Kinetic patterns of benign and malignant breast lesions on contrast enhanced digital mammogram

Purpose

To evaluate the kinetic patterns of benign and malignant breast lesions using contrast-enhanced digital mammogram (CEDM).

Methods

Women with suspicious breast lesions on mammography or ultrasound were enrolled. Single-view mediolateral oblique (MLO) CEDM of an affected breast was acquired at 2, 3, 4, 7, and 10 min after injection of contrast agent. Three readers visually and semi-quantitatively analyzed the enhancement of suspicious lesions. The kinetic pattern of each lesion was classified as persistent, plateau, or washout over two time intervals, 2–4 min and 2–10 min, by comparing the signal intensity at the first time interval with that at the second.

Results

There were 73 malignant and 75 benign lesions in 148 patients (mean age: 52 years). Benign and malignant breast lesions showed the highest signal intensity at 3 min and 2 min, respectively. Average areas under receiver operating characteristic (ROC) curve for diagnostic accuracy based on lesion enhancement at different time points were 0.73 at 2 min, 0.72 at 3 min, 0.69 at 4 min, 0.67 at 7 min, and 0.64 at 10 min. Diagnostic performance was significantly better at 2, 3, and 4 min than at 7 and 10 min (all p < 0.05). A washout kinetic pattern was significantly associated with malignant lesions at 2–4 min and 2–10 min frames according to two of the three readers’ interpretations (all p ≤ 0.001).

Conclusion

Applications of optimal time intervals and kinetic patterns show promise in differentiation of benign and malignant breast lesions on CEDM.

A phased approach to implementing the Breast Imaging Reporting and Data System (BI-RADS) in low-income and middle-income countries

BACKGROUND

Successful breast cancer detection programs rely on standardized reporting and interpreting systems, such as the Breast Imaging Reporting and Data System (BI-RADS), to improve system performance. In low-income and middle-income countries, evolving diagnostic programs have insufficient resources to either fully implement BI-RADS or to periodically evaluate the program's performance, which is a necessary component of BI-RADS. This leads to inconsistent breast ultrasound interpretation and a failure to improve performance.

METHODS

The authors applied the Breast Health Global Initiative's phased implementation strategy to implement diagnostic ultrasound and BI-RADS within the context of a limited-resource setting.

RESULTS

The authors recommended starting with triage ultrasound to distinguish suspicious masses from normal breast tissue and benign masses such as cysts because the majority of health workers performing ultrasounds at this level have minimal breast imaging experience. Transitioning to full diagnostic ultrasound with condensed or full BI-RADS should occur after performance and quality metrics have been met.

CONCLUSIONS

Transitioning through these phases across facilities likely will occur at different times, particularly in rural versus urban settings.

A comparative study of perioperative techniques to attain negative margins and spare healthy breast tissue in breast conserving surgery

BACKGROUND AND AIM

Traditionally lumpectomy as a part of breast-conserving surgery (BCS) is performed by palpation-guided method leading to positive margins and large excision volumes. There is no evidence suggesting that wide margin excisions decrease intra-breast tumour recurrence. Various perioperative techniques are used for margin assessment. We aimed to compare three commonly used techniques, i.e., ultrasound-guided surgery, palpation-guided surgery and cavity shaving for attaining negative margins and estimating the extent of healthy breast tissue resection.

METHOD

A prospective comparative study was performed on 90 patients who underwent breast conservation surgery for early breast cancer between August 2018 and June 2019. Tumour excision with a minimum of 1 cm margin was done either using ultrasound, palpation or cavity shaving. Histopathological evaluation was done to assess the margin status and excess amount of resected normal breast tissue. Calculated resection ratio (CRR) defining the excess amount of the resected breast tissue was achieved by dividing the total resection volume (TRV) by optimal resection volume (ORV). The time taken for excision was also recorded.

RESULTS

Histopathology of all 90 patients (30 in each group) revealed a negative resection margin in 93.3% of 30 patients in palpation-guided surgery group and 100% in both ultrasound-guided surgery and cavity shaving groups. Two patients (6.7%) from the cavity shaving group had positive margins on initial lumpectomy but shave margins were negative. TRV was significantly less in the ultrasound-guided surgery group compared to the palpation-guided surgery group and cavity shaving group (76.9 cm3, 94.7 cm3 and 126.3 cm3 respectively; p < 0.0051). CRR was 1.2 in ultrasound group compared to 1.9 in palpation group and 2.1 in cavity shave group which was also statistically significant (p < 0.0001).Excision time was significantly less (p < 0.001) in palpation-guided surgery group (13.8 min) compared to cavity shaving group (15.1 min) and ultrasound-guided group (19.4 min).

CONCLUSION

Ultrasound-guided surgery is more accurate in attaining negative margins with the removal of least amount of healthy breast tissue compared to palpation-guided surgery and cavity shaving.

