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Correlation of Resistive Index Values Using Spectral Doppler Ultrasound with Histopathological Results in Breast Tumors
J Surg Ultrasound 2023;10:42-51
Published online November 30, 2023;  https://doi.org/10.46268/jsu.2023.10.2.42
© 2023 The Korean Surgical Ultrasound Society

Yohana Azhar1, Valeska Siulinda Candrawinata2

1Division of Oncology, Head and Neck Surgery, Department of Surgery, Hasan Sadikin Hospital, Padjadjaran University, Bandung, West Java, 2Faculty of Medicine, Pelita Harapan University, Tangerang, Indonesia
Correspondence to: Yohana Azhar
Division of Oncology, Head and Neck Surgery, Department of Surgery, Hasan Sadikin Hospital, Pasteur No. 38, Sukajadi, Bandung, West Java 40161, Indonesia
Tel: +62-813-2164-9491
Fax: +6222-6440494
E-mail: r.yohana@unpad.ac.id
Received October 30, 2023; Revised November 23, 2023; Accepted November 24, 2023.
Journal of Surgical Ultrasound is an Open Access Journal. All articles are distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
This study aimed to investigate the diagnostic value of the resistive index (RI) in Spectral Doppler ultrasound for determining breast malignancy, as there is currently no optimal cut-off point for the determination of breast malignancy. The B-mode and Doppler (including Color and Spectral) breast ultrasound examinations of 62 subjects were gathered. These included histopathological results of 31 cases with malignant tumors and 31 cases of benign tumors which served as controls. All examinations and measurements just before the core-needle biopsy of the mass were validated by expert radiologists. All patients were examined using a 7 to 15 MHz GE Logiq linear array transducer. Color Doppler and Spectral Doppler were set on PRF 700-1,000 Hz, maximal gain 85-90%, and wall filler 50-100 Hz. Histopathological results were used as the gold standard. The study's average RI value in benign breast tumors was 0.55 ± 0.16, and the average RI value in malignant breast tumors was 0.97 ± 0.10. According to the Spearman correlation test, the relationship coefficient R is 0.887 (P-value<0.0001), showing a strong and statistically significant relationship with a positive correlation direction between the increasing RI value on a Spectral Doppler ultrasound examination and the increasing possibility of malignancy in breast tumors. An increase in the value of the RI indicates an increase in the risk of malignancy. Studies relating to this correlation might benefit from future prospective research with a longer follow-up on patients with Breast Imaging-Reporting and Data System (BI-RADS) lesion Category 3.
Keywords : Breast, Breast neoplasms, Doppler ultrasound
INTRODUCTION

Breast cancer is one of the most prevalent cancers worldwide to date and ranks first because of its high morbidity and mortality. Global Burden of Cancer (GLOBOCAN) in 2020 recorded 2,261,419 new cases (11.7%) out of a total of 19,292,789 cases and 684,996 deaths (6.9%). According to GLOBOCAN 2020, new cases of breast cancer in Indonesia reach 25,858 cases (16.6%) out of a total of 396,914 cases, with deaths reaching 22,430 cases (9.6%).(1) Data-driven National Breast and Ovarian Cancer Centre stated the risk of breast cancer in women aged <40 years is 1 per 200 population, and this risk will increase dramatically with age reaching up to 1 per 10 population over the age of 40 years old. The incidence of breast cancer in women aged <25 years is 10 new cases per 100,000 women and increases 100 times at the age of 45 years.(1,2)

Numerous factors are associated with the occurrence of breast cancer including age (often diagnosed in women aged >50 years), previous history of breast cancer, family history, reproductive history (not having children, not breastfeeding, or giving birth to children at the age of >35 years) and menstruation (early menarche <13 years old, late menopause >55 years old), diet, lifestyle (alcohol consumption and lack of exercise), hormonal (contraceptive intake or undergoing hormone replacement therapy on an ongoing basis for >5 years), obesity, history of chest wall radiation, breast tissue density, and environmental factors.(3,4)

