Differential diagnosis of breast mucinous carcinoma with oval shape from fibroadenoma based on ultrasonographic features

Differential diagnosis of breast mucinous carcinoma with oval shape from fibroadenoma based on ultrasonographic features | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Differential diagnosis of breast mucinous carcinoma with oval shape from fibroadenoma based on ultrasonographic features Hongli Wang, Yue Hu, Cui Tan, Ran Gu, Yudong Li, Liang Jin, Xiaofang Jiang, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3106676/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 03 Feb, 2024 Read the published version in BMC Women's Health → Version 1 posted 10 You are reading this latest preprint version Abstract Background Approximately 50% of breast mucinous carcinomas (MCs) are oval and have the possibility of being misdiagnosed as fibroadenoma (FA). We aimed to identify the key features that can help differentiate breast MC with oval shape from fibroadenoma (FA) on ultrasonography (US). Methods Seventy-six MCs in 71 consecutive patients and 50 FAs with oval shape in 50 consecutive patients were included in our study. All lesions had pathological diagnoses. According to the Breast Imaging Reporting and Data System (BI-RADS), first, the ultrasonographic features of the MCs and FAs were recorded and a final category was assessed. Then, the differences of ultrasonographic characteristics between category 4A (low-risk group) and category 4B-5 (medium-high risk group) of MCs were identified. Finally, other ultrasonographic features of MC and FA both with oval shape were compared to determine the key factors for differential diagnosis. The Mann-Whitney test, the χ 2 test or Fisher’s exact test was used in our study. Results MCs with oval shape (81.2%) and circumscribed margin (25%) on US were more common assessed in the low-risk group (BI-RADS 4A) than in the medium-high risk group (BI-RADS 4B-5) ( 20%， p <0.001 and 0% p =0.001, respectively). Compared with FA, patients with MC were older, and with masses being more likely to appear non-hypoechoic, not circumscribed margin, and posterior echo enhancement on US ( p <0.001, p <0.001, p =0.003, respectively). Conclusion: The oval shape was the main reason for the underestimation of MCs. On US, an oval mass found in the breast of an old woman with non-hypoechoic echo, not circumscribed margin, and posterior echo enhancement was associated with an increased risk of MC, and active biopsy should be recommended. Breast Ultrasonography Mucinous carcinoma Figures Figure 1 Figure 2 Figure 3 Background Breast mucinous carcinoma (MC) is characterized by clusters of generally small and uniform cells floating in large amounts of extracellular mucin. It is a rare histological type with a prevalence of 1 to 7% among all breast carcinomas[ 1 ]. MC grows slowly, has a low rate of lymph nodal metastasis, and a good prognosis [ 2 , 3 ]. At present, ultrasonography (US) is one of the most widely available diagnostic options for women with breast mass[ 4 ]. The descriptions of ultrasonographic features of breast masses are mainly based on the Breast Imaging Reporting and Data System (BI-RADS) [ 5 ]. Morphological feature is an important factor in the differential diagnosis of benign and malignant masses[ 6 , 7 ]. In general, irregular shape is shown to be highly suggestive of malignancy, while oval shape indicates benign [ 6 , 7 ]. However, as a slow-growing carcinoma, the proportion of oval shape in MCs was nearly 50% [ 8 ]. Due to the relative high frequency of MC with oval shape, there is potential for misdiagnosis of MC for fibroadenoma (FA), which is most common benign breast solid mass. Bode et al [ 9 ] reported that 92% MCs could be classified as BI-RADS category 4 or above on US. However, the malignant ultrasonographic features of MCs were subtle in comparison to typical breast carcinoma, and some of them may be assessed as BI-RADS category 4A. Compared with category 4B and above, the malignant likelihood of the category 4A lesions is relatively low between 2%-10%, which belong to low-risk. In addition, the likelihood of malignancy is lower in the category 4A masses with oval shape than those with irregular shape, even less than 2% [ 10 ]. Follow-up instead of biopsy was advised for the category 4A masses with oval shape, which may be MCs [ 10 , 11 ]. Thus, MCs which were assessed category 4A maybe delayed diagnosis. Therefore, firstly, this retrospective study explored the ultrasonographic features, which lead to MCs being assessed as BI-RADS category 4A (low-risk group) by comparing it with BI-RADS category 4B and above (medium-high risk group). Secondly, the specific ultrasonographic features that can help differentiate MC with oval shape from FA were identified. Methods Patients The pathology database of our hospital was searched from January 2013 to January 2021 for surgically treated MC. Depending on the proportion of MC components, the MCs were separated into two pathologic types: pure mucinous carcinoma (PMC, ≥ 90% mucinous carcinoma) and mixed mucinous carcinoma (MMC, < 90% mucinous carcinoma). The inclusion criteria for patients with MC were as follows: (1) underwent surgical excision of the breast MCs; and (2) underwent breast US before biopsy in our hospital. The exclusion criteria were as follows: (1) unavailable US images; or (2) neoadjuvant chemotherapy, or (3) no history of breast cancer. Consequently, 76 MCs in 71 consecutive patients (two patients had three MCs each, and one patient had two MCs) (Fig. 1 ) were selected for retrospective analysis. And 49 (64.5%) were PMCs, while 27 (35.5%) were MMCs. In addition, the pathology database was searched for FA between June 2019 and January 2021. The inclusion and exclusion criteria for patients with FA were the same as those for patients with MC, but the shape of the FA was limited to oval. If the patients had multiple FAs in the unilateral breast, the largest one was included in our study. Finally, 50 FAs in 50 consecutive patients were selected for the research. Ultrasonography Breast US examinations were performed with a high-resolution US unit (S2000, S1000 or ACUSON Oxana2; Siemens Medical Solutions, Erlangen, Germany). During the examination, the patients were in the supine position with their arms raised and hands placed behind their heads. All US scans were performed and interpreted simultaneously by one dedicated breast radiologists with a minimum of 5 years of experience. The age of patients [ 12 ] and the following features of the MCs and FAs according to the fifth edition of the BI-RADS guidelines [ 5 ], were evaluated: maximum dimension (cm), shape (oval, irregular), orientation (parallel, not parallel), margin (circumscribed, not circumscribed), echo pattern (hypoechoic, isoechoic, heterogeneous and complex cystic and solid), posterior features (enhancement, no posterior features), calcifications in the mass (yes, no) and vascularity (absent, internal vascularity and vessels in rim). Because of the small number of cases in this study, the isoechoic, heterogeneous and complex cystic and solid echo were classified as non-hypoechoic. Then, a final category was assessed. All MCs were assessed as category 4A and above. Further, MCs were divided into low-risk group (category 4A) and medium-high-risk group (categories 4B-5). Consequently, 16 MCs were classified as the low-risk group and 60 as the medium-high-risk group. 