[BI-RADS-analogue DEGUM criteria for findings in breast ultrasound--consensus of the DEGUM Committee on Breast Ultrasound]

Patient perception of meander-like versus radial breast ultrasound

Background  Radial breast ultrasound scanning (r-US) and commonly used meander-like ultrasound scanning (m-US) have recently been shown to be equally sensitive and specific with regard to the detection of breast malignancies. As patient satisfaction has a strong influence on patient compliance and thus on the quality of health care, we compare here the two US scanning techniques with regard to patient comfort during breast ultrasound (BUS) and analyze whether the patient has a preference for either scanning technique. Materials and Methods  Symptomatic and asymptomatic women underwent both m-US and r-US scanning by two different examiners. Patient comfort and preference were assessed using a visual analog scale-based (VAS) questionnaire and were compared using a Mann-Whitney U test. Results  Analysis of 422 VAS-based questionnaires showed that perceived comfort with r-US (r-VAS 8 cm, IQR [5.3, 9.1]) was significantly higher compared to m-US (m-VAS 5.6 cm, IQR [5.2, 7.4]) (p < 0.001). 53.8% of patients had no preference, 44.3% of patients clearly preferred r-US, whereas only 1.9% of patients preferred m-US. Conclusion: Patients experience a higher level of comfort with r-US and favor r-US over m-US. As the diagnostic accuracy of r-US has been shown to be comparable to that of m-US and the time required for examination is shorter, a switch from m-US to r-US in routine clinical practice might be beneficial. R-US offers considerable potential to positively affect patient compliance but also to save examination time and thus costs.

Application of computer-aided diagnosis to predict malignancy in BI-RADS 3 breast lesions

Purpose

To evaluate the ability of computer-aided diagnosis (CAD) system (S-Detect) to identify malignancy in ultrasound (US) -detected BI-RADS 3 breast lesions.

Materials and methods

148 patients with 148 breast lesions categorized as BI-RADS 3 were included in the study between January 2021 and September 2022. The malignancy rate, accuracy, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under the curve (AUC) were calculated.

Results

In this study, 143 breast lesions were found to be benign, and 5 breast lesions were malignant (malignancy rate, 3.4 %, 95 % confidence interval (CI): 0.5-6.3). The malignancy rate rose significantly to 18.2 % (4/22, 95 % CI: 2.1-34.3) in the high-risk group with a "possibly malignant" CAD result (p = 0.017). With a "possibly benign" CAD result, the malignancy rate decreased to 0.8 % (1/126, 95 % CI: 0-2.2) in the low-risk group (p = 0.297). The AUC, sensitivity, specificity, accuracy, PPV, and NPV of the CAD system in BI-RADS 3 breast lesions were 0.837 (95 % CI: 77.7-89.6), 80.0 % (95 % CI: 73.6-86.4), 87.4 % (95 % CI: 82.0-92.7), 87.2 % (95 % CI: 81.8-92.6), 18.2 % (95 % CI: 2.1-34.3) and 99.2 % (95 % CI: 97.8-100.0), respectively.

Conclusions

CAD system (S-Detect) enables radiologists to distinguish a high-risk group and a low-risk group among US-detected BI-RADS 3 breast lesions, so that patients in the low-risk group can receive follow-up without anxiety, while those in the high-risk group with a significantly increased malignancy rate should actively receive biopsy to avoid delayed diagnosis of breast cancer.

Impact of a brochure and empathetic physician communication on patients' perception of breast biopsies

PURPOSE

This study investigated the effect of an intervention designed to reduce patients' emotional distress associated with breast biopsy.

METHODS

125 breast biopsy patients receiving standard of care (control group, CG) were compared to 125 patients (intervention group, IG) who received a brochure with information prior to the biopsy and were biopsied by physicians trained in empathic communication. Anxiety was assessed by the State-Anxiety Inventory (STAI-S) at four time points (pre- and post-procedural, pre- and post-histology). All participants completed pre- and post-procedural questionnaires addressing worries, pain and comprehension. We evaluated the impact of the intervention on STAI-S levels using a log-transformed linear mixed effects model and explored patients' and physicians' perceptions of the procedure descriptively.

RESULTS

Post-procedural and post-histology timepoints were associated with 13% and17% lower with STAI-S levels than at the pre-procedural timepoint on average. The histologic result had the strongest association with STAI-S: malignancy was associated with 28% higher STAI-S scores than a benign finding on average. Across all time points, the intervention did not affect patient anxiety. Nevertheless, IG participants perceived less pain during the biopsy. Nearly all patients agreed that the brochure should be handed out prior to breast biopsy.

CONCLUSION

While the distribution of an informative brochure and a physician trained in empathic communication did not reduce patient anxiety overall, we observed lower levels of worry and perceived pain regarding breast biopsy in the intervention group. The intervention seemed to improve patient's understanding of the procedure. Moreover, professional training could increase physicians' empathic communication skills.

TRIAL REGISTRATION NUMBER

NCT02796612 (March 19, 2014).