Signs and symptoms of breast cancer include lumps in the breast, fluid or changes from the nipple, or changes in the skin around the breast. Since mild symptoms of breast cancer are rarely noticed, patients often seek treatment in advanced conditions. In Indonesia, more than 80% of cases are found to be in advanced stages (III and IV), where the treatment efforts are difficult and the prognosis is poor. The most common symptom of breast cancer is a palpable breast mass, but cancer can also be diagnosed with unpalpable lesions, so additional radiological modalities are needed. Breast self-examination (BSE), clinical breast examination (CBE), and radiological examination are among the most common modalities to identify changes in the breast. The main goal of early detection of breast cancer is to diagnose cancer in an early stage in hopes leading to better management and prognosis.(2,5,6)

The most common radiographic modalities of choice for the screening and diagnosis of breast pathologies are mammography, ultrasound, Computed Tomography scan (CT scan) and Magnetic Resonance Imaging (MRI). From the radiographic point of view, mammography is considered the gold standard to detect microcalcifications, which are an early sign of malignancy, for which no other modality can replace them yet. Mammography has the sensitivity and specificity of 75-90% and 90-95%, respectively. Its positive predictive values for breast cancer are approximately 20% in women aged <50 years and 60-80% in women aged 50-69 years. The limitation of mammography is low sensitivity (62.2-68.1%) in women with dense breasts because it is difficult to distinguish dense breast tissue from breast lesions.(7) Ultrasound is a radiographic modality for diagnosis in women under the age of 40 years with dense fibroglandular density of the breast, women who are pregnant and breastfeeding, useful to distinguish solid or cystic lesions. It is non-invasive, without any radiation, affordable, and widely available with derivatives such as Doppler and elastography. However, ultrasound also has several limitations, such as operator-dependent and a narrow field of view with 2-dimensional imaging.(8)

Gray Scale ultrasound can accurately distinguish different layers of breast parenchyma. Stavros (9) described specific features to distinguish benign and malignant nodules, which showed Gray Scale with a sensitivity of 98.4% and specificity of 67.8%. Gray Scale ultrasound has a derivative: Doppler which can detect the presence of vascularization in lesions that distinguish solid lesions benign, and malignant. Doppler utrasound examination consists of Color Doppler, Power Doppler, and Spectral Doppler. Color Doppler ultrasound is used to assess the vascular characteristics of lesions based on the principle of angiogenesis, which is the process of neovascularization formation that is structurally and functionally abnormal. The advantages of Color Doppler ultrasound are its ability to convert colors according to the direction and speed of blood flow in the blood vessels. Whereas the limitations of Color Doppler ultrasound i.e., lack of sensitivity to slow flow, at small lesion size due to lack of vascularity. Power Doppler ultrasound is more sensitive in assessing slow blood flow but unable to see the direction of flow and sensitive to artifacts. A study by Ibrahim et al.(10) found the combination of Gray Scale ultrasound with Power Doppler has a sensitivity of 76.5% and specificity of 89% in distinguishing malignant and benign lesions of the breast.(11-14)