14 FAs were classified as category 4A and 11 as category 3. According to BI-RADS guideline, the category 3 lesions only require six months follow-up, and no biopsy is required. However, 11 patients with category 3 lesions strongly requested biopsy. Statistical analysis Age and maximum dimension were compared between groups using the Mann-Whitney test. The χ 2 test or Fisher’s exact test was used to compare the ultrasonographic features of the low-risk group and medium-high-risk group of MCs as well as FA and MC both with oval shape on US. SPSS 20.0 (IBM, Chicago, IL, USA) was used for the statistical analyses. All P values were two-tailed, and P < 0.05 was considered statistically significant. Results The patient and ultrasonographic features of MC The median age of the 71 patients with MC was 47 years (range: 27–86 years). 76 MCs presented as masses on US. The median maximum dimension was 2.5 cm (range: 1.0–8.0 cm). The ultrasonographic features of the MCs are shown in Table 1 . No correlations were found between ultrasonographic features and pathologic types. Table 1 The ultrasonographic features of the mucinous carcinomas Features MC PMC MMC P value Age 47 (41∽61) 47 (42∽57) 45 (39∽65) 0.757 Maximum dimension 2.5 (1.7∽3.2) 2.5 (1.7∽3.4) 2.4 (1.8∽3.0) 0.879 Shape 0.653 Oval 25 (32.9%) 17 (34.7%) 8 (29.6%) Irregular 51 (67.1%) 32 (65.3%) 19 (70.4%) Orientation 0.338 Parallel 65 (85.5%) 40 (81.6%) 25 (92.6%) Not parallel 11 (14.5%) 9 (18.4%) 2 (7.4%) Margin 0.323 Circumscribed 4 (5.3%) 4 (8.2%) 0 (0.0%) Not circumscribed 72 (94.7%) 45 (91.8%) 27 (100.0%) Echo 0.445 Hypoechoic 33 (43.4%) 21 (42.9%) 12 (44.5%) Isoechoic 25 (32.9%) 14 (28.5%) 11 (40.7%) Heterogeneous 16 (21.1%) 12 (24.5%) 4 (14.8%) Complex cystic and solid 2 (2.6%) 2 (4.1%) 0 (0.0%) Posterior features 0.838 No posterior features 27 (35.5%) 17 (34.7%) 10 (37.0%) Enhancement 49 (64.5%) 32 (65.3%) 17 (63.0%) Calcifications in the mass 0.822 No 67 (88.2%) 44 (89.8%) 23 (85.2%) Yes 9 (11.8%) 5 (10.2%) 4 (14.8%) Vascularity 0.161 Absent 15 (19.7%) 12 (24.5%) 3 (11.1%) Internal vascularity or vessels in rim 61 (80.3%) 37 (75.5%) 24 (88.9%) Abbreviations: MC : mucinous carcinoma; PMC : pure mucinous carcinoma; MMC : mixed mucinous carcinoma Differences in ultrasonographic features of MC between low-risk group and medium-high-risk group According to BI-RADS, the MCs were divided into the low-risk group (BI-RADS category 4A) and medium-high-risk group (BI-RADS category 4B-5), and the differences in the shape and the margin between the two groups were statistically significant (p < 0.001, p = 0.001, respectively) (Table 2 ), especially shape. A total of 81.2% MCs in the low-risk group were oval, but only 20.0% in the medium-high-risk group. Moreover, all MCs in the medium-high-risk group had not circumscribed margins, while only 75% MCs in the low-risk group. Table 2 Differences in ultrasonographic features between the low-risk group and the medium-high risk group of mucinous carcinomas Feature Low-risk group medium-high risk group P value Age 48 (42∽60) 46 (40∽62) 0.610 Maximum dimension 2.1(1.5∽2.8) 2.5 (1.8∽3.5) 0.096 Shape < 0.001 Oval 13(81.2%) 12(20.0%) Irregular 3(18.8%) 48(80.0%) Orientation 1.000 Parallel 14(87.5%) 51(85.0%) Not parallel 2(12.5%) 9(15.0%) Margin 0.001 Circumscribed 4(25.0%) 0(0.0%) Not circumscribed 12(75.0%) 60(100.0%) Echo 0.976 Hypoechoic 7(43.8%) 26(43.3%) Non-hypoechoic 9(56.2%) 34(56.7%) Posterior features 0.115 No posterior features 3(18.8%) 24(40.0%) Enhancement 13(81.2%) 36(60.0%) Calcifications in the mass 0.225 No 16(100%) 51(85.0%) Yes 0(0%) 9(15.0%) Vascularity 0.098 Absent 6(37.5%) 9(15.0%) Internal vascularity and vessels in rim 10(62.5%) 51(85.0%) Comparison of ultrasonographic features between MC with oval shape and FA with oval shape Then, the other ultrasonographic features of MC and FA both with oval shape on US were compared. The differences in patient’s age, the ultrasonographic margin, internal echo, and posterior features between the two groups were statistically significant ( p < 0.001, p < 0.001, p < 0.001, p = 0.003, respectively) (Table 3 ). Compared to those with FA (Fig. 2 ), the patients with MC were older, and more MCs had not circumscribed margins, and were non-hypoechoic (including isoechoic, heterogeneous, complex cystic and solid echo) with posterior echo enhancement (Fig. 3 ). Table 3 Comparison of other ultrasonographic features between MC with oval shape and FA with oval shape Features MC FA P value Age 47 (42∽56) 30 (24∽36) < 0.001 Maximum dimension 2.3 (1.4∽3.3) 2.1 (1.4∽2.6) 0.306 Orientation 0.069 Parallel 22(88.0%) 49(98.0%) Not parallel 3(12.0%) 1(2.0%) Margin < 0.001 Circumscribed 4(16.0%) 42(84.0%) Not circumscribed 21(84.0%) 8(16.0%) Echo < 0.001 Hypoechoic 9(36.0%) 49(98.0%) Non-hypoechoic 16(64.0%) 1(2.0%) Posterior features 0.003 No posterior features 6(24.0%) 30(60.0%) Enhancement 19(76.0%) 20(40.0%) Calcifications in the mass 1.000 No 24(96.0%) 48(96.0%) Yes 1(4.0%) 2(4.0%) Vascularity 0.307 Absent 7(28.0%) 20(40.0%) Internal vascularity and vessels in rim 18(72.0%) 30(60.0%) Abbreviations: FA : fibroadenoma; MC : mucinous carcinoma Discussion Breast MC is rare in the clinic, and preoperative diagnose is difficult to obtain due to the variety of ultrasonographic features and its morphological features overlap with those of benign tumours reported in the literature [ 8 , 9 , 13 – 17 ]. In our study, although most MCs showed malignant signs and were assessed as the medium-high-risk group (BI-RADS 4B and above), 21.1% (16/76) MCs were assessed as the low-risk group (BI-RADS category 4A), for which the malignancy likelihood is exceptionally low. By comparing the ultrasonographic features of MCs in the low-risk group and medium-high-risk group, we confirmed that the majority (81.2%) of MCs in the low-risk group were oval. Lam et al.[ 8 ]reported that the ratio of oval shape masses on US was 40.6% for all MCs, 47.4% for PMCs and 30.8% for MMCs, while Kaoku et al [ 15 ]. reported that this proportion of PMC was only 9.1%. In our research, an oval shape mass on US accounted for 32.9% (25/76) of all MCs, 34.7% of PMCs and 29.6% of MMCs. Apparently, the proportion of oval masses in PMCs was higher than in MMCs, but there was no statistical difference between both in our and previous studies. Oval shape is an ultrasonographic feature of benign breast masses, which may be suggested follow-up instead of biopsy [ 10 , 11 , 18 , 19 ]. On US, if the shape of MC is oval, it may be underestimated. In addition to the shape, there were also statistically significant differences in marginal features between the low-risk group and the medium-risk group. However, although the percentage of MCs with a circumscribed margin in the low-risk group was higher than that in medium-high-risk group, the majority (75%) of MCs in the low-risk group had not circumscribed margins, which is an ultrasonographic feature of malignancy [ 6 , 7 , 10 , 11 , 19 ]. Overall, oval shape was the main reason why MCs were underestimated as the low-risk group which suggested benign masses. Fibroadenomas are the most common benign tumours of the breast [ 20 ]. Compared with FA which is commonly found in young women, typically in 20 to 30 years old [ 21 ], patients with MC were older, the median age was 47, which was younger than 51 to 71 years previously reported [ 22 , 23 ]. Regarding ultrasonographic features, most FAs are oval or round, well circumscribed, hypoechoic with the long axis parallel to the skin surface and have normal or increased posterior echogenicity [ 24 ], which are almost consistent with our study findings. By comparing the other features of MC and FA both with oval shape, we found that the marginal features, internal echo and posterior echo features were helpful for the differential diagnosis of them. Among internal echo, marginal and posterior features, internal echo is usually the first feature to attract the attention of the ultrasound physicians. And hypoechoic is the most common type of echo in both typical benign and typical malignant masses [ 6 , 7 , 12 , 19 ]. Compared with FA, the internal echo of most MC was non-hypoechoic including heterogeneous, isoechoic, or complex cystic and solid, which may be related to the complex tissue composition of the