Best Practice Guideline - DEGUM Recommendations on Breast Ultrasound

Alongside mammography, breast ultrasound is an important and well-established method in assessment of breast lesions. With the "Best Practice Guideline", the DEGUM Breast Ultrasound (in German, "Mammasonografie") working group, intends to describe the additional and optional application modalities for the diagnostic confirmation of breast findings and to express DEGUM recommendations in this Part II, in addition to the current dignity criteria and assessment categories published in Part I, in order to facilitate the differential diagnosis of ambiguous lesions.The present "Best Practice Guideline" has set itself the goal of meeting the requirements for quality assurance and ensuring quality-controlled performance of breast ultrasound. The most important aspects of quality assurance are explained in this Part II of the Best Practice Guideline.

Best Practice Guideline - DEGUM Recommendations on Breast Ultrasound

For many years, breast ultrasound has been used in addition to mammography as an important method for clarifying breast findings. However, differences in the interpretation of findings continue to be problematic 1 2. These differences decrease the diagnostic accuracy of ultrasound after detection of a finding and complicate interdisciplinary communication and the comparison of scientific studies 3. In 1999, the American College of Radiology (ACR) created a working group (International Expert Working Group) that developed a classification system for ultrasound examinations based on the established BI-RADS classification of mammographic findings under consideration of literature data 4. Due to differences in content, the German Society for Ultrasound in Medicine (DEGUM) published its own BI-RADS-analogue criteria catalog in 2006 3. In addition to the persistence of differences in content, there is also an issue with formal licensing with the current 5th edition of the ACR BI-RADS catalog, even though the content is recognized by the DEGUM as another system for describing and documenting findings. The goal of the Best Practice Guideline of the Breast Ultrasound Working Group of the DEGUM is to provide colleagues specialized in senology with a current catalog of ultrasound criteria and assessment categories as well as best practice recommendations for the various ultrasound modalities.

Agreement in breast lesion assessment and final BI-RADS classification between radial and meander-like breast ultrasound

BACKGROUND

This study prospectively investigates the agreement between radial (r-US) and meander-like (m-US) breast ultrasound with regard to lesion location, lesion size, morphological characteristics and final BI-RADS classification of individual breast lesions.

METHODS

Each patient of a consecutive, unselected, mixed collective received a dual ultrasound examination.

RESULTS

The agreement between r-US and m-US for lesion location ranged from good (lesion to mammilla distance ICC 0.64; lesion to skin distance ICC 0.72) to substantial (clock-face localization κ 0.70). For lesion size the agreement was good (diameter ICC 0.72; volume ICC 0.69), for lesion margin and architectural distortion it was substantial (κ 0.68 and 0.70, respectively). Most importantly, there was a substantial agreement (κ 0.76) in the final BI-RADS classification between r-US and m-US.

CONCLUSIONS

Our recent comparison of radial and meander-like breast US revealed that the diagnostic accuracy of the two scanning methods was comparable. In this study, we observe a high degree of agreement between m-US and r-US for the lesion description (location, size, morphology) and final BI-RADS classification. These findings corroborate that r-US is a suitable alternative to m-US in daily clinical practice. Trial registration NCT02358837. Registered January 2015, retrospectively registered https://clinicaltrials.gov/ct2/results?cond=&term=NCT02358837&cntry=&state=&city=&dist =.

Consensus Meeting of Breast Imaging: BI-RADS® and Beyond

Organizers of medical educational courses are often confronted with questions that are clinically relevant yet trespassing the frontiers of scientifically proven, evidence-based medicine at the point of care. Therefore, since 2007 organizers of breast teaching courses in German language met biannually to find a consensus in clinically relevant questions that have not been definitely answered by science. The questions were prepared during the 3 months before the meeting according to a structured process and finally agreed upon the day before the consensus meeting. At the consensus meeting, the open questions concerning 2D/3D mammography, breast ultrasound, MR mammography, interventions as well as risk-based imaging of the breast were presented first for electronic anonymized voting, and then the results of the audience were separately displayed from the expert votes. Thereafter, an introductory statement of the moderator was followed by pros/cons of two experts, and subsequently the final voting was performed. With ≥75% of votes of the expert panel, an answer qualified as a consensus statement. Seventeen consensus statements were gained, addressing for instance the use of 2D/3D mammography, breast ultrasound in screening, MR mammography in women with intermediate breast cancer risk, markers for localization of pathologic axillary lymph nodes, and standards in risk-based imaging of the breast. After the evaluation, comments from the experts on each field were gathered supplementarily. Methodology, transparency, and soundness of statements achieve a unique yield for all course organizers and provide solid pathways for decision making in breast imaging.

Can acoustic structural quantification be used to characterize the ultrasound echotexture of the peripheral zone of breast lesions?

BACKGROUND:

Besides mammography, breast ultrasound is the most important imaging modality for women with suspected breast cancer. New software tools bear high potential for improved detectability and specification of malignant breast lesions.

OBJECTIVE:

To compare the halo depicted around malignant breast lesions by ultrasound using Acoustic Structure Quantification (ASQ) of raw image data with the echogenic rim seen in B-mode ultrasound.

METHODS:

This retrospective study included 37 women for whom conventional B-mode ultrasound of the breast and ASQ were available as well as histopathology findings for comparison. Software tools were used to measure the halo area or echogenic rim and tumor area and calculate halo-to-lesion ratios for the two ultrasound modes. Six inexperienced readers characterized the breast lesions based on this information. Specificity, sensitivity, positive predictive value (PPV), and negative predictive value (NPV) were determined. ANOVA, the Wilcoxon test, and ROC curve analysis were performed.