Svensson et al.(15) found that the combination of Gray Scale and Color Doppler (morphological pattern of blood vessels) ultrasound has a sensitivity of 99.1% and specificity of 92.6% in distinguishing breast cancer and fibroade-noma. Color Doppler is more widely used in assessing vascularization of lesions and functions as a complement to Gray Scale ultrasound and cannot be utilized alone. Color Doppler and Power Doppler ultrasound qualitatively assess the presence or absence of vascularity, morphology, number, and distribution (central, peripheral, and penetrating blood vessels). Spectral Doppler ultrasound evaluates Resistive Index (RI), Pulsatility Index (PI), Peak Systolic Velocity (PSV), and end-diastolic velocity (EDV) quantita-tively. Some researchers have assessed vascularity of breast lesions with Spectral Doppler in terms of RI, PI, average velocity (Vmean) and Vmax with varying results RI = (Vmax - Vmin/Vmax); PI = (Vmax - Vmin/Vmean). The RI assessment provides an overview of arterial wave analysis (PSV/V.max and EDV/Vmin), which is a quantitative measure of resistance to arterial flow in blood vessels. An increase in the size of the cancerous lesion requires the formation of new blood vessels so that breast cancer is expected to show increased vascularity compared to benign masses when examined with Doppler. RI is an estimate of resistance offered by vessels to the flowing blood. Cancerous growths release vascular growth factors, which promote development of newer vessels. However, this vessels are tortuous with an abnormal structure, resulting in increased resistance to blood. Thus, Doppler ultrasound of malignant masses reveals a higher RI as compared to benign or normal tissues with normal or reduced number of vessels. Malignant lesions also have features such as central vascularity, hypervascularity or tortuous vessels while benign lesions are usually having normal or reduced number of vessels.(16)

According to Amin et al.(13), the criteria Doppler used to diagnose benign lesions are peripheral vascularization and Spectral Doppler shows a decrease in RI (0.58 ± 0.05) with 94% sensitivity and 92% specificity. In malignant lesions is central vascularization and Spectral Doppler shows an increase in RI (0.76 ± 0.03) with 92% sensitivity, 94% specificity. Aziz et al.(17) reported grades cut off the adequate value for diagnosing malignancy is 0.675, where an RI value of 0.785 has 100% specificity. Lehman et al.(18) report that RI 0.78 is the value cut off which is appropriate for distinguishing malignant tumors from benign tumors. The size of the lesion becomes a limiting factor in ultrasound evaluation Doppler. According to Ozdemir et al.(19) using ultrasound Spectral Doppler improves Gray Scale ultrasound specificity as high as 88.9-100% in lesion size ≤ 10 mm and 70-96.6% in lesion size > 10 mm. Differences between the cut-off values of RI and the difference between sensitivity and specificity proposed in studies greatly vary because tumor behavior depends on vascularity. Some studies even doubted its usefulness.(10,14,15,19,20)

Since Spectral Doppler parameters are not considered as standard parameters yet, this study aims to investigate the diagnostic value of RI Spectral Doppler ultrasound to determine breast malignancy as there is currently no optimal cut-off point to determine breast malignancy.

METHODS

This retrospective studies was conducted at Surgery and Radiology Departments of Hasan Sadikin General Hospital, Bandung, West Java Indonesia. The study was approved by Ethics Committee of Hasan Sadikin General Hospital, Bandung, West Java Indonesia (Ethics Approval Number: LB.02.01/X.2.2.1/2016/2021). The total of study participants were 62 patients, ranging between 18-78 years, who presented with abnormalities on breast ultrasound were investigated during September 2021 to October 2021. Histopathological examinations were done in these patients.

The examination was carried out using GE Logic S9, a 7-15 MHz linear transducer. The study subjects were positioned, arms were extended above the head, examination was carried out on the entire breast. Vascularization assessment of breast lesions using GE Logic S9 ultrasound, 7-15 MHz linear transducer. It is manufactured by SOMA Soma Tech Intl, Bloomfield, CT 06002. Techniques used include Color Doppler and Spectral Doppler. The tool was set to PRF 700-1,000 Hz, maximum gain 85-90%, wall filler 50-100 Hz. Vascular flow patterns were evaluated taking into consideration the surrounding marginal flow and penetrating flow. When surrounding marginal flow and penetrating flow were both present, the dominant flow pattern was chosen. Subjects with ultrasound examination results of pure cystic lesions (Chang classification types I, II, III) and BIRADS 0 and 1 were excluded from this study.