MC. MCs are composed of large amounts of extracellular mucin, stroma, and clusters of cancer cells. Kaoku et al[ 15 ] reported that the internal echo of MC varied with the proportions of the different components, and the proportion of stroma tended to increase as the internal echogenicity increased. As for the difference in marginal feature of MC and FA, unlike the circumscribed margins of most FAs (84%), the margins of most MCs (84%) were not circumscribed in our study. Previous studies reported that the ratio of MC with not circumscribed margin was between 23.5–95.0% [ 8 , 9 , 13 , 14 , 16 ]. The large ratio range may be related to the different number of cases included in the studies. Compared with previous studies with fewer cases or only including PMCs, our study was more convincing, because it had the largest number of cases and included two pathologic types of PMC and MMC. Maybe, the not circumscribed margin of MC is related to the aggressive growth pattern of malignant masses [ 11 , 19 ]. Furthermore, posterior enhancement was another common ultrasonographic feature of MC. This feature is probably due to the transmission of the ultrasound beam through large amounts of extracellular mucin [ 8 ]. This study had some limitations. First, our study only included commonly used ultrasonographic features. US elastography was not extensively used in our study, although it was added to the BI-RADS for US. Second, this was a single-institution retrospective study. Multicentre studies with greater numbers of patients are needed to confirm our findings. Conclusion In this study, MCs with oval shape on US may be underestimated as the low-risk group. If an oval breast mass is found in an old woman and is non-hypoechoic with posterior echo enhancement and has not circumscribed margin, the possibility of MC should be considered, and active biopsy should be recommended. Abbreviations BI-RADS: Breast Imaging Reporting and Data System; FA: fibroadenoma MC: mucinous carcinoma PMC: pure mucinous carcinoma MMC: mixed mucinous carcinoma US: ultrasonography Declarations Ethics approval and consent to participate All procedures in this study were approved by the ethical review board committee of Sun Yat-Sen Memorial Hospital (SYSEC-KY-KS-2021-252) and in accordance with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The informed consent was waived by the same ethics committee that approved the study (ethical review board committee of Sun Yat-Sen Memorial Hospital) because of the retrospective nature of the study. Consent for publication Not applicable Availability of data and materials Data can be obtained with appropriate reason by request to the corresponding author through email [email protected] Competing interests The authors declared no conflicts of interest. Funding Comply with the rules of blind review, this part is added in the submission system. Authors ’ contributions HL.W., Y.H., Q.L. and C.G. contributed to the conception and design of the work; C.T., R.G., YD. L., L.J., XF.J. and JS.M. contributed to the data acquisition; HL.W. and Y.H. contributed to the data analysis and interpretation. HL.W. and Y.H. drafted the work; Q.L. and C.G. revised it. All authors read and approved the final manuscript. Acknowledgements Not applicable. References Toikkanen S, Kujari H. Pure and mixed mucinous carcinomas of the breast: a clinicopathologic analysis of 61 cases with long-term follow-up. Hum Pathol. 1989;20:758–64. Bae SY, Choi MY, Cho DH, Lee JE, Nam SJ, Yang JH. 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Cite Share Download PDF Status: Published Journal Publication published 03 Feb, 2024 Read the published version in BMC Women's Health → Version 1 posted Editorial decision: Revision requested 20 Nov, 2023 Reviews received at journal 14 Nov, 2023 Reviewers agreed at journal 11 Nov, 2023 Reviewers agreed at journal 20 Oct, 2023 Reviewers agreed at journal 12 Oct, 2023 Reviewers invited by journal 26 Sep, 2023 Editor assigned by journal 20 Sep, 2023 Editor invited by journal 04 Jul, 2023 Submission checks completed at journal 04 Jul, 2023 First submitted to journal 25 Jun, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3106676","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":215519211,"identity":"51595516-44e3-43cc-8c18-7855f1676b52","order_by":0,"name":"Hongli Wang","email":"","orcid":"","institution":"Sun Yat-sen Memorial Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hongli","middleName":"","lastName":"Wang","suffix":""},{"id":215519214,"identity":"c8390007-3057-4081-b585-5c42cbd2cbb3","order_by":1,"name":"Yue Hu","email":"","orcid":"","institution":"Sun Yat-sen Memorial 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Gong","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/klEQVRIiWNgGAWjYFACHhBhw8DAzNwAEzIgRksaUAsjaVoOAzGxWuTdzx78XPDrfDR/O2MD48+2usQG9uZtEgw1d3BqMTyTlyw9s+927ozDjA3MvG2HExt4jpVJMBx7hlvLDB4Dad6e27kNIC2MbQcSGyRyzCQYGw7j02L8m7fnXO78wzCHyb/Br0VegsdMmufHgdwNQC0MvG3MQFt48Gsx4Mkxs+ZtSM7dCNRymOfcYeM2nrRii4RjeGxpP2N8m+ePXe6884cPPvxRVifbz354440PNXhsOQAkGNsgnAOMbAwMbCBWAk4NQFsaQOQfGPcPToWjYBSMglEwggEAtj5WRigB1ZMAAAAASUVORK5CYII=","orcid":"","institution":"Sun Yat-sen Memorial Hospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Chang","middleName":"","lastName":"Gong","suffix":""}],"badges":[],"createdAt":"2023-06-25 11:14:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3106676/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3106676/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12905-024-02910-w","type":"published","date":"2024-02-03T15:00:57+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":39792523,"identity":"b9eacd6d-9da1-49dd-8cf3-a6a7ea6c3538","added_by":"auto","created_at":"2023-07-10 13:55:55","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":152212,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart of the selection process for mucinous carcinomas (MC) patients\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3106676/v1/c0a5f1d010272bcb07f4b9bb.jpg"},{"id":39792525,"identity":"b1d9dc5a-3be9-417d-8e91-72f54699e2bd","added_by":"auto","created_at":"2023-07-10 13:55:55","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":81548,"visible":true,"origin":"","legend":"\u003cp\u003eFibroadenoma. 37-year-old woman. A mass which was oval, hypoechoic with circumscribed margin and no posterior features was found in the right breast. The mass was assessed as 4A mainly because of its lobulated appearance. Pathological diagnosis: fibroadenoma.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3106676/v1/6048cd69624e2f0a89a551d5.jpg"},{"id":39792524,"identity":"a3872f09-7a97-4819-8077-57dc455930e9","added_by":"auto","created_at":"2023-07-10 13:55:55","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":94191,"visible":true,"origin":"","legend":"\u003cp\u003eMucinous carcinoma. 45-year-old woman. A mass which was oval, non-hypoechoic with not circumscribed margin and posterior echo enhancement was found in the right breast. The mass was assessed as BI-RADS 4A mainly due to the not circumscribed margin. Pathological diagnosis: mucinous carcinoma.\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3106676/v1/cb6248d12c1c45ca59bb2957.jpg"},{"id":50673838,"identity":"a9dba20b-8921-4f16-9265-b4e83fc618a4","added_by":"auto","created_at":"2024-02-05 15:07:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":501618,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3106676/v1/a159ae85-6379-4e93-b564-37f59547ddaa.