Objective To analyze the clinical value of elastography combined with automatic breast full volume imaging in distinguishing benign and malignant breast nodules of breast imaging reporting and data system (BI-RADS) category 4. MethodsThis retrospective study included patients with breast nodules of BI-RADS category 4 who confirmed by routine ultrasound in Zhengzhou Third People’s Hospital from January 2018 to December 2023. To compare the clinical efficacy of conventional conventional color doppler ultrasound (CDUS), coronal automated breast volume scanner (ABVS), ultrasound elastography (UE), coronal automatic breast volume imaging combined with UE in differential diagnosis of benign and malignant breast nodules of BI-RADS category 4. ResultsA total of 280 cases with 301 lesions were enrolled in this study, among which 195 lesions were pathologically diagnosed as benign and 106 as malignant. The Kappa values for the consistency between the diagnostic results of benign and malignant breast nodules of BI-RADS category 4 by CDUS, ABVS, UE, and the combination of coronal ABVS and UE with the pathological results were 0.702, 0.625, 0.717 and 0.978, respectively. The sensitivity of coronal ABVS combined with UE was 99.06% (105/106), the specificity was 98.97% (193/195), and the accuracy was 99.00% (298/301); The sensitivity of CDUS was 76.42% (81/106), the specificity was 92.31% (180/195), and the accuracy was 86.71% (261/301); the sensitivity of UE was 88.68% (94/106), the specificity was 77.95% (152/195), and the accuracy was 81.73% (246/301); the sensitivity of coronal ABVS was 87.74% (93/106), the specificity was 86.71% (168/195), and the accuracy was 86.71% (261/301). Receiver operating characteristic curve analysis showed that the area under the curve of the combination of coronal ABVS and UE was 0.990, which had superior diagnostic efficacy than CDUS (Z=–6.572, P<0.001), UE (Z=–7.525, P<0.001) and coronal ABVS (Z=–6.167, P<0.001). ConclusionThe combination of coronal ABVS and UE can effectively improve the differential diagnosis of benign and malignant breast nodules of BI-RADS category 4 and reduce the risk of clinical overdiagnosis.