Breast Ultrasound Technology and Performance Evaluation of Ultrasound Equipment: B-Mode

Ultrasound (US) has become increasingly important in imaging and image-guided interventional procedures. In order to ensure that the imaging equipment performs to the highest level achievable and thus provides reliable clinical results, a number of quality control (QC) methods have been developed. Such QC is increasingly required by accrediting agencies and professional organizations; however, these requirements typically do not include detailed procedures for how the tests should be performed. In this paper, a detailed overview of QC methods for general and breast US imaging using computer-based objective methods is described. The application of QC is then discussed within the context of a common clinical application (US-guided needle biopsy) as well as for research applications, where QC may not be mandated, and thus is rarely discussed. The implementation of these methods will help in finding early stage equipment faults and in optimizing image quality, which could lead to better detection and classification of suspicious findings in clinical applications, as well as improving the robustness of research studies.

Computer-Aided Diagnosis for Breast Ultrasound Using Computerized BI-RADS Features and Machine Learning Methods

This work identifies effective computable features from the Breast Imaging Reporting and Data System (BI-RADS), to develop a computer-aided diagnosis (CAD) system for breast ultrasound. Computerized features corresponding to ultrasound BI-RADs categories were designed and tested using a database of 283 pathology-proven benign and malignant lesions. Features were selected based on classification performance using a "bottom-up" approach for different machine learning methods, including decision tree, artificial neural network, random forest and support vector machine. Using 10-fold cross-validation on the database of 283 cases, the highest area under the receiver operating characteristic (ROC) curve (AUC) was 0.84 from a support vector machine with 77.7% overall accuracy; the highest overall accuracy, 78.5%, was from a random forest with the AUC 0.83. Lesion margin and orientation were optimum features common to all of the different machine learning methods. These features can be used in CAD systems to help distinguish benign from worrisome lesions.

Study on female breast cancer imaging screening consultation network in Guangdong Province, China

OBJECTIVE

This study aimed to construct breast cancer image screening consultation network (BISCN) that connects all levels of medical institutions in Guangdong Province.

MATERIALS AND METHODS

Fourteen hospitals in different cities and counties (districts) of Guang-dong were selected for breast cancer screening with imaging (breast X-ray, ultrasound, and MRI). "Breast Imaging Reporting and Data System (BI-RADS)" was taken as reference to build up image data base of breast cancer screening and BISCN that is an internet-based network platform. BISCN quality control was performed to improve the diagnostic accuracy and collaboration of members. In 2011, the BISCN members underwent breast imaging diagnosis training and conducted a questionnaire survey.

RESULTS

BISCN allowed quick, synchronous, and accurate communication and feedback of diagnostic imaging in breast cancer among all levels of medical institutions and improved the ability of breast cancer screening in the province, as well as the detection rate of early breast cancer throughout the province, especially in the grassroot units. The survey results showed that the trainees' understanding situation of the training contents before training was 2.02 ± 1.75 points. Through the study, the participants considered that the teaching contents could solve the daily diagnose problems (2.91 ± 0.70 points), the post-training scores were improved (2.88 ± 1.23 points), and highly satisfactory with the teaching contents (2.81 ± 0.53 points). All students passed the examination and were qualified for the future.

CONCLUSIONS

BISCN is of good feasibility in construction and applicability in management by raising diagnosis level of breast cancer in Guangdong Province.

Breast Sclerosing Adenosis and Accompanying Malignancies: A Clinicopathological and Imaging Study in a Chinese Population

Sclerosing adenosis (SA) is a less common histopathological lesion of the breast that can coexist with proliferative lesions as well as malignancies. We aimed to analyze the clinicopathological characteristics of SA and to investigate the radiological features of SA.Patients who underwent breast surgery at our institute from 2007 to 2013 were retrospectively reviewed. A total of 815 breasts (722 patients) were included in the final analysis. Synchronous bilateral SA was defined as the detection of another SA arising in the contralateral breast within 1 month after surgery for the initial breast lesion. Baseline characteristics, imaging records (ultrasonography, mammography, and magnetic resonance imaging [MRI]), and pathology were included in the analysis.The median age at diagnosis was 47 years old. The majority of patients had unilateral non-Bc-SA (457/722). Among 102 patients with bilateral SA, 78.4% were diagnosed synchronously. In total, 26 patients suffered from synchronous bilateral breast cancer. Upon final pathological investigation, 226 cases were SA involving breast cancer (Bc-SA), most (56.2%) of which were ductal carcinoma in situ (DCIS). In addition, lobular carcinoma in situ (LCIS) and diseases that involved LCIS also comprised up to 11.1% of cases. The majority of SA cases (405; 49.7%) had no obvious symptoms except for imaging changes in mammography or ultrasound. Compared with non-Bc-SA cases, Bc-SA cases were more likely to exhibit features of mass (32.8% vs. 28.6%) and architectural distortion (20.4% vs. 13.0%) on mammography. Ultrasonography, mammography, and MRI revealed unsatisfactory sensitivity and specificity to differentiate Bc-SA from non-Bc-SA. MRI exhibited the highest sensitivity and lowest specificity, whereas the specificity of mammography was as low as 50.0%.A tendency for synchronous bilaterality in both Bc-SA and non-Bc-SA was noted. DCIS was the most commonly observed malignancy involved in Bc-SA. Although most patients with SA were asymptomatic, the ability of imaging studies to accurately differentiate non-Bc-SA from Bc-SA remained unsatisfactory.