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Differential diagnosis of breast mucinous carcinoma with oval shape from fibroadenoma based on ultrasonographic features","fulltext":[{"header":"Background","content":"\u003cp\u003eBreast mucinous carcinoma (MC) is characterized by clusters of generally small and uniform cells floating in large amounts of extracellular mucin. It is a rare histological type with a prevalence of 1 to 7% among all breast carcinomas[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. MC grows slowly, has a low rate of lymph nodal metastasis, and a good prognosis [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAt present, ultrasonography (US) is one of the most widely available diagnostic options for women with breast mass[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The descriptions of ultrasonographic features of breast masses are mainly based on the Breast Imaging Reporting and Data System (BI-RADS) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Morphological feature is an important factor in the differential diagnosis of benign and malignant masses[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In general, irregular shape is shown to be highly suggestive of malignancy, while oval shape indicates benign [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, as a slow-growing carcinoma, the proportion of oval shape in MCs was nearly 50% [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Due to the relative high frequency of MC with oval shape, there is potential for misdiagnosis of MC for fibroadenoma (FA), which is most common benign breast solid mass.\u003c/p\u003e \u003cp\u003eBode et al [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] reported that 92% MCs could be classified as BI-RADS category 4 or above on US. However, the malignant ultrasonographic features of MCs were subtle in comparison to typical breast carcinoma, and some of them may be assessed as BI-RADS category 4A. Compared with category 4B and above, the malignant likelihood of the category 4A lesions is relatively low between 2%-10%, which belong to low-risk. In addition, the likelihood of malignancy is lower in the category 4A masses with oval\u003c/p\u003e \u003cp\u003eshape than those with irregular shape, even less than 2% [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Follow-up instead of biopsy was advised for the category 4A masses with oval shape, which may be MCs [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Thus, MCs which were assessed category 4A maybe delayed diagnosis.\u003c/p\u003e \u003cp\u003eTherefore, firstly, this retrospective study explored the ultrasonographic features, which lead to MCs being assessed as BI-RADS category 4A (low-risk group) by comparing it with BI-RADS category 4B and above (medium-high risk group). Secondly, the specific ultrasonographic features that can help differentiate MC with oval shape from FA were identified.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eThe pathology database of our hospital was searched from January 2013 to January 2021 for surgically treated MC. Depending on the proportion of MC components, the MCs were separated into two pathologic types: pure mucinous carcinoma (PMC, \u0026ge;\u0026thinsp;90% mucinous carcinoma) and mixed mucinous carcinoma (MMC, \u0026lt; 90% mucinous carcinoma). The inclusion criteria for patients with MC were as follows: (1) underwent surgical excision of the breast MCs; and (2) underwent breast US before biopsy in our hospital. The exclusion criteria were as follows: (1) unavailable US images; or (2) neoadjuvant chemotherapy, or (3) no history of breast cancer. Consequently, 76 MCs in 71 consecutive patients (two patients had three MCs each, and one patient had two MCs) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) were selected for retrospective analysis. And 49 (64.5%) were PMCs, while 27 (35.5%) were MMCs.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn addition, the pathology database was searched for FA between June 2019 and January 2021. The inclusion and exclusion criteria for patients with FA were the same as those for patients with MC, but the shape of the FA was limited to oval. If the patients had multiple FAs in the unilateral breast, the largest one was included in our study. Finally, 50 FAs in 50 consecutive patients were selected for the research.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eUltrasonography\u003c/h2\u003e \u003cp\u003eBreast US examinations were performed with a high-resolution US unit (S2000, S1000 or ACUSON Oxana2; Siemens Medical Solutions, Erlangen, Germany). During the examination, the patients were in the supine position with their arms raised and hands placed behind their heads.\u003c/p\u003e \u003cp\u003eAll US scans were performed and interpreted simultaneously by one dedicated breast radiologists with a minimum of 5 years of experience. The age of patients [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] and the following features of the MCs and FAs according to the fifth edition of the BI-RADS guidelines [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], were evaluated: maximum dimension (cm), shape (oval, irregular), orientation (parallel, not parallel), margin (circumscribed, not circumscribed), echo pattern (hypoechoic, isoechoic, heterogeneous and complex cystic and solid), posterior features (enhancement, no posterior features), calcifications in the mass (yes, no) and vascularity (absent, internal vascularity and vessels in rim). Because of the small number of cases in this study, the isoechoic, heterogeneous and complex cystic and solid echo were classified as non-hypoechoic. Then, a final category was assessed. All MCs were assessed as category 4A and above. Further, MCs were divided into low-risk group (category 4A) and medium-high-risk group (categories 4B-5). Consequently, 16 MCs were classified as the low-risk group and 60 as the medium-high-risk group. 14 FAs were classified as category 4A and 11 as category 3. According to BI-RADS guideline, the category 3 lesions only require six months follow-up, and no biopsy is required. However, 11 patients with category 3 lesions strongly requested biopsy.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eAge and maximum dimension were compared between groups using the Mann-Whitney test. The \u003cem\u003eχ\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e test or Fisher\u0026rsquo;s exact test was used to compare the ultrasonographic features of the low-risk group and medium-high-risk group of MCs as well as FA and MC both with oval shape on US. SPSS 20.0 (IBM, Chicago, IL, USA) was used for the statistical analyses. All \u003cem\u003eP\u003c/em\u003e values were two-tailed, and \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eThe patient and ultrasonographic features of MC\u003c/h2\u003e \u003cp\u003eThe median age of the 71 patients with MC was 47 years (range: 27\u0026ndash;86 years). 76 MCs presented as masses on US. The median maximum dimension was 2.5 cm (range: 1.0\u0026ndash;8.0 cm). The ultrasonographic features of the MCs are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. No correlations were found between ultrasonographic features and pathologic types.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe ultrasonographic features of the mucinous carcinomas\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFeatures\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMC\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePMC\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMMC\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47 (41∽61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47 (42∽57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45 (39∽65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.757\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaximum dimension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.5 (1.7∽3.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.5 (1.7∽3.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.4 (1.8∽3.