Univariable analysis was carried out to obtain the proportion of each variable descriptively, which was then analysed further into descriptive analysis and hypothesis testing. Numerical data such as values RI was presented in mean, standard deviation, median, and range. Categorical data such as the BIRADS category and histopathology results, was coded and presented in frequency and percentage distribution.(21,22)

Logistic regression test and spearman correlation test were used to see the correlation of research variables. The logistic regression test was used to test nominal categorical with ordinal categorical variables with odds ratio results. The Spearman correlation test was used to test numerical categorical with ordinal categorical variables.

The R value obtained shows a correlation relationship between variables, R value of 0.81-0.99 indicate a very strong correlation value, 0.61-0.80 indicates a strong relationship, 0.41-0.60 indicates a medium relationship, 0.21-0.40 indicates a weak relationship, and 0.01-0.20 indicates a very weak relationship. The criterion of meaning used is P-value. If P-value ≤ 0.05 is statistically significant or meaningful, and P-value > 0.05 is not statistically significant or meaningful. The data obtained is recorded in a special form and then processed through the IBM SPSS Statistics for Windows, Version 24.0. Armonk, NY: IBM Corp.(21,22)

RESULTS

Table 1 describes the characteristic description of research subjects based on age category, sex, BIRADS, histopathological group, and histopathological description results. All of the study subjects were female (100%) with the majority of them aged ≥40 years, which was 43 people (69.3%). The characteristics of the most lesions on ultrasound examination were BIRADS 3 with 27 lesions (43.5%), then BIRADS 5 with 20 lesions (32.3%), BIRADS 4 with 11 lesions (17.7%), and BIRADS 2 with 4 lesions (6.5%). The histopathological group of the study subjects was malignant lesions with a total of 31 lesions (50%) where the results of the description of the most histopathological of malignant lesions were invasive carcinoma of no special type with a total of 23 (37.1%) and benign lesions with a total of 31 lesions (50%) where the results of the description of the most histopathological of benign lesions were fibroadenomas with a total of 22 (35.5%).

Table 2 describes the characteristic description of lesions on ultrasound examination, which consists of BIRADS 2 with a total of 4 lesions (13%) and BIRADS 3 with a total of 22 lesions (71%) with the results of benign histopathological are fibroadenoma, usual ductal hyperplasia, microglandular adenosis, adenomioepithelioma, benign phyllodes. Furthermore, there are also 5 lesions of BIRADS 3 with the results of malignant histopathological are invasive carcinoma of no special type, DCIS. We evaluated and looked back the USG results, The inconsistent results between BIRADS Classification cause by DCIS and Invasive Ductal Carcinoma of Non Special Type (NST) present just only small amount in one breast lesion (only 10% in benign breast lesion).

Table 3 describes the difference in mean age, tumor size, age of menarche, age of first childbirth against breast malignancy. The average age of patients with benign breast tumors is younger than the average age of patients with malignant breast tumors. The average age of patients with benign breast tumors was 40.34 ± 9.71 and the average age of patients with malignant breast tumors was 52.03 ± 12.50. The mean age difference of the malignant and benign groups was statistically significant with a P-value of 0.0001.

As shown in Table 3, we also evaluated the tumor size between two groups. Previous literatures have shown that size of tumor is not useful as a tool to predict malignancy. In this study, we found no significant difference between the median tumor size. The age of menarche in patients with malignant breast tumors has an average of 11.90 ± 1.32 and the average age of menarche in patients with benign breast tumors is 11.65 ± 1.13. From the age of menarche, there was no statistically significant difference in the average age of menarche in the group of patients with malignant and benign breast tumors with a P-value of 0.405. We also found no significant difference in the average age of first childbirth between the group of patients with malignant and benign breast tumors with a P-value of 0.063, the average age of first childbirth in patients with malignant breast tumors 24.90 ± 6.43 and patients with benign breast tumors 21.38 ± 3.50.