Intensity-Invariant Texture Analysis for Classification of BI-RADS Category 3 Breast Masses

Radiologists likely incorrectly classify benign masses as Breast Imaging Reporting and Data System (BI-RADS) category 3. A computer-aided diagnosis (CAD) system was developed in this study as a second viewer to avoid misclassification of carcinomas. Sixty-nine biopsy-proven BI-RADS category 3 masses, including 21 malignant and 48 benign masses, were used to evaluate the CAD system. To improve the texture features, gray-scale variations between images were reduced by transforming pixels into intensity-invariant ranklet coefficients. The textures of the tumor and speckle pixels were extracted from the transformed ranklet images to provide more robust features than in conventional CAD systems. As a result, tumor texture and speckle texture with ranklet transformation achieved significantly better areas under the receiver operating characteristic curve (Az) compared with those without ranklet transformation (Az = 0.83 vs. 0.58 and Az = 0.80 vs. 0.56, p value < 0.05). The improved CAD system can be a second reader to confirm the classification of BI-RADS category 3 masses.

Bayesian probability of malignancy with BI-RADS sonographic features

OBJECTIVES

The purpose of this study was to develop a quantitative approach for combining individual American College of Radiology Breast Imaging Reporting and Data System (BI-RADS) sonographic features of breast masses for assessing the overall probability of malignancy.

METHODS

Sonograms of solid breast masses were analyzed by 2 observers blinded to patient age, mammographic features, and lesion pathologic findings. BI-RADS sonographic features were determined by using American College of Radiology criteria. A naïve Bayes model was used to determine the probability of malignancy of all the sonographic features together and with age and BI-RADS mammographic features. The diagnostic performance for various combinations was evaluated by using the area under the receiver operating curve (Az).

RESULTS

Sonographic features had high positive and negative predictive values. The Az values for BI-RADS sonographic features for the 2 observers ranged from 0.772 to 0.884, which increased to 0.866 to 0.924 when used with patient age and BI-RADS mammographic features. The benefit of adding age and mammographic information was more marked for the observer with lower initial diagnostic performance. Age-specific analysis showed that diagnostic performance varied with age, with higher performance for patients aged 45 years and younger and patients older than 60 years compared to those aged 46 to 60 years. In 85% of cases, the diagnosis of the observers matched. When the consensus between the observers was used for diagnostic decisions, a high level of diagnostic performance (Az, 0.954) was achieved.

CONCLUSIONS

A naïve Bayes model provides a systematic approach for combining sonographic features and other patient characteristics for assessing the probability of malignancy to differentiate malignant and benign breast masses.

[Experience with virtual sonography of the breast]

OBJECTIVE

To assess the capabilities of and the first experience with an ACUSON S2000 automated breast volume scanner (ABVS) (Siemens, Germany) to detect abnormal breast lumps.

MATERIAL AND METHODS

Examinations were made in 97 patients who underwent radiological studies encompassing digital mammography, B-mode ultrasonography of the breast, and its pathomorphological examination. All the cases were classified according to the BI-RADS system. Abnormal breast lumps (BI-RADS 1) were not found in 27 cases; clearly defined benign masses (BI-RADS 2) were detected in 18, and pathomorphologically verified breast cancer (BC) (BI-RADS 5) in 29 cases. All the patients also underwent breast ultrasonography using an ACUSON S2000 system (Siemens, Germany). The results of ABVS examination were compared with those of standard comprehensive breast radiologic examination. Having no preliminary additional information on each patient, an independent expert--a radiologic diagnostician appraised all ultrasound scanning data at a special review station.

RESULTS

The sensitivity of the automated scanning assay in detecting breast abnormalities was 100%; its specificity and diagnostic accuracy were 40 and 88%, respectively. The independent expert established the diagnosis of BC in 26 (90%) of the 29 cases. According to the results of automated breast scanning, pre-examination using a set of radiation methods was recommended in 66 (66%) cases. The hyperdiagnosis was 24%.