RESULTS:

There was a linear relationship between ASQ-based and B-mode-based halo-to-lesion ratios; however, a systematic error was also noted. ASQ-derived ratios tended to be higher for breast lesions with lymphangioinvasion (p = 0.051, n.s.) and higher N-stages (p > 0.925, n.s.), while there was no correlation with other markers. Because of the significantly greater conspicuity of peritumoral halos in the ASQ mode, inexperienced readers achieved greater sensitivity (78% vs. 74%) and specificity (75% vs. 71%) and higher NPVs (75% vs. 71%) and PPVs (78% vs. 74%) compared with B-mode images. Greater halo conspicuity affected the identification of malignant lesions with both modes; ASQ was found to be particularly well suited (F_Bimage (1,100) = 19.253, p < 0.001; F_ASQ (1,100) = 52.338, p < 0.001). The inexperienced readers were significantly more confident about their diagnosis using the ASQ maps (z = –3.023, p = 0.003).

CONCLUSIONS:

We conclude that the halo in ASQ and the echogenic rim in B-mode ultrasound are attributable to different morphologic correlates. ASQ improves diagnostic accuracy and confidence of inexperienced examiners because of improved halo visibility.

Correlation between Ultrasound Appearance of Small Breast Cancer and Axillary Lymph Node Metastasis

To study the correlation of ultrasonographic signs of small breast cancer (maximum diameter ≤2.0 cm) with axillary lymph node metastasis, pre-operative ultrasonographic images of 153 small breast malignant neoplasms in 143 breast cancer patients were analyzed according to their pathologic features. Of the small breast tumors included, 47 showed axillary lymph node metastasis. Diagnosis of all patients was obtained with radical axillary surgery or a sentinel lymph node biopsy procedure. Ultrasonographic signs included irregular shape, microlobulated contour, spiculation, microcalcification, posterior echo attenuation, blood-flow grade, perforating vessels, changes in fascia or cooper's ligament and maximum cortical thickness of lymph nodes. The relationship between ultrasonographic features and axillary lymph node metastasis was analyzed using a chi-square test for univariate distributions and logistic regression for multivariate analysis. A logistic regression model was established by taking the pathologic diagnosis of lymph node metastasis as the dependent variable and the ultrasonographic signs of each small breast cancer as independent variables. In small breast cancer, characteristics such as perforating vessels and maximum cortical thickness of lymph nodes >3.0 mm correlated well with axillary lymph node metastasis as determined by univariate analysis (χ² = 13.945, 51.276, respectively, p <0.05) and multivariate analysis (OR = 48.783, 46.754, respectively, p <0.05).

[Diagnostic imaging of breast cancer : An update]

Advances in imaging of the female breast have substantially influenced the diagnosis and probably also the therapy and prognosis of breast cancer in the past few years. This article gives an overview of the most important imaging modalities in the diagnosis of breast cancer. Digital mammography is considered to be the gold standard for the early detection of breast cancer. Digital breast tomosynthesis can increase the diagnostic accuracy of mammography and is used for the assessment of equivocal or suspicious mammography findings. Other modalities, such as ultrasound and contrast-enhanced magnetic resonance imaging (MRI) play an important role in the diagnostics, staging and follow-up of breast cancer. Percutaneous needle biopsy is a rapid and minimally invasive method for the histological verification of breast cancer. New breast imaging modalities, such as contrast-enhanced spectral mammography, diffusion-weighted MRI and MR spectroscopy can possibly further improve breast cancer diagnostics; however, further studies are necessary to prove the advantages of these methods so that they cannot yet be recommended for routine clinical use.

Clinical Data as an Adjunct to Ultrasound Reduces the False-Negative Malignancy Rate in BI-RADS 3 Breast Lesions

PURPOSE

Ultrasound (US) is a well-established diagnostic procedure for breast examination. We investigated the malignancy rate in solid breast lesions according to their BI-RADS classification with a particular focus on false-negative BI-RADS 3 lesions. We examined whether patient history and clinical findings could provide additional information that would help determine further diagnostic steps in breast lesions.

MATERIALS AND METHODS

We conducted a retrospective study by exploring US BI-RADS in 1469 breast lesions of 1201 patients who underwent minimally invasive breast biopsy (MIBB) from January 2002 to December 2011.

RESULTS

The overall sensitivity and specificity of BI-RADS classification was 97.4% and 66.4%, respectively, with a positive (PPV) and negative predictive value (NPV) of 65% and 98%, respectively. In 506 BI-RADS 3 lesions, histology revealed 15 malignancies (2.4% malignancy rate), which corresponds to a false-negative rate (FNR) of 2.6%. Clinical evaluation and patient requests critically influenced the further diagnostic procedure, thereby prevailing over the recommendation given by the BI-RADS 3 classification.

CONCLUSION

Clinical criteria including age, family and personal history, clinical examination, mammography and patient choice ensure adequate diagnostic procedures such as short-term follow-up or MIBB in patients with lesions classified as US-BI-RADS 3.