Table 4 describes the association between family history of malignancy, history of oral contraceptives use, nutritional status, and breast tumors. Patients with malignant breast tumors who have a family history of malignancy as much as 61.5% and who do not have a family history of malignancy as much as 41.7%. Patients who have a family history of malignancy are 2.240 times at higher risk than patients who do not have a family history of malignancy to occur in the breast. There is no statistically significant results in Table 4.

Patients with malignant breast tumors with the use of oral contraceptives were 57.5% and those who do not use oral contraceptives were 36.4%. Patients who use oral contraceptives have a 2.368 times higher risk of malignancy in the breast compared to patients who do not use oral contraceptives. Based on nutritional status, obese and overweight patients with malignant breast tumors are 84.6% and 50%, respectively. Patients with obese nutritional status have a risk of 3.30 times compared to overweight nutritional status for malignancy in the breast.

Table 5 explains the correlation between RI values and malignancy in the breast based on histopathological results. The average RI value in malignant and benign lesions were 0.97 ± 0.10 and 0.55 ± 0.16, respectively. Based on Table 5, the R value of the correlation between the RI and malignancy was 0.887, which indicates a very strong, statistically significant relationship (P-value 0.0001). The direction of the relationship is positive, meaning if an increase in the value of the RI indicates an increase of risk of malignancy.

Ultrasound results of benign and malignant breast tumors are shown in Fig. 1 and 2, respectively. Fig. 1 comprised of (A) of Gray Scale Ultrasound and (B) Spectral Doppler Ultrasound. While Fig. 2 comprised of (A) and (B) Gray Scale Ultrasound; (C) Spectral Doppler Ultrasound.

DISCUSSION

The majority age distribution of breast tumors in this study is the age group ≥40 years (69.3%). This finding is in accordance with the evidence-based literatures stating that the age of ≥40 years as a risk factor for malignant breast tumors and 95% of cases of breast malignancy occur in women aged 40 years or more. Abdulkareem (2) also found the risk of breast cancer increases 100 times starting at the age of 45 years.

All subjects of this study were patients with female breast tumors who came for treatment. The characteristics of most breast tumors examined by ultrasound examination were BIRADS 3 (27 lesions, 43.5%) then BIRADS 5 (20 lesions, 32.3%) and histopathological results in the form of fibroadenomas were 22 lesions (35.5%) and invasive carcinoma of no special type were 23 (37.1%), which require further examination, including radiological and histopathological examinations.(2,5,18,23,24)

The characteristics of lesions on ultrasound examination of BIRADS 2 with a total of 4 lesions (13%) and BIRADS 3 with a total of 22 lesions (71%) with the results of benign histopathological including: fibroadenoma, usual ductal hyperplasia, micro glandular adenosis, adenomyoepi-thelioma, benign phyllodes. However, there are also 5 lesions of BIRADS 3 with the malignant histopathological results of invasive carcinoma of no special type and ductal carcinoma in situ. This is in accordance with findings of previous studies where BIRADS 2 with categories Benign i.e. there is no possibility of malignancy (0%) and BIRADS 3 with category Probably Benign, has a >0-2% chance of malignancy so that a 6-month ultrasound follow-up examination is needed to consider the assessment.(25)

The average age of patients with benign breast tumors is younger than the average age of patients with malignant breast tumors (40.34 ± 9.71 and 52.03 ± 12.50, respectively). The mean age difference between both groups was statistically significant with a P-value of 0.0001. This finding is consistent with one of the risk for malignant breast tumors which is age of ≥40 years and that 95% of cases of breast malignancy occur in women aged 40 years or older.

The age of menarche in patients with malignant breasts has an average of 11.90 ± 1.32 and the average age of menarche in patients with benign breasts is 11.65 ± 1.13. It is widely accepted that the earlier the age of menarche, the higher the risk of malignancy and research by The Collaborative Group on Hormonal Factors in Breast Cancer which states that the risk of breast malignancy is reduced by 15-20% per 1 year delay in menarche.(26) However, there was no statistically significant difference in the average age of menarche in the group of patients with malignant and benign breasts with P-value of 0.405.