CONCLUSION

Taking into consideration the fact that none of the BC case was overlooked, the first experience with ABVS showed encouraging results and the need for further clinical tests of the automated breast scanning system.

Comb-push ultrasound shear elastography (CUSE): a novel method for two-dimensional shear elasticity imaging of soft tissues

Fast and accurate tissue elasticity imaging is essential in studying dynamic tissue mechanical properties. Various ultrasound shear elasticity imaging techniques have been developed in the last two decades. However, to reconstruct a full field-of-view 2-D shear elasticity map, multiple data acquisitions are typically required. In this paper, a novel shear elasticity imaging technique, comb-push ultrasound shear elastography (CUSE), is introduced in which only one rapid data acquisition (less than 35 ms) is needed to reconstruct a full field-of-view 2-D shear wave speed map (40 × 38 mm). Multiple unfocused ultrasound beams arranged in a comb pattern (comb-push) are used to generate shear waves. A directional filter is then applied upon the shear wave field to extract the left-to-right (LR) and right-to-left (RL) propagating shear waves. Local shear wave speed is recovered using a time-of-flight method based on both LR and RL waves. Finally, a 2-D shear wave speed map is reconstructed by combining the LR and RL speed maps. Smooth and accurate shear wave speed maps are reconstructed using the proposed CUSE method in two calibrated homogeneous phantoms with different moduli. Inclusion phantom experiments demonstrate that CUSE is capable of providing good contrast (contrast-to-noise ratio ≥ 25 dB) between the inclusion and background without artifacts and is insensitive to inclusion positions. Safety measurements demonstrate that all regulated parameters of the ultrasound output level used in CUSE sequence are well below the FDA limits for diagnostic ultrasound.

The influence of technical factors on sonoelastographic assessment of solid breast nodules

PURPOSE

The aim of the study was to assess the influence of technical factors and/or lesion characteristics on the final elastographic score in solid breast nodules.

MATERIALS AND METHODS

Patients with solid breast masses examined between May 2007 and May 2008 in the Radiology Department of Cluj District University Hospital were included in the study. All lesions were examined with conventional ultrasound, Doppler ultrasound and sonoelastography, according to a preset protocol. The influence of the following factors on the elastographic score was evaluated: type of section (sagittal versus transverse); size of region of interest (small versus large); amplitude and frequency of movement; initial compression (light versus strong); angulation (perpendicular versus angulated transducer); characteristics of the lesion (size and location). The reference diagnosis was the histopathology diagnosis and, in twenty cases, short-term follow-up.

RESULTS

Ninety-two patients with a mean age of 48.11 years and 101 breast nodules were included in the study. The overall sensitivity and specificity for elastography were 79 % [68-88 %] and 79 % [65 - 89 %], respectively, with a negative predictive value of 74 % [60-85 %] and a positive predictive value of 84 % [72-91 %]. The following factors did not influence the elastographic score: type of section (scores on transverse and longitudinal section, Z = -0.641, p = 0.552); the amplitude and frequency of movements during the elastographic examination (Cochran's Q concordance = 0.706, p = 0.872); strong initial compression in the case of benign nodules (Z = 0.000, p = 1.000); size of the lesions. Of the elastographically benign nodules, 9 were false negative and of the 46 elastographically malignant nodules, 12 were false positive. The following factors influenced the elastographic scores: size of the region of interest (the scores were significantly different when small or large region of interest was used, Z = -0.671, p < 0.0001); transducer angulation (Z = -5.42, p < 0.0001); strong initial compression in the case of malignant nodules (Z = -6.044, p < 0.0001) and the location of the mass in the vicinity of the chest wall.

CONCLUSION

The most important factors that influence the final elastographic score, leading to false negative results, are the size of the region of interest, the initial compression and angulation of the transducer, while the frequency and amplitude of movement during the examination proved to be of no importance as long as the images were obtained within a range of assessment usefulness. Changing the scanning parameters never led to false positive results in the case of malignant breast masses.

Ultrasound is a useful adjunct to mammography in the assessment of breast tumours in all patients

BACKGROUND

Ultrasound is the first-line breast imaging modality in younger patients and an adjunct to mammography in older patients. The objectives of this study were to evaluate the complementary value of ultrasound to mammography in breast cancer and to investigate the use of ultrasound in patients above and below the age of 50 years.

METHODS

Clinical presentation and investigations for consecutive patients undergoing triple assessment at a symptomatic breast clinic were prospectively recorded between January 2000 and August 2003. Clinical data were compared with pathological findings. Patients were divided into two groups, above and below 50 years of age for subgroup analyses.