[Pictocam instead of Pictogram - a quality improvement study in abdominal ultrasound imaging]

AIM

To replace pictograms with pictocam pictures: A prospective blinded quality improvement study in documenting image orientation and localisation in abdominal ultrasound imaging.

MATERIALS AND METHODS

A minicam was mounted on the ultrasound scanhead to record pictocam pictures. The primary examiner produced an ultrasound image together with the routinely embedded pictogram. Subsequently the pictogram was covered by the synchronically taken pictocam picture. Subsequently, the primary examiner assessed the pictograms and the second examiner the pictocam pictures (blinded to the pictogram findings of the primary examiner).

RESULTS

A total of 679 paired pictogram and pictocam pictures were available from 114 patients. The localisation of the utrasound head showed an absolute or close agreement of 99.7% (677/679) with a 95% confidence interval of [98.94%-99.96%]. The angle of the ultrasound head showed an absolute or close agreement of 99.0% (672/679) with a 95% confidence interval of [97.98% - 99.58%].

CONCLUSION

This study shows that the pictogram can validely be replaced by a pictocam picture. The routine addition of a minicam to the ultrasound scanhead would thus not only improve the quality of the documentation, but would also result in time savings during examinations.

Breast Lesions during Pregnancy - a Diagnostic Challenge: Case Report

BACKGROUND

Palpable masses of the breast often occur during pregnancy and should be further investigated. The standard diagnostic during pregnancy is an ultrasound combined, if needed, with a core needle biopsy. Most lesions are benign in younger women but, nevertheless, the incidence of pregnancy-associated breast cancer is 1 in 3,000 deliveries and rising.

CASE REPORT

We report the case of a 24-year-old patient diagnosed with a palpable breast lesion at 37 weeks of gestation. An ultrasound was performed and the lesion was rated BI-RADS 4. The initial core needle biopsy showed a ductal carcinoma in situ. After delivery and ablactating, a mammography, breast magnetic resonance imaging and a second ultrasound-guided biopsy was performed. Due to the inconclusive imaging and histological results, a wide excision was performed and a juvenile papillomatosis was confirmed. No further resection was necessary as the initial margins were sufficient.

CONCLUSION

This case suggests that the diagnosis of masses of the breast during pregnancy and lactation can be quite difficult. Diagnosis should be confirmed by an excision biopsy and by histological examination through an experienced pathologist. As a significant proportion of papillomas contain malignant regions, an argument exists for the complete excision of all papillary tumours.

Preoperative MRI in patients with locoregional recurrent breast cancer: influence on treatment modalities

RATIONALE AND OBJECTIVES

The purpose of this analysis was to evaluate the impact of preoperative magnetic resonance imaging (MRI) on management in patients with locoregional recurrent breast cancer.

MATERIALS AND METHODS

Forty-three patients who underwent treatment for locoregional relapse of breast cancer from 2008 through 2012 were analyzed. All patients underwent both conventional surveillance by mammography, ultrasound, and clinical examination and subsequent bilateral breast MRI.

RESULTS

Preoperative MRI detected additional tumor foci in 15 of 43 patients (34.9%). In two cases (4.7%), the diagnosis of occult sites had no influence on the subsequent treatment. Two patients (4.7%) had an unfavorable change of surgical management with unnecessary additional resection of benign foci. Eleven patients benefited from the MRI scan detecting malignant occult lesions (25.6%) resulting in either additional surgical resection or radiotherapy. Patient and tumor characteristics in primary disease did not differ significantly between patients with a favorable impact on surgical management and patients who experienced either no benefit or even disadvantage from MRI scan.

CONCLUSIONS

Preoperative breast MRI has a strong impact on the management of locoregional recurrent breast cancer. This study demonstrates that breast MRI is a powerful supplement to conventional diagnostic work-up, both during follow-up or preoperative treatment planning in recurrent disease.

The biology of malignant breast tumors has an impact on the presentation in ultrasound: an analysis of 315 cases

Background

The aim of this study was to evaluate the relation of some ultrasound morphological parameters to biological characteristics in breast carcinoma.

Methods

Ultrasound data from 315 breast masses were collected. We analyzed the ultrasound features of the tumors according to the ACR BI-RADS®-US classification system stratified by hormone receptor status, HER2 status, histology grade, tumor type (ductal versus lobular), triple-negativity, breast density, tumor size, lymph node involvement and patient’s age.

Results

We found a variety of ultrasound features that varied between the groups. Invasive lobular tumors were more likely to have an angulated margin (39% versus 22%, p = 0.040) and less likely to show posterior acoustic enhancement (3% versus 16%, p = 0.023) compared to invasive ductal carcinoma. G3 tumors were linked to a higher chance of posterior acoustic enhancement and less shadowing and the margin of G3 tumors was more often described as lobulated or microlobulated compared to G1/G2 tumors (67% versus 46%, p = 0.001). Tumors with an over-expression of HER2 exhibited a higher rate of architectural distortions in the surrounding tissue, but there were no differences regarding the other features. Hormone receptor negative tumors were more likely to exhibit a lobulated or microlobulated margin (67% versus 50%, p = 0.037) and less likely to have an echogenic halo (39% versus 64%, p = 0.001). Furthermore, the posterior acoustic feature was more often described as enhancement (33% versus 13%, p = 0.001) and less often as shadowing (20% versus 47%, p < 0.001) compared to hormone receptor positive tumors.