The average periode from the age of first childbirth in patients with malignant and benign breast tumors were 24.90 ± 6.43 and 21.38 ± 3.50, respectively, which were not statistically significant (P-value 0.063). This finding is contrary to the current literature that women who give birth to their first child at an older age have a higher risk of breast cancer compared to women who give birth to their first child at a younger age, because gestational age >35 years causes the risk of breast cancer due to increased exposure to estrogen and progesterone that promotes proliferation in cells that have already been initiated.(2,23,26)

Patients with malignant breast tumors, with and without a family history of malignancy were 61.5% and 41.7%, respectively. Patients who have a family history of malignancy have a risk of 2.240 times higher than patients who do not have a family history of malignancy to occur in the breast. It is consistent with current literatures stating family history of malignancy is a risk factor for malignant breast tumors. It is also in accordance with Razif et al.(27) who stated a family history of malignancy has a 4.8 times higher risk than those who do not have a family history of malignancy for malignancy.

Patients with malignant breast tumors with and without the use of oral contraceptives were 57.5% and 36.4%, respectively. Patients who use oral contraceptives have a 2.368 times higher risk of developing malignancy in the breast compared to patients who do not use them. It is widely accepted that the use of oral contraceptives is closely related to the incidence of breast cancer caused by estrogen content from oral contraceptives that play a role in the pathogenesis of breast cancer. Nindrea et al.(28) also found that patients who use oral contraceptives have a risk 1.27 times higher than patients who do not use oral contraceptives for malignancy in the breast.

Based on nutritional status, patients with breast malignancy who were obese and overweight were 84.6% and 50%, respectively. Patients with obese nutritional status have a risk of 3.30 times compared to nutritional status underweight for malignancy of the breast, consistent with the studies by Nindrea et al.(29) and Sangrajrang et al.(30) in which high BMI has the potential to increase the risk of breast cancer because estrogen synthesis in body fat correlates with the proliferation of breast tissue and the nutritional status of obesity has a risk 1.67 times higher at the time Post Menopause for breast malignancy to occur.

Ultrasound examination resulted in malignant histopathological lesions of BIRADS 3 were 5 lesions, which might be misleading for patients because the follow-up period of breast ultrasound is quite long, at least 6 months. Ultrasound examination Spectral Doppler may improve diagnosis in breast tumors. In Table 5, the average RI value for lesions with malignant histopathological results was 0.97 ± 0.10 and RI values for lesions with benign histopathological results of 0.55 ± 0.16. Based on Spearman's analysis, the value of the correlation coefficient R is 0.887, meaning that the association between RI and malignant histopathological outcomes is very strong and statistically significant with P-value of 0.0001. The direction of the relationship is positive that is, if there is an increase in RI value then the risk for malignancy increases. This is in accordance with the research of Amin et al.(13) which stated an increase in the value of RI on malignancy with RI for benign lesions of 0.58 ± 0.005 and malignant lesions of 0.76 ± 0.03 and the research of del Cura JL et al.(31) which stated the value of RI in malignant lesions of >0.99.

CONCLUSION

There is a very strong and significant correlation between RI value and risk of breast malignancy. An increase in the value of the RI indicates an increase of risk of malignancy. Studies relating to this correlation might benefit from future prospective research with a longer follow-up on patients with BIRADS lesion category 3.

ACKNOWLEDGMENTS

None.

FUNDING

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

CONFLICT OF INTEREST

The authors declare that there is no conflict of interest.