RESULTS

A total of 999 of 2185 patients had both mammography and ultrasound investigations performed and constituted the study population. Subgroup analysis of the 2185 patients demonstrated that 99 of the 127 patients who were diagnosed with breast cancer had both investigations performed (median age 57.0, range: 34-89 years). Mammography was normal/benign in 14.1%, indeterminate in 29.3% and suspicious of cancer in 56.6% of patients. Adjunctive ultrasound was normal/benign in 13.1%, indeterminate in 6.1% and suspicious of cancer in 80.8% of patients. In these 99 patients, adjunctive ultrasound was more sensitive than mammogram alone (80.8% vs. 56.6%, p < 0.001). Ultrasound upgraded nine of 14 mammographically normal and 16 of 29 mammographically indeterminate X-rays to a cancer. Mammography appeared to be more sensitive in patients over 50 years compared with those patients under 50 years (62.5% vs. 45.7%, p = 0.10). The sensitivity of ultrasound was comparable between patients above and below the age of 50 years (82.8% vs. 77.1%, p = 0.60). Further subgroup analysis demonstrated a higher sensitivity with combined mammography and ultrasound compared with mammography alone in either patient group (below 50: 45.7%-->77.1% and above 50: 62.5%-->82.8%). These results also suggested that the difference in the sensitivities of mammography vs. the combined investigation approach was more marked in patients under 50 years of age (below 50 = 31.4% vs. above 50 = 20.3%).

CONCLUSION

Adjunctive ultrasound assessment improves breast cancer detection in women of all ages and should be routinely used in symptomatic breast clinics.

The role of ultrasound in breast imaging

This report describes several patients in whom diagnostic ultrasound played a significant role in the detection and diagnosis of breast masses. Diagnostic ultrasound was able to verify whether breast mass was or was not present. Secondly, ultrasound was able to determine whether the mass was definitely benign and no further evaluation was necessary, or whether the mass was possibly malignant and needed a biopsy. The important role diagnostic ultrasound plays in breast imaging and its appropriate clinical applications are discussed.

Automated method for improving system performance of computer-aided diagnosis in breast ultrasound

The purpose of this research was to demonstrate the feasibility of a computerized auto-assessment method in which a computer-aided diagnosis (CADx) system itself provides a level of confidence for its estimate for the probability of malignancy for each radiologist-identified lesion. The computer performance was assessed within a leave-one-case-out protocol using a database of sonographic images from 542 patients (19% cancer prevalence). We investigated the potential of computer-derived confidence levels both as 1) an output aid to radiologists and 2) as an automated method to improve the computer classification performance-in the task of differentiating between cancerous and benign lesions for the entire database. For the former, the CADx classification performance was assessed within ranges of confidence levels. For the latter, the computer-derived confidence levels were used in the determination of the computer-estimated probability of malignancy for each actual lesion based on probabilities obtained from different views. The use of this auto-assessment method resulted in the modest but statistically significant increase in the area under the receiver operating characteristic (ROC) curve (AUC value) of 0.01 with respect to the performance obtained using the "traditional" CADx approach, increasing the AUC value from 0.89 to 0.90 ( p -value 0.03). We believe that computer-provided confidence levels may be helpful to radiologists who are using CADx output in diagnostic image interpretation as well as for automated improvement of the CADx classification for cancer.

BI-RADS decoded: detailed guidance on potentially confusing issues

The American College of Radiology (ACR) Breast Imaging Reporting and Data System (BI-RADS) is the product of the initial collaboration between various committees of the ACR and several other organizations, such as the American College of American Pathologists and the American College of Surgeons. The impetus to establish a standardized method of reporting and follow-up began as early as 1985 when several of our clinical colleagues made a plea to the ACR to improve the reporting of mammograms. Reports were ambiguous and difficult to interpret, often leaving the clinician without a clear-cut management scenario. Over the years of increasing BI-RADS usage, the BI-RADS committee of the ACR received questions which, when analyzed, focused on specific areas of BI-RADS. A review of these problematic areas, with appropriate guidance, will be presented along with an introduction to the new US and MR imaging lexicons focusing on unique descriptors.

Is there a role for sonography in breast cancer screening?

Sonography can disclose tumors that remain mammographically occult. As a result, many have suggested to perform sonography in addition to screening mammography, especially in women with dense breasts. This approach, however, should be dealt with very cautiously. First of all, the term "mammographically occult" should be used carefully, because lesions that are missed because of suboptimal mammographic image quality or bad positioning or because no attempt has been made to compare with previous mammograms must not automatically be considered as mammographically occult. Secondly, introduction of sonography in mammographic screening is not straightforward because (1) it is extremely difficult to detect small malignant lesions with sonography without concurrently causing an excess of false positive results, (2) it is unclear how sonographic screening should be organized and quality-assured, (3) it is not unreasonable to expect that the excess costs of sonographic screening would favor other prevention strategies with more favorable cost/benefit ratio to decrease overall mortality. But most importantly, no large-scale trials have unequivocally proven the validity of sonography screening so far, neither in the general population, nor in subgroups with dense mammograms and/or at increased risk of breast cancer. Therefore, mammography remains currently the only screening tool that is associated with a decrease of breast cancer specific mortality and that should be used for mass screening.