Conclusion

Depending on their biological and clinical profile, breast cancers are more or less likely to exhibit the typical criteria for malignancy in ultrasound. Moreover, certain types of breast cancer tend to possess criteria that are usually associated with benign masses. False-negative diagnosis may result in serious consequences for the patient. For the sonographer it is essential to be well aware of potential variations in the ultrasound morphology of breast tumors, as described in this paper.

Measurement of tumour size with mammography, sonography and magnetic resonance imaging as compared to histological tumour size in primary breast cancer

Background

Tumour size in breast cancer influences therapeutic decisions. The purpose of this study was to evaluate sizing of primary breast cancer using mammography, sonography and magnetic resonance imaging (MRI) and thereby establish which imaging method most accurately corresponds with the size of the histological result.

Methods

Data from 121 patients with primary breast cancer were analysed in a retrospective study. The results were divided into the groups “ductal carcinoma in situ (DCIS)”, invasive ductal carcinoma (IDC) + ductal carcinoma in situ (DCIS)”, “invasive ductal carcinoma (IDC)”, “invasive lobular carcinoma (ILC)” and “other tumours” (tubular, medullary, mucinous and papillary breast cancer). The largest tumour diameter was chosen as the sizing reference in each case. Bland-Altman analysis was used to determine to what extent the imaging tumour size correlated with the histopathological tumour sizes.

Results

Tumour size was found to be significantly underestimated with sonography, especially for the tumour groups IDC + DCIS, IDC and ILC. The greatest difference between sonographic sizing and actual histological tumour size was found with invasive lobular breast cancer. There was no significant difference between mammographic and histological sizing. MRI overestimated non-significantly the tumour size and is superior to the other imaging techniques in sizing of IDC + DCIS and ILC.

Conclusions

The histological subtype should be included in imaging interpretation for planning surgery in order to estimate the histological tumour size as accurately as possible.

Ultrasound real-time elastography can predict malignancy in BI-RADS®-US 3 lesions

Background

Lesions of the breast that are classified BI-RADS^®-US 3 by ultrasound are probably benign and observation is recommended, although malignancy may occasionally occur.

In our study, we focus exclusively on BI-RADS^®-US 3 lesions and hypothesize that sonoelastography as an adjunct to conventional ultrasound can identify a high-risk-group and a low-risk-group within these patients.

Methods

A group of 177 breast lesions that were classified BI-RADS^®-US 3 were additionally examined with real-time sonoelastography. Elastograms were evaluated according to the Tsukuba Elasticity Score. Pretest and posttest probability of disease (POD), sensitivity (SE), specificity (SP), positive (PPV) and negative predictive values (NPV) and likelihood-ratios (LR) were calculated. Furthermore, we analyzed the false-negative and false-positive cases and performed a model calculation to determine how elastography could affect the proceedings in population screening.

Results

In our collection of BI-RADS^®-US 3 cases there were 169 benign and eight malignant lesions. The pretest POD was 4.5% (95% confidence interval (CI): 2.1–9.0). In patients with a suspicious elastogram (high-risk group), the posttest POD was significantly higher (13.2%, p = 0.041) and the positive LR was 3.2 (95% CI: 1.7–5.9). With a benign elastogram (low-risk group), the posttest POD decreased to 2.2%. SE, SP, PPV and NPV for sonoelastography in BI-RADS^®-US 3 lesions were 62.5% (95% CI: 25.9–89.8), 80.5% (95% CI: 73.5–86.0), 13.2% (95% CI: 5.0–28.9) and 97.8% (95% CI: 93.3–99.4), respectively.

Conclusions

Sonoelastography yields additional diagnostic information in the evaluation of BI-RADS^®-US 3 lesions of the breast. The examiner can identify a low-risk group that can be vigilantly observed and a high-risk group that should receive immediate biopsy due to an elevated breast cancer risk.

Nipple discharge: role of ductoscopy in comparison with standard diagnostic tests

BACKGROUND

This study aims to assess the role of ductoscopy for detecting intraductal anomalies in patients with nipple discharge in comparison to conventional tests and to find an effective combination of both approaches.

MATERIALS AND METHODS

Prior to duct excision, ductoscopy was performed in 97 women. Histologic and all other diagnostic results were compared. Sensitivity, specificity, and efficiency were calculated for all methods. These parameters were also calculated for all possible test combinations in 12 patients who had completed all tests.

RESULTS

Breast sonography reached the highest sensitivity (64.1%) and efficiency (64%); mammography had the highest specificity (100%). The sensitivity of ductoscopy was 53.2%, its specificity 60%, and its efficiency 55.1%. Among combinations of all methods, the combination ductoscopy + galactography was the most sensitive (80%). Mammography, magnetic resonance imaging, and ductoscopy were each 100% specific. Ductoscopy was the most efficient (75%) single method.

CONCLUSION

Ductoscopy is a valuable test for diagnosing intraductal lesions in patients with nipple discharge. It is more efficient than conventional tests in patients undergoing all tests.

