While mammography remains essential for population-based screening, sono-mammography adds significant diagnostic value in symptomatic women, particularly those with dense parenchyma. Integration with FNAC provides a near-definitive diagnosis, reducing unnecessary biopsies [24,25].

Mammography and sono-mammography are individually effective tools for the evaluation of breast lesions, but when used in combination, they provide superior diagnostic accuracy. Mammography excels in detecting microcalcifications and occult lesions, whereas sono-mammography offers advantages in dense breasts and cystic lesion evaluation [26]. The integration of imaging with FNAC ensures accurate and early diagnosis. Malignant indicators include irregular shape, high density, spiculated margins, suspicious calcifications (mammography), and hypoechoic, non-parallel, vascular lesions with posterior shadowing (sono-mammography). Benign lesions were typically oval or round, circumscribed, hypoechoic, or anechoic with posterior enhancement [27,28]. This study concludes that the triple assessment approach (clinical + imaging + FNAC) remains the most reliable strategy for diagnosis, minimizing false negatives and ensuring timely treatment of breast cancer. The findings reinforce the need for widespread use of combined imaging in breast lesion evaluation in Indian clinical practice.

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