Diagnostic accuracy of mammography, ultrasonography and magnetic resonance imaging in the detection of intraductal spread of breast cancer following neoadjuvant chemotherapy

The purpose of this study is to evaluate the accuracy of mammography, ultrasonography, and contrast-enhanced magnetic resonance imaging for the diagnosis of intraductal spread of breast cancer following preoperative neoadjuvant chemotherapy. We evaluated a total of 168 areas of normal breast tissue outside the mass in 42 consecutive female patients with breast cancer using each imaging modality both before and after neoadjuvant chemotherapy. Neoadjuvant chemotherapy comprised two to four cycles of adriamycin-based CAF regimen. Multivariate analysis indicated that calcification on mammography and size of hypoechoic structures on ultrasonography prior to neoadjuvant chemotherapy shows a correlation with intraductal spread on pathologic study. Our study reveals that mammography and ultrasonography are useful in avoiding residual cancer cells caused by intraductal spread following conservative breast surgery.

Management of breast cysts revisited

The aim of this study was to evaluate the role of mammography and the outpatient follow up in the management of breast cysts. Prospective data was collected in 203 women from July 2000 to July 2005. All women had an ultrasound scan and aspiration. One hundred and seventy-six women above 35 years had a mammogram. All women were followed up 4-6 weeks later. Women with M3 or M4 mammography or with suspicious ultrasound findings on initial clinical visit were investigated further; 96.53% presented with a lump in the breast. Aspiration was performed in all women. Three patients had a residual lump on 4-6 week follow up. One was found to be benign and two were revealed to have cancer. The mammogram findings in these two patients were M3 and they would have merited further investigation anyway. In total 176 patients had a mammogram and a departmental ultrasound scan of the breasts of which 41 patients required further investigations following which cancer was found in nine patients (4.4%). Mammography is an important tool in the management of breast cysts. Outpatient follow up did not contribute significantly to the care of these patients.

Application of the breast imaging reporting and data system final assessment system in sonography of palpable breast lesions and reconsideration of the modified triple test

OBJECTIVE

The purpose of our study was to evaluate the utility of the American College of Radiology's Breast Imaging Reporting and Data System (BI-RADS) sonographic final assessment system and palpation-guided fine-needle aspiration (FNA) for evaluation of palpable breast lesions.

METHODS

Our computerized database identified 160 palpable lesions of the breast in which follow-up palpation-guided FNA, targeted sonography, and pathologic confirmation were performed. We used BI-RADS sonographic data on all lesions. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of malignancy were calculated for sonography and palpation-guided FNA. Two-sample binomial proportion tests were used as the statistical analysis (P<.05).

RESULTS

The FNA results were defined as benign, atypical cells, suspicious for malignancy, malignancy, and insufficiency. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were 90.9%, 82.7%, 84.3%, 57.7%, and 97.2%, respectively, on sonography and 75.8% to 90.9%, 82.7% to 98.4%, 84.3% to 94.4%, 57.7% to 92.6%, and 93.9% to 97.2% on FNA. There was no statistically significant difference for sensitivity and negative predictive value between the two examinations.

CONCLUSIONS

The diagnostic accuracy of sonography was similar to that of palpation-guided FNA for not missing the malignancy. Clinical application of FNA results can be difficult, especially when the result is insufficiency or atypical cells. Moreover, FNA is invasive and overlaps other procedures. Therefore, we conclude that sonography can replace palpation-guided FNA for diagnosis of palpable lesions of the breast when the BI-RADS sonographic final assessment system is used appropriately.

Guidelines from the European Society of Breast Imaging for diagnostic interventional breast procedures

The aim of the breast team is to obtain a definitive, nonoperative diagnosis of all potential breast abnormalities in a timely and cost-effective way. Percutaneous needle biopsy with its high sensitivity and specificity should now be standard practice, removing the need for open surgical biopsy or frozen section. For patients with cancer, needle biopsy provides a cost-effective and rapid way of providing not only a definitive diagnosis but prognostic information, allowing prompt discussion of treatment options, be they surgical or medical. Early removal of uncertainty also allows better psychosocial adjustment to the disease. Patients with benign conditions found either by themselves or as a result of population or opportunistic screening can be promptly reassured and discharged, removing the health care and psychological costs of surgical biopsy or repeated follow-up. Radiologists involved in breast imaging should ensure that they have the necessary skills to carry out core biopsy and/or fine-needle aspiration (FNA) under all forms of image guidance. This paper provides guidelines on best practice for diagnostic interventional breast procedures and standards, against which all practitioners should audit themselves, from the European Society of Breast Imaging.