Real-time ultrasound elastography in 180 axillary lymph nodes: elasticity distribution in healthy lymph nodes and prediction of breast cancer metastases

BACKGROUND

To determine the general appearance of normal axillary lymph nodes (LNs) in real-time tissue sonoelastography and to explore the method's potential value in the prediction of LN metastases.

METHODS

Axillary LNs in healthy probands (n=165) and metastatic LNs in breast cancer patients (n=15) were examined with palpation, B-mode ultrasound, Doppler and sonoelastography (assessment of the elasticity of the cortex and the medulla). The elasticity distributions were compared and sensitivity (SE) and specificity (SP) were calculated. In an exploratory analysis, positive and negative predictive values (PPV, NPV) were calculated based upon the estimated prevalence of LN metastases in different risk groups.

RESULTS

In the elastogram, the LN cortex was significantly harder than the medulla in both healthy (p=0.004) and metastatic LNs (p=0.005). Comparing healthy and metastatic LNs, there was no difference in the elasticity distribution of the medulla (p=0.281), but we found a significantly harder cortex in metastatic LNs (p=0.006). The SE of clinical examination, B-mode ultrasound, Doppler ultrasound and sonoelastography was revealed to be 13.3%, 40.0%, 14.3% and 60.0%, respectively, and SP was 88.4%, 96.8%, 95.6% and 79.6%, respectively. The highest SE was achieved by the disjunctive combination of B-mode and elastographic features (cortex >3mm in B-mode or blue cortex in the elastogram, SE=73.3%). The highest SP was achieved by the conjunctive combination of B-mode ultrasound and elastography (cortex >3mm in B-mode and blue cortex in the elastogram, SP=99.3%).

CONCLUSIONS

Sonoelastography is a feasible method to visualize the elasticity distribution of LNs. Moreover, sonoelastography is capable of detecting elasticity differences between the cortex and medulla, and between metastatic and healthy LNs. Therefore, sonoelastography yields additional information about axillary LN status and can improve the PPV, although this method is still experimental.

Sonographic features of triple-negative and non-triple-negative breast cancer

OBJECTIVES

Triple-negative breast cancer (TNBC) is known to have unique molecular, clinical, and pathologic characteristics. The growth pattern of this cancer may also affect its appearance on sonography. Our study evaluated the sonographic features of TNBC according to the American College of Radiology Breast Imaging Reporting and Data System sonographic classification system and compared these features with those of non-TNBC.

METHODS

Data from 315 consecutive breast cancer cases were collected. The images were reevaluated by an examiner blinded to the patients' characteristics and histologic results according to the Breast Imaging Reporting and Data System. The sonographic features of TNBC (n = 33) and non-TNBC (n = 282) were compared.

RESULTS

Triple-negative breast cancer was significantly correlated with a younger patient age (P = .002) and was associated with higher tumor grades (P < .001), more lymph node involvement (P = .014), and a trend toward a larger tumor size. With regard to sonographic features, the margin of TNBC was more frequently described as lobulated or microlobulated (75.8% versus 49.5% in non-TNBC; P = .005). The echoic halo was observed significantly less often in TNBC than in non-TNBC(39.4% versus 62.8%; P = .014). Cooper ligaments were displaced rather than disrupted in TNBC compared to non-TNBC (P = .003). Regarding the posterior acoustic features, enhancement was observed significantly more often in TNBC (36.4% versus 13.0% in non-TNBC; P = .031).

CONCLUSIONS

Triple-negative breast cancer and non-TNBC have different sonographic features. This finding can be explained by the pathologic profile of this breast cancer subtype. Some of the distinct sonographic criteria for TNBC are more likely to be associated with benign masses. Knowledge of the distinct sonographic features of TNBC would help the examiner avoid false-negative classification of this tumor type.

The Automated Breast Volume Scanner (ABVS): initial experiences in lesion detection compared with conventional handheld B-mode ultrasound: a pilot study of 50 cases

The idea of an automated whole breast ultrasound was developed three decades ago. We present our initial experiences with the latest technical advance in this technique, the automated breast volume scanner (ABVS) ACUSON S2000(™). Volume data sets were collected from 50 patients and a database containing 23 women with no detectable lesions in conventional ultrasound (BI-RADS(®)-US 1), 13 women with clearly benign lesions (BI-RADS(®)-US 2), and 14 women with known breast cancer (BI-RADS(®)-US 5) was created. An independent examiner evaluated the ABVS data on a separate workstation without any prior knowledge of the patients' histories. The diagnostic accuracy for the experimental ABVS was 66.0% (95% confidence interval [CI]: 52.9-79.1). The independent examiner detected all breast cancers in the volume data resulting in a calculated sensitivity of 100% in the described setting (95% CI: 73.2%-100%). After the ABVS examination, there were a high number of requests for second-look ultrasounds in 47% (95% CI: 30.9-63.5) of the healthy women (with either a clearly benign lesion or no breast lesions at all in conventional handheld ultrasound). Therefore, the specificity remained at 52.8% (95% CI: 35.7-69.2). When comparing the concordance of the ABVS with the gold standard (conventional handheld ultrasound), Cohen's Kappa value as an estimation of the inter-rater reliability was κ = 0.37, indicating fair agreement. In conclusion, the ABVS must still be regarded as an experimental technique for breast ultrasound, which definitely needs to undergo further evaluation studies.