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.879\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShape\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.653\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOval\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (32.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (34.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (29.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIrregular\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51 (67.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (65.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (70.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrientation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.338\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParallel\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65 (85.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40 (81.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 (92.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot parallel\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (14.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (18.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (7.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMargin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.323\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCircumscribed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (5.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (8.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot circumscribed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72 (94.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45 (91.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27 (100.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEcho\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.445\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypoechoic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (43.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (42.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (44.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIsoechoic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (32.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (28.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (40.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeterogeneous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (21.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (24.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (14.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplex cystic and solid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (2.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (4.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePosterior features\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.838\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo posterior features\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (35.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (34.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (37.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnhancement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49 (64.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (65.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (63.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCalcifications in the mass\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.822\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67 (88.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44 (89.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23 (85.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (11.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (10.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (14.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVascularity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.161\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbsent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (19.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (24.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (11.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInternal vascularity or vessels in rim\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61 (80.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37 (75.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24 (88.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cb\u003eAbbreviations: MC\u003c/b\u003e: mucinous carcinoma; \u003cb\u003ePMC\u003c/b\u003e: pure mucinous carcinoma; \u003cb\u003eMMC\u003c/b\u003e: mixed mucinous carcinoma\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eDifferences in ultrasonographic features of MC between low-risk group and medium-high-risk group\u003c/h2\u003e \u003cp\u003eAccording to BI-RADS, the MCs were divided into the low-risk group (BI-RADS category 4A) and medium-high-risk group (BI-RADS category 4B-5), and the differences in the shape and the margin between the two groups were statistically significant \u003cem\u003e(p\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001, respectively) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), especially shape. A total of 81.2% MCs in the low-risk group were oval, but only 20.0% in the medium-high-risk group. Moreover, all MCs in the medium-high-risk group had not circumscribed margins, while only 75% MCs in the low-risk group.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDifferences in ultrasonographic features between the low-risk group and the medium-high risk group of mucinous carcinomas\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFeature\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow-risk group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003emedium-high risk group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 (42∽60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46 (40∽62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.610\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaximum dimension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.1(1.5∽2.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.5 (1.8∽3.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.096\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShape\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOval\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13(81.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12(20.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIrregular\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3(18.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48(80.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrientation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParallel\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14(87.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51(85.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot parallel\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(12.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9(15.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMargin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCircumscribed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4(25.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0(0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot circumscribed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12(75.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60(100.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEcho\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.976\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypoechoic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7(43.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26(43.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-hypoechoic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9(56.