Anthropomorphic Breast Phantoms for Qualification of Investigators for ACRIN Protocol 6666

The purpose of this study was to evaluate various ultrasonic properties of breast phantoms developed for use in qualifying investigators for participation in the American College of Radiology Imaging Network (ACRIN) protocol 6666, "Screening Breast Ultrasound in High-Risk Women." Specifically, a tool was sought to consistently measure the performance of radiology personnel in detecting and characterizing lesions similar to those expected with screening breast ultrasonography (US). The phantoms are equivalent to one another except for the randomization of positions of 14 of the 17 simulated lesions. The lesions differ in depth and ultrasonic properties. Representative values of propagation speed, attenuation, relative echogenicity, and mass density are reported for all tissue-mimicking components. Beam refraction occurs at the interface between the subcutaneous fat layer and the glandular parenchyma and can result in beam distortion artifacts similar to those encountered in clinical breast US.

Characterization of solid breast masses: use of the sonographic breast imaging reporting and data system lexicon

OBJECTIVE

The purpose of this study was to determine the reliability of sonographic American College of Radiology Breast Imaging Reporting And Data System (BI-RADS) classification in differentiating benign from malignant breast masses.

METHODS

One hundred seventy-eight breast masses studied by sonography with a known diagnosis were reviewed. All lesions were classified according to the sonographic BI-RADS lexicon. Pathologic results were compared with sonographic features. Sensitivity, specificity, accuracy, and positive predictive value (PPV) and negative predictive value (NPV) for the sonographic BI-RADS lexicon were calculated.

RESULTS

Twenty-six cases were assigned to class 3, 73 to class 4, and 79 to class 5. Pathologic results revealed 105 malignant and 73 benign lesions. The sonographic BI-RADS lexicon showed 71.3% accuracy, 98.1% sensitivity, 32.9% specificity, 67.8% PPV, and 92.3% NPV. The NPV for class 3 was 92.3%. The PPVs for classes 4 and 5 were 46.6% and 87.3%. Typical signs of malignancy were irregular shape, antiparallel orientation, noncircumscribed margin, echogenic halo, and decreased sound transmission. Typical signs of benignity were oval shape and circumscribed margin.

CONCLUSIONS

The sonographic BI-RADS lexicon is an important system for describing and classifying breast lesions.

Three-dimensional ultrasound for the assessment of breast lesions

OBJECTIVE

To evaluate the diagnostic accuracy of three-dimensional (3D) ultrasound in comparison with conventional two-dimensional (2D) ultrasound in the characterization of breast lesions.

METHODS

The digitally stored 2D ultrasound images and the corresponding 3D scans of 100 breast lesions (57 malignant, 43 benign) that had been morphologically classified as solid tumors, were independently analyzed by six investigators. Ten 2D and 13 3D ultrasound characteristics were determined. Lesion characterization was classified on a four-point scale and a logistic regression model was used to analyze the data. A receiver-operating characteristics curve (ROC) analysis was performed to determine the diagnostic performance of 2D and 3D ultrasound, respectively.

RESULTS

Ultrasound criteria showed major differences between 2D and 3D ultrasound. Logistic regression revealed the retraction phenomenon in the coronal plane of the 3D ultrasound scan to be a significant and independent factor for lesion characterization. The characteristics determined on the conventional planes of 3D ultrasound differed from those determined on the 2D ultrasound images. The diagnostic accuracy of 2D and 3D ultrasound in the ROC analysis was almost identical (area under the curve 0.846 and 0.851, respectively).

CONCLUSIONS

Ultrasound features on 3D ultrasound differ significantly from those on 2D ultrasound. However, the diagnostic accuracy of both methods is almost identical. 3D ultrasound as an adjunct to conventional 2D ultrasound should be evaluated in larger trials to determine its clinical value in breast imaging.

Breast imaging in general practice

This is the fourth article in a series of breast disorders with an emphasis on diagnosis and management in the general practice setting. This article provides guidance for general practitioners on the role of breast imaging in screening and the investigation of breast symptoms, with an emphasis on indications for imaging and common abnormal findings. It is presented as a summary of key facts supplemented by a mini-atlas of breast imaging to facilitate use of imaging in routine general practice.

[Patient safety in diagnostic ultrasound II--ultrasound guided interventions]

New digital ultrasound techniques simplify the documentation of ultrasound images and allow better comparison with respect to different image modalities. New vascular imaging modes including contrast enhanced power Doppler and 3D power Doppler allow for the detection of very small vessels and leakages. B-flow, a recently introduced digital substraction technique is advancing the detection of residual blood flow in high-grade stenosis without vibration artifacts. Modern contrast agents allow to perform ultrasound guided intervetion such as biopsies and ablation therapies with improved accuracy. This way, the risk for complications can be significantly reduced.