Breast Sonography - 2D, 3D, 4D Ultrasound or Elastography?

SUMMARY: The aim of this publication is to give an answer to the question whether 2D, 3D and 4D sonography of the breast can be replaced by elastography or whether elastography is an adjunct tool to B-mode imaging. The Breast Imaging and Reporting Data System (BI-RADS) ultrasound (US) descriptors of a lesion besides vascularity are based on B-mode imaging. US elastography displays the mechanical tissue properties. This information can be obtained by freehand compression and decompression. Acoustic radiation force impulse imaging (ARFI) produces stress with low-frequency push pulses. Manual compression by the transducer is not necessary. Shear wave elastography (SWE) is the combination of ARFI and the measurement of the consecutive shear wave propagations in the tissue. A quantification of the elasticity in kilopascal (kPa) is offered. Discussing B-mode imaging and elastography combined with the literature, elastography is seen as an addition to B-mode imaging with the potential to increase the specificity of the B-mode imaging-based BI-RADS assessment. In spite of additional elasticity information, the sensitivity remains high. A time-saving diagnostic algorithm for 2D, 3D US and elastography is described. In conclusion, it must be said that elasticity is not a stand-alone US modality able to replace 2D and 3D sonography.

Role of Breast Ultrasound for the Detection and Differentiation of Breast Lesions

Diagnosis of breast cancer has been widely improved since the development of high-resolution ultrasound equipment. In the past, ultrasound was only considered useful for the diagnosis of cysts. Meanwhile, it improves the differential diagnosis of benign and malignant lesions, local preoperative staging and guided interventional diagnosis. In dense breasts, mammography has limited sensitivity. Furthermore, women with dense parenchyma have a highly increased risk of breast cancer development. Ultrasound is useful to examine dense breast tissue. Recent studies have shown that the detection of small cancers with high-resolution ultrasound is increased by 3-4 cancers per 1,000 women without clinical or mammographic abnormalities. Furthermore, stage distribution is similar between mammographically and sonographically detected carcinomas. Ultrasound is routinely used for curative diagnosis, to overcome the limitations of mammography. However, within the mammographic screening in Germany, breast density is not considered as important. Ultrasound is only used if a suspicious lesion is detected by mammography. Interestingly, 2 years ago, a screening project started in Austria in which ultrasound is always added in cases of dense breasts. Preliminary data show that the detection of additional carcinomas is increased in the same order as shown in previous studies. Therefore, an improved cancer detection and differentiation can be expected with high-resolution ultrasound.

Early detection of breast cancer: benefits and risks of supplemental breast ultrasound in asymptomatic women with mammographically dense breast tissue. A systematic review

BACKGROUND

Mammographic screening alone will miss a certain fraction of malignancies, as evidenced by retrospective reviews of mammograms following a subsequent screening. Mammographic breast density is a marker for increased breast cancer risk and is associated with a higher risk of interval breast cancer, i.e. cancer detected between screening tests. The purpose of this review is to estimate risks and benefits of supplemental breast ultrasound in women with negative mammographic screening with dense breast tissue.

METHODS

A systematic search and review of studies involving mammography and breast ultrasound for screening of breast cancer was conducted. The search was performed for the period 1/2000-8/2008 within the data source of PubMed, DARE, and Cochrane databases. Inclusion and exclusion criteria were determined prospectively, and the Oxford evidence classification system for diagnostic studies was used for evidence level. The parameters biopsy rate, positive predictive value (PPV) for biopsy, cancer yield for breast ultrasound alone, and carcinoma detection rate by breast density were extracted or constructed.

RESULTS

The systematic search identified no randomized controlled trials or systematic reviews, six cohort studies of intermediate level of evidence (3b) were found. Only two of the studies included adequate follow-up of subjects with negative or benign findings. Supplemental breast ultrasound after negative mammographic screening permitted diagnosis of primarily invasive carcinomas in 0.32% of women in breast density type categories 2-4 of the American College of Radiology (ACR); mean tumor size for those identified was 9.9 mm, 90% with negative lymph node status. Most detected cancers occurred in mammographically dense breast ACR types 3 and 4. Biopsy rates were in the range 2.3%-4.7%, with PPV of 8.4-13.7% for those biopsied due to positive ultrasound, or about one third of the PPV of biopsies due to mammography.

LIMITATIONS

The study populations included wide age ranges, and the application to women age 50-69 years as proposed for mammographic screening could result in less striking benefit. Further validation studies should employ a uniform assessment system such as BI-RADS and report not only PPV, but also negative predictive value, sensitivity and specificity.

CONCLUSION

Supplemental breast ultrasound in the population of women with mammographically dense breast tissue (ACR 3 and 4) permits detection of small, otherwise occult, breast cancers. Potential adverse impacts for women in this intermediate risk group are associated with an increased biopsy rate.

Mammotome versus ATEC: a comparison of two breast vacuum biopsy techniques under sonographic guidance

PURPOSE

The study evaluates the differences between the Mammotome (MT) and ATEC (A) vacuum biopsy (VB) of the breast in terms of diagnostic reliability, biopsy duration and complications.

METHODS

In a prospective randomized study, 62 ultrasound-guided VBs of the breast were performed. MT and A were compared using Mann-Whitney U test.