Figures
Fig. 1. Ultrasound results of benign breast tumor (A) Gray Scale Ultrasound; (B) Spectral Doppler Ultrasound.
Fig. 2. Ultrasound results of malig-nant breast tumor (A) and (B) Gray Scale Ultrasound; (C) Spectral Do-ppler Ultrasound.
Tables

Characteristics of the Research Subjects

Variable N = 62
Age
19-39 years 19 (30.7)
≥40 years 43 (69.3)
Gender
Woman 62 (100.0)
Man 0 (0)
BIRADS
BIRADS 2 4 (6.5)
BIRADS 3 27 (43.5)
BIRADS 4 11 (17.7)
BIRADS 5 20 (32.3)
Histopathological group
Malignant 31 (50.0)
Benign 31 (50.0)
Results description of histopathological
Malignant
Invasive carcinoma of no special type 23 (37.1)
B cell lymphoma high grade 2 (3.2)
Invasive ductal carcinoma mammary grade II 1 (1.6)
Ductal carcinoma in situ 1 (1.6)
Invasive lobular carcinoma 4 (6.5)
Beningn
Fibroadenoma 22 (35.5)
Adenomyoepithelioma 2 (3.2)
Benign phyllodes tumor 4 (6.5)
Microglandular adenosis 1 (1.6)
Usual ductal hyperplasia 2 (3.2)

The Features of BIRADS 2 and BIRADS 3 Associated with Histopathological Results

Variable Histopathological results (n = 31)

Benign Malignant
BIRADS
BIRADS 2 4 (13) 0 (0)
BIRADS 3 22 (71) 5 (16)

Remarks: For categorical data presented by number / frequency and percentage.


Clinical Hormone Reproductive Factors and Their Asso-ciation with Breast Cancer

Variable Malignant Benign P value
Age
Mean ± SD 52.03 ± 12.50 40.34 ± 9.71 0.0001*
Median 51.50 40.00
Range (min-max) 52.00
(26.00-78.00)
42.00
(18.00-60.00)
Size of tumor (cm) 3.06 ± 2.94 2.43 ± 1.83 0.111
Age of menarche
Mean ± SD 11.90 ± 1.32 11.65 ± 1.13 0.405
Median 12.00 11.00
Range (min-max) 6.00
(9.00-15.00)
4.00
(10.00-14.00)
Age of first full term pregnancy
Mean ± SD 24.90 ± 6.43 21.38 ± 3.50 0.063
Median 24.00 21.00
Range (min-max) 23.00
(14.00-37.00)
16.00
(16.00-32.00)

Description: For numeric data the P value is tested with an unpaired T test because the data is normally distributed. The value of meaning is based on the value of P < 0.05. The * sign indicates a value of P < 0.05 meaning statistically significant or meaningful.


Relationship of Use of Hormonal Birth Control and Nutritional Status to Breast Malignancy

Variable Breast tumors Odds ratio P value

Malignant Benign
Family history of malignancy
Yes 16 (61.5) 10 (38.5) 2.240
(0779-6.282)
0.123
No 15 (41.7) 21 (58.3) Reff
History of hormonal birth control
Yes 23 (57.5) 17 (42.5) 2.368
(0.811-6.911)
0.111
No 8 (36.4) 14 (63.6) Reff
BMI
Underweight 5 (62.5) 3 (37.5) Reff
Normal 8 (29.6) 19 (70.4) 0.253
(0.048-1.319)
0.103
Overweight 7 (50.0) 7 (50.0) 0.600
(0.102-3.536)
0.572
Obesity 11 (84.6) 2 (15.4) 3.300
(0.413-26.366)
0.260

Description: For categorical data the P value is tested with odd ratio.


Correlation between Resistive Index Value and Malignancy in the Breast

Variable Breast tumors R value (Spearman) P value

Malignant Benign
Resistive index (RI)
Mean ± SD 0.97 ± 0.10 0.55 ± 0.16 0.887 0.0001*
Median 1.000 0.56
Range (min-max) 0.75-1.25 0.09-0.78

Remarks: The value P < 0.05 means significant or statistically meaningful marked *. R close to the number 1 means that there is a very strong correlation. With the direction of the correlation relationship positive.


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