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34(56.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePosterior features\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.115\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo posterior features\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3(18.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24(40.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnhancement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13(81.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36(60.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCalcifications in the mass\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.225\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16(100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51(85.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0(0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9(15.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVascularity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.098\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbsent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6(37.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9(15.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInternal vascularity and vessels in rim\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10(62.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51(85.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eComparison of ultrasonographic features between MC with oval shape and FA with oval shape\u003c/h2\u003e \u003cp\u003eThen, the other ultrasonographic features of MC and FA both with oval shape on US were compared. The differences in patient\u0026rsquo;s age, the ultrasonographic margin, internal echo, and posterior features between the two groups were statistically significant (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.003, respectively) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Compared to those with FA (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), the patients with MC were older, and more MCs had not circumscribed margins, and were non-hypoechoic (including isoechoic, heterogeneous, complex cystic and solid echo) with posterior echo enhancement (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of other ultrasonographic features between MC with oval shape and FA with oval shape\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFeatures\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMC\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47 (42∽56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (24∽36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaximum dimension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.3 (1.4∽3.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.1 (1.4∽2.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.306\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrientation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.069\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParallel\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22(88.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49(98.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot parallel\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3(12.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(2.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMargin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCircumscribed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4(16.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42(84.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot circumscribed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21(84.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8(16.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEcho\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypoechoic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9(36.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49(98.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-hypoechoic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16(64.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(2.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePosterior features\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo posterior features\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6(24.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30(60.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnhancement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19(76.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20(40.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCalcifications in the mass\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24(96.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48(96.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(4.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(4.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVascularity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.307\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbsent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7(28.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20(40.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInternal vascularity and vessels in rim\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18(72.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30(60.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cb\u003eAbbreviations: FA\u003c/b\u003e: fibroadenoma; \u003cb\u003eMC\u003c/b\u003e: mucinous carcinoma\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eBreast MC is rare in the clinic, and preoperative diagnose is difficult to obtain due to the variety of ultrasonographic features and its morphological features overlap with those of benign tumours reported in the literature [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan additionalcitationids=\"CR14 CR15 CR16\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our study, although most MCs showed malignant signs and were assessed as the medium-high-risk group (BI-RADS 4B and above), 21.1% (16/76) MCs were assessed as the low-risk group (BI-RADS category 4A), for which the malignancy likelihood is exceptionally low. By comparing the ultrasonographic features of MCs in the low-risk group and medium-high-risk group, we confirmed that the majority (81.2%) of MCs in the low-risk group were oval. Lam et al.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]reported that the ratio of oval shape masses on US was 40.6% for all MCs, 47.4% for PMCs and 30.8% for MMCs, while Kaoku et al [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. reported that this proportion of PMC was only 9.1%. In our research, an oval shape mass on US accounted for 32.9% (25/76) of all MCs, 34.7% of PMCs and 29.6% of MMCs. Apparently, the proportion of oval masses in PMCs was higher than in MMCs, but there was no statistical difference between both in our and previous studies. Oval shape is an ultrasonographic feature of benign breast masses, which may be suggested follow-up instead of biopsy [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. On US, if the shape of MC is oval, it may be underestimated. In addition to the shape, there were also statistically significant differences in marginal features between the low-risk group and the medium-risk group. However, although the percentage of MCs with a circumscribed margin in the low-risk group was higher than that in medium-high-risk group, the majority (75%) of MCs in the low-risk group had not circumscribed margins, which is an ultrasonographic feature of malignancy [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Overall, oval shape was the main reason why MCs were underestimated as the low-risk group which suggested benign masses.