RESULTS

The mean lesion size and the BI-RADS distribution were equal in both groups. Representative tissue was extracted in all 62 biopsies; thus no repeat biopsies were necessary. A sonographically guided complete excision was possible in 46 cases. More imaging-guided complete excisions were achieved with the MT than with A (87 vs. 63%). Technical complications occurred twice with A and once with MT. No medical complications occurred in either group.

CONCLUSIONS

Both systems are suitable for the diagnostic clarification of unclear breast lesions as well as complete excision of benign lesions under sonographic imaging. Sonographically guided complete resection was achieved more often with the MT.

Depressive symptoms and proinflammatory cytokine levels in chronic renal failure patients

BACKGROUND/AIMS

Cytokine secretion is known to play an important role in the pathophysiology of depression, and levels of proinflammatory cytokines are increased in chronic renal failure (CRF) patients. The objective of this study was to examine the correlation between levels of proinflammatory cytokines in CRF patients and degree of depression.

METHODS

31 patients on hemodialysis, 31 patients on continuous ambulatory peritoneal dialysis, and 31 conservatively managed chronic kidney disease (CKD) patients were enrolled in this study. Depressive symptoms were measured with the Beck Depression Inventory (BDI), and 'elevated symptoms of depression' were defined as a BDI score > or =17. IL-6 and TNFalpha cytokine levels were measured by ELISA.

RESULTS

'Elevated symptoms of depression' occurred in 37 of 93 patients (40%). IL-6 and TNFalpha levels were not significantly different among CRF patients with and without elevated depressive symptoms (p = 0.937 and p = 0.414, respectively). When analyzed by treatment subgroup, proinflammatory cytokine levels were not significantly different in patients with and without elevated symptoms of depression.

CONCLUSION

In patients with CRF, elevated symptoms of depression were not associated with increased cytokine levels.

Diagnostic algorithm: How to make use of new 2D, 3D and 4D ultrasound technologies in breast imaging

The aim of this publication is to present a time saving diagnostic algorithm consisting of two-dimensional (2D), three-dimensional (3D) and four-dimensional (4D) ultrasound (US) technologies. This algorithm of eight steps combines different imaging modalities and render modes which allow a step by step analysis of 2D, 3D and 4D diagnostic criteria. Advanced breast US systems with broadband high frequency linear transducers, full digital data management and high resolution are the actual basis for two-dimensional breast US studies in order to detect early breast cancer (step 1). The continuous developments of 2D US technologies including contrast resolution imaging (CRI) and speckle reduction imaging (SRI) have a direct influence on the high quality of three-dimensional and four-dimensional presentation of anatomical breast structures and pathological details. The diagnostic options provided by static 3D volume datasets according to US BI-RADS analogue assessment, concerning lesion shape, orientation, margin, echogenic rim sign, lesion echogenicity, acoustic transmission, associated calcifications, 3D criteria of the coronal plane, surrounding tissue composition (step 2) and lesion vascularity (step 6) are discussed. Static 3D datasets offer the combination of long axes distance measurements and volume calculations, which are the basis for an accurate follow-up in BI-RADS II and BI-RADS III lesions (step 3). Real time 4D volume contrast imaging (VCI) is able to demonstrate tissue elasticity (step 5). Glass body rendering is a static 3D tool which presents greyscale and colour information to study the vascularity and the vascular architecture of a lesion (step 6). Tomographic ultrasound imaging (TUI) is used for a slice by slice documentation in different investigation planes (A-,B- or C-plane) (steps 4 and 7). The final step 8 uses the panoramic view technique (XTD-View) to document the localisation within the breast and to make the position of a lesion simply reproducible.

Intra-operative sonography: a valuable aid during breast-conserving surgery for occult breast cancer

BACKGROUND

Breast cancer is increasingly detected during an early non-palpable stage. Together with pre-operative marking of the mass, intra-operative imaging provides invaluable clues. This study was designed to evaluate the usefulness of intra-operative sonography in the hands of the surgeon.

METHODS

Between July 2001 and October 2006, 567 patients underwent treatment for operable breast cancer at the landeskrankenhaus (LHK) Feldkirch. Three hundred and sixty lesions were not palpable. Two hundred and ninety-nine patients with poorly definable or non-definable lesions well seen by ultrasound imaging underwent intra-operative sonography (group 1), while 61 patients with non-palpable lesions only seen on mammography (group 2) were subjected to pre-operative needle localization. The study was non-randomized with prospective data acquisition

RESULTS

All lesions were identified by both sonography and pre-operative needle localization. In the ultrasound group (group 1) 81% of the lesions were successfully removed by primary intention without metachronous secondary surgery versus 62% in group 2 (p < 0.00228). Eighty-eight percent of the lesions in group 1 were eligible for breast-conserving surgery versus 75% in group 2. The mean clear margin in group 1 was substantially smaller (4.8 mm) than in group 2 (7.2 mm) (p < 0.0001).

CONCLUSION

Intra-operative sonography proved to be a reliable and helpful tool in the hands of the surgeon, not only for tumor localization, but also for orientation during tumor excision. It simplifies organizational work and spares the patient the discomfort of pre-operative needle localization.