"Color Doppler Twinkling Change Between Ultrasound Platform Generations \u2015 A Comparison Using Breast Biopsy Markers"

"Rationale and ObjectivesBreast biopsy markers are used to mark biopsied tissues in the breast or axilla for potential future surgical excision. While ultrasound is the preferred imaging modality for secondary localization of the marked biopsied site before surgery, conventional B-mode imaging fails to identify markers in up to 50% of cases. Color Doppler twinkling signatures are repeatably present on certain markers (Cork, Professional Q, and Tumark MRI). This study evaluated the color Doppler twinkling strength of 38 different markers in a systematic manner using two different series ultrasound systems and multiple transducers from the same vendor to assess if newer technology provides sufficient twinkling for clinical use.Materials and MethodsThirty-eight breast biopsy markers (37 commercially available and one polymethyl methacrylate [PMMA] research marker) were embedded in homogeneous gelatin phantoms and imaged using two ultrasound platforms from the same manufacturer (General Electric LOGIQ E9 and LOGIQ E10). Multiple linear and curvilinear transducers were evaluated, including three probes common to both systems. Color Doppler settings were optimized for twinkling, and system parameters, including transmit frequency and mechanical index, were recorded. Peak negative pressure was estimated from mechanical index values. Two experienced breast radiologists independently scored twinkling strength in two separate sessions using an ordinal 0\u20134 scale, with scores \u22653 considered actionable twinkling. Statistical analyses included intra- and inter-observer reliability assessment, correlation analyses between twinkling scores and imaging parameters, and ordinal logistic regression modeling to evaluate system-, marker-, and transducer-level effects. Results were considered to be statistically significant if p < 0.05.ResultsTwinkling score assignment demonstrated excellent reproducibility, with high intra-observer agreement for both readers (weighted Cohen\u2019s = 0.96 [95% CI: 0.91\u20131.00] and 0.94 [0.89\u20130.98]) and near-perfect inter-observer agreement ( = 0.97 [0.96\u20130.97]). Of the 38 biopsy markers evaluated, 14 exhibited measurable twinkling and were included in statistical analyses. Across transducers common to both platforms, the LOGIQ E10 produced significantly higher twinkling scores than the LOGIQ E9, indicating a system-level improvement. Several markers that demonstrated weak or non-actionable twinkling on the E9 achieved consistently higher and actionable scores on the E10. Model-based analysis showed substantial system-dependent differences by transducers, with the L8-18i demonstrating the largest improvement on the E10 (odds ratio (OR) 251.11 [95% CI: 67.52\u2013933.88]; p < 0.001)), while the ML6-15 showed no significant system-level difference (OR 1.28 [0.54\u20133.05]; p = 0.577). Twinkling on the E9 was strongly dependent on Doppler transmit frequency (\u03c1 = \u20130.69; p < 0.001) and peak negative pressure (\u03c1 = 0.45; p < 0.001), whereas these associations were weaker or absent on the E10 (frequency: \u03c1 = \u20130.21; p = 0.001; peak negative pressure: \u03c1 = 0.06; p = 0.359). The PMMA research marker demonstrated consistently high and reproducible twinkling across both systems (mean twinkling scores: E9 = 3.4, E10 = 3.6).ConclusionColor Doppler twinkling by breast biopsy markers is strongly influenced by ultrasound system generation, transducer selection, and acquisition parameters. The newer-generation system demonstrated more robust and less parameter-sensitive twinkling across a wider range of markers and probes. These findings highlight meaningful system-level advancements in twinkling detection and support the role of color Doppler twinkling as a complementary tool for ultrasound-based marker localization."