\u003c/p\u003e \u003cp\u003eFibroadenomas are the most common benign tumours of the breast [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Compared with FA which is commonly found in young women, typically in 20 to 30 years old [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], patients with MC were older, the median age was 47, which was younger than 51 to 71 years previously reported [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRegarding ultrasonographic features, most FAs are oval or round, well circumscribed, hypoechoic with the long axis parallel to the skin surface and have normal or increased posterior echogenicity [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], which are almost consistent with our study findings. By comparing the other features of MC and FA both with oval shape, we found that the marginal features, internal echo and posterior echo features were helpful for the differential diagnosis of them. Among internal echo, marginal and posterior features, internal echo is usually the first feature to attract the attention of the ultrasound physicians. And hypoechoic is the most common type of echo in both typical benign and typical malignant masses [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCompared with FA, the internal echo of most MC was non-hypoechoic including heterogeneous, isoechoic, or complex cystic and solid, which may be related to the complex tissue composition of the MC. MCs are composed of large amounts of extracellular mucin, stroma, and clusters of cancer cells. Kaoku et al[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] reported that the internal echo of MC varied with the proportions of the different components, and the proportion of stroma tended to increase as the internal echogenicity increased.\u003c/p\u003e \u003cp\u003eAs for the difference in marginal feature of MC and FA, unlike the circumscribed margins of most FAs (84%), the margins of most MCs (84%) were not circumscribed in our study. Previous studies reported that the ratio of MC with not circumscribed margin was between 23.5\u0026ndash;95.0% [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The large ratio range may be related to the different number of cases included in the studies. Compared with previous studies with fewer cases or only including PMCs, our study was more convincing, because it had the largest number of cases and included two pathologic types of PMC and MMC. Maybe, the not circumscribed margin of MC is related to the aggressive growth pattern of malignant masses [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Furthermore, posterior enhancement was another common ultrasonographic feature of MC. This feature is probably due to the transmission of the ultrasound beam through large amounts of extracellular mucin [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study had some limitations. First, our study only included commonly used ultrasonographic features. US elastography was not extensively used in our study, although it was added to the BI-RADS for US. Second, this was a single-institution retrospective study. Multicentre studies with greater numbers of patients are needed to confirm our findings.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this study, MCs with oval shape on US may be underestimated as the low-risk group. If an oval breast mass is found in an old woman and is non-hypoechoic with posterior echo enhancement and has not circumscribed margin, the possibility of MC should be considered, and active biopsy should be recommended.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eBI-RADS:\u0026nbsp;\u003c/strong\u003eBreast Imaging Reporting and Data System;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFA:\u0026nbsp;\u003c/strong\u003efibroadenoma\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMC:\u0026nbsp;\u003c/strong\u003emucinous carcinoma\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePMC:\u003c/strong\u003e pure mucinous carcinoma \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMMC:\u0026nbsp;\u003c/strong\u003emixed mucinous carcinoma\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUS:\u0026nbsp;\u003c/strong\u003eultrasonography\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures in this study were approved by the ethical review board committee of Sun Yat-Sen Memorial Hospital (SYSEC-KY-KS-2021-252) and in accordance with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The informed consent was waived by the same ethics committee that approved the study (ethical review board committee of Sun Yat-Sen Memorial Hospital) because of the retrospective nature of the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData can be obtained with appropriate reason by request to the corresponding author\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ethrough email [email protected]\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declared no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eComply with the rules of blind review, this part is added in the submission system.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u003c/strong\u003e\u003cstrong\u003e\u0026rsquo;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003econtributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHL.W., Y.H., Q.L. and C.G. contributed to the conception and design of the work; \u0026nbsp; C.T., R.G., YD. L., L.J., XF.J. and JS.M. contributed to the data acquisition; HL.W. and \u0026nbsp;Y.H. contributed to the data analysis and interpretation. HL.W. and Y.H. drafted the work; Q.L. and C.G. revised it. All authors read and approved the final manuscript.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eToikkanen S, Kujari H. Pure and mixed mucinous carcinomas of the breast: a clinicopathologic analysis of 61 cases with long-term follow-up. Hum Pathol. 1989;20:758\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBae SY, Choi MY, Cho DH, Lee JE, Nam SJ, Yang JH. Mucinous carcinoma of the breast in comparison with invasive ductal carcinoma: clinicopathologic characteristics and prognosis. J Breast Cancer. 2011;14:308\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCao AY, He M, Liu ZB, Di GH, Wu J, Lu JS, et al. Outcome of pure mucinous breast carcinoma compared to infiltrating ductal carcinoma: a population-based study from China. Ann Surg Oncol. 2012;19:3019\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerg WA. Current Status of Supplemental Screening in Dense Breasts. J Clin Oncol. 2016;34:1840\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMendelson EB, B\u0026ouml;hm-V\u0026eacute;lez M, Berg WA, Whitman GJ, Feldman MI, Madjar H, et al. ACR BI-RADS ultrasound. In: Orsi CJ, Sickles EA, Mendelson EB, Morris EA, editors. ACR BI-RADS Atlas, Breast Imaging Reporting and Data System Reston. American College of Radiology; 2013. pp. 1\u0026ndash;173. D'.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRahbar G, Sie AC, Hansen GC, Prince JS, Melany ML, Reynolds HE, et al. benign versus malignant solid breast masses: US differentiation. Radiology. 1999;213:889\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHong AS, Rosen EL, Soo MS, Baker JA. BI-RADS for Sonography: Positive and negative predictive values of sonographic features. AJR Am J Roentgenol. 2005;184:1260\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLam WW, Chu WC, Tse GM, Ma TK. Sonographic appearance of mucinous carcinoma of the breast. AJR Am J Roentgenol. 2004;182:1069\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBode MK, Rissanen T. Imaging findings and accuracy of core needle biopsy in mucinous carcinoma of the breast. Acta Radiol. 