Comparative Analysis of Automated and Handheld Breast Ultrasound Findings for Small (≤1 cm) Breast Cancers Based on BI-RADS Category.

Objectives: This study aimed to compare ultrasound (US) findings between automated and handheld breast ultrasound (ABUS and HHUS, respectively) in small breast cancers, based on the breast imaging reporting and data system (BI-RADS) category. Methods: We included 51 women (mean age: 52 years; range: 39-66 years) with breast cancer (invasive or DCIS), all of whom underwent both ABUS and HHUS. Patients with tumors measuring ≤1 cm on either modality were enrolled. Two breast radiologists retrospectively evaluated multiple imaging features, including shape, orientation, margin, echo pattern, and posterior characteristics and assigned BI-RADS categories. Lesion sizes were compared between US and pathological findings. Statistical analyses were performed using Bowker's test of symmetry, a paired t-test, and a cumulative link mixed model. Results: ABUS assigned lower BI-RADS categories than HHUS while still maintaining malignancy suspicion in categories 4A or higher (54.8% consistent with HHUS; 37.3% downcategorized in ABUS, p = 0.005). While ABUS demonstrated less aggressive margins in some cases (61.3% consistent with HHUS; 25.8% showing fewer suspicious margins in ABUS), this difference was not statistically significant (p = 0.221). Similarly, ABUS exhibited slightly greater height-width ratios compared to HHUS (median, interquartile range: 0.98, 0.7-1.12 vs. 0.86, 0.74-1.10, p = 0.166). No significant differences were observed in other US findings or tumor sizes between the two modalities (all p > 0.05). Conclusions: Small breast cancers exhibited suspicious US features on both ABUS and HHUS, yet they were assigned lower BI-RADS assessment categories on ABUS compared to HHUS. Therefore, when conducting breast cancer screening with ABUS, it is important to remain attentive to even subtle suspicious findings, and active consideration for biopsy may be warranted.