2011;52:128\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNiu Z, Tian JW, Ran HT, Ren WD, Chang C, Yuan JJ, et al. Risk-predicted dual nomograms consisting of clinical and ultrasound factors for downgrading BI-RADS category 4a breast lesions - A multiple centre study. J Cancer. 2021;12:292\u0026ndash;304.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang Y, Hu Y, Shen S, Jiang X, Gu R, Wang H, et al. A new nomogram for predicting the malignant diagnosis of Breast Imaging Reporting and Data System (BI-RADS) ultrasonography category 4A lesions in women with dense breast tissue in the diagnostic setting. Quant Imaging Med Surg. 2021;11:3005\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHu Y, Yang Y, Gu R, Jin L, Shen S, Liu F, et al. Does patient age affect the PPV3 of ACR BI-RADS Ultrasound categories 4 and 5 in the diagnostic setting? Eur Radiol. 2018;28:2492\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTan JZ-Y, Waugh J, Kumar B, Evans J. Mucinous carcinomas of the breast: Imaging features and potential for misdiagnosis. J Med Imaging Radiat Oncol. 2013;57:25\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu H, Tan H, Cheng Y, Zhang X, Gu Y, Peng W. Imaging findings in mucinous breast carcinoma and correlating factors. Eur J Radiol. 2011;80:706\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaoku S, Konishi E, Fujimoto Y, Tohno E, Shiina T, Kondo K, et al. Sonographic and pathologic image analysis of pure mucinous carcinoma of the breast. Ultrasound Med Biol. 2013;39:1158\u0026ndash;67.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMemis A, Ozdemir N, Parildar M, Ustun EE, Erhan Y. Mucinous (colloid) breast cancer: mammographic and US features with histologic correlation. Eur J Radiol. 2000;35:39\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChopra S, Evans AJ, Pinder SE, Yeoman LJ, Ellis IO, Elston CW, et al. Pure mucinous breast cancer-mammographic and ultrasound findings. Clin Radiol. 1996;51:421\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBouzghar G, Levenback BJ, Sultan LR, Venkatesh SS, Cwanger A, Conant EF, et al. Bayesian probability of malignancy with BI-RADS sonographic features. J Ultrasound Med. 2014;33:641\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElverici E, Barca AN, Aktas H, Ozsoy A, Zengin B, Cavusoglu M, et al. Nonpalpable BI-RADS 4 breast lesions: sonographic findings and pathology correlation. Diagn Interv Radiol. 2015;21:189\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStachs A, Stubert J, Reimer T, Hartmann S. Benign Breast Disease in Women. Dtsch Arztebl Int. 2019;116:565\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCheema HS, Mehta R, Slanetz PJ. Imaging and management of fibroepithelial breast lesions on percutaneous core needle biopsy. Breast J. 2020;26:1216\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarkley CR, Ligibel JA, Wong JS, Lipsitz S, Smith BL, Golshan M. Mucinous breast carcinoma: a large contemporary series. Am J Surg. 2008;196:549\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDi Saverio S, Gutierrez J, Avisar E. A retrospective review with long term follow up of 11,400 cases of pure mucinous breast carcinoma. Breast Cancer Res Treat. 2008;111:541\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCiurea AI, Herta HA, Iacoban CG, Fetica B, Rogojan L, Ciortea CA. Fibroadenomas and breast carcinoma: a possible answer to a frequently asked question. A pictorial essay. Med Ultrason. 2018;20:385\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Breast, Ultrasonography, Mucinous carcinoma","lastPublishedDoi":"10.21203/rs.3.rs-3106676/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3106676/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground \u003c/strong\u003eApproximately 50% of breast mucinous carcinomas (MCs) are oval and have the possibility of being misdiagnosed as fibroadenoma (FA). We aimed to identify the key features that can help differentiate breast MC with oval shape from fibroadenoma (FA) on ultrasonography (US).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods \u003c/strong\u003eSeventy-six MCs in 71 consecutive patients and 50 FAs with oval shape in 50 consecutive patients were included in our study. All lesions had pathological diagnoses. According to the Breast Imaging Reporting and Data System (BI-RADS), first, the ultrasonographic features of the MCs and FAs were recorded and a final category was assessed.\u0026nbsp; Then, the differences of ultrasonographic characteristics between category 4A (low-risk group) and category 4B-5 (medium-high risk group) of MCs were identified. Finally, other ultrasonographic features of MC and FA both with oval shape were compared to determine the key factors for differential diagnosis. The Mann-Whitney test, the \u003cem\u003eχ\u003c/em\u003e\u003csup\u003e\u003cem\u003e2 \u003c/em\u003e\u003c/sup\u003etest or Fisher’s exact test was used in our study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults \u003c/strong\u003eMCs with oval shape (81.2%) and circumscribed margin\u0026nbsp; (25%) on US were more common assessed in the low-risk group (BI-RADS 4A) than in the medium-high risk group (BI-RADS 4B-5) \u003cem\u003e(\u003c/em\u003e20%，\u003cem\u003ep\u003c/em\u003e\u0026lt;0.001\u0026nbsp; and 0% \u003cem\u003ep\u003c/em\u003e=0.001, respectively).\u0026nbsp; Compared with FA, patients with MC were older, and with masses being more likely to appear non-hypoechoic, not circumscribed margin, and posterior echo enhancement on US (\u003cem\u003ep\u003c/em\u003e\u0026lt;0.001, \u003cem\u003ep\u003c/em\u003e\u0026lt;0.001, \u003cem\u003ep\u003c/em\u003e=0.003, respectively).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eThe oval shape was the main reason for the underestimation of MCs. On US, an oval mass found in the breast of an old woman with non-hypoechoic echo, not circumscribed margin, and posterior echo enhancement was associated with an increased risk of MC, and active biopsy should be recommended.\u003c/p\u003e","manuscriptTitle":"Differential diagnosis of breast mucinous carcinoma with oval shape from fibroadenoma based on ultrasonographic features","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-07-10 13:55:50","doi":"10.21203/rs.3.rs-3106676/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2023-11-20T10:55:42+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-11-14T18:27:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"2c8f4d10-d31b-4bc0-9f9b-862f374ecec8","date":"2023-11-11T23:37:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"b0d7ba98-ae33-48c4-985c-3039efcb4a5c","date":"2023-10-20T14:34:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"c4885d92-0453-4894-92e3-732608e0d7e6","date":"2023-10-12T19:39:55+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-09-26T08:50:26+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-09-20T10:43:33+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2023-07-04T05:57:12+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-07-04T05:53:59+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Women's Health","date":"2023-06-25T10:59:27+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1907dd19-a7af-4ed6-97c1-4304c6a4c52e","owner":[],"postedDate":"July 10th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-02-05T15:03:01+00:00","versionOfRecord":{"articleIdentity":"rs-3106676","link":"https://doi.org/10.1186/s12905-024-02910-w","journal":{"identity":"bmc-womens-health","isVorOnly":false,"title":"BMC Women's Health"},"publishedOn":"2024-02-03 15:00:57","publishedOnDateReadable":"February 3rd, 2024"},"versionCreatedAt":"2023-07-10 13:55:50","video":"","vorDoi":"10.1186/s12905-024-02910-w","vorDoiUrl":"https://doi.org/10.1186/s12905-024-02910-w","workflowStages":[]},"version":"v1","identity":"rs-3106676","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3106676","identity":"rs-3106676","version":["v1"]},"buildId":"oE6Zbj460LM0Up2FdVbMZ","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}