Diagnostische Mammographie und Sonographie: Korrelation von diagnostischer BI-RADS-Einstufung mit dem histologischen und klinischen Endbefund

PURPOSE

The purpose of the study was to assess the final clinical outcome of BI-RADS Categories for diagnostic mammography and sonography.

MATERIAL AND METHODS

We analysed 632 mammography and sonography examinations from women with diagnostic indications (age: 23 - 100, mean 58) performed during 2001 and 2003. All patients received mammography and sonography examinations at different outside facilities and all patients received an additional sonography examination at the university radiology department and if necessary supplemental mammographic views. Final clinical outcome (Histology: 554; follow-up: 78) was ascertained in each case and concordance of BI-RADS-categories for mammography and sonography and final diagnosis were analysed.

RESULTS

Final diagnosis yielded 230 benign lesions (36 %) and 402 cancers (64 %). Concordance of BI-RADS Assessment and final outcome was documented in 542 cases (86 %). There were 11 correct category 1 and 2 assessments (2 %). 142 lesions were classified with BI-RADS 3 (22 %) with 5 false negative ratings. There were 264 category 4 lesions (42 %) with a PPV for a malignant lesion of 71 % (187/264) and finally 215 BI-RADS 5 lesions with a PPV of 98 % (210/215). Overall sensitivity of mammography was 92 % with specificity of 75 % and for sonography 86 % and 76 %. Mammography had a significantly higher detection rate for malignant lesions than sonography. The highest correlation between BI-RADS category and final outcome was documented for the diagnostic combination of mammography and sonography with a kappa-value of 0.817 (p < 0.001), followed by mammography (kappa: 0.684) and sonography (kappa: 0.631). The overall correlation was 0.681 (p < 0.001).

CONCLUSION

BI-RADS assessments of diagnostic mammography and sonography yields in a high cancer detection rate with a justifiable part of false positive ratings.

Woman feels breast lump – surgeon cannot: the role of ultrasound in arbitration

The role of ultrasound scanning (USS) in patients complaining of a breast lump where the clinical examination (CE) is normal is not clearly defined. To determine this in greater detail, all patients complaining of a breast lump underwent CE. Where no lump could be found, but was still reported by the patient, an USS was performed. All lesions underwent biopsy and/or aspiration, as well as mammography in suspicious cases or those over 40 years of age. This cohort represented 5% of all referrals in the study period. Four hundred and twenty women were prospectively studied in this way. Median follow up is 3.4 years (range 2.5-4.2 years). Twenty two had solid lumps (of which 3 were cancers) and 48 had cysts. Nineteen patients re-presented with symptoms in the same breast (median time = 12 months (range 4.5-20 months), all of which were imaged on USS: 15 cysts and 4 further cancers (3 in the same quadrant as the original lump, one contralateral) were identified. Women with symptomatic breast lumps and a normal CE can be considered a reliable indication that cancer is very unlikely to be present (negative predictive value = 0.98). Ultrasound may be a suitable complimentary investigation, which will relieve symptoms in those with cysts and can detect small clinically--and sometimes mammographically--occult breast cancers.

Breast imaging flow models

Economically efficient and clinically effective breast imaging can be achieved through combinations and permutations of four fundamental breast imaging flow models: (1) the traditional flow model, (2) the online flow model, (3) the women's imaging flow model, and (4) the combination-care flow model. The structure, strengths, and weaknesses of these four individual breast imaging flow models are described and compared.

Analysis of sonographic features for the differentiation of benign and malignant breast tumors of different sizes

OBJECTIVE

To analyze the value of various sonographic features in differentiating benign from malignant breast tumors of different sizes to improve the diagnostic accuracy in small lesions.

METHODS

The sonographic features of 1203 histologically confirmed solid breast lesions were prospectively documented with respect to anteroposterior (AP) diameter/width ratio, shape, margin, echogenicity, echotexture, posterior echo and bilateral refraction sign. The sensitivity, specificity and accuracy of breast ultrasound were calculated for lesions grouped according to size (< or = 1, 1.1-2 and > 2 cm). Univariate and multiple logistic regression analyses including calculation of odds ratios for single sonographic features were used to analyze the significance of the different diagnostic features.

RESULTS

The accuracy of breast sonography in differentiating between benign and malignant tumors < or = 1, 1.1-2 and > 2 cm in size was 75.6%, 86.4% and 88.4%, respectively. Univariate analysis demonstrated that all sonographic features were significant in tumors > or = 1.1 cm. Shape, margin, echogenicity and echotexture were the significant factors in those tumors < or = 1 cm. Multiple logistic regression analysis demonstrated that margin, shape, posterior echo and echogenicity were the significant factors for differential diagnosis in tumors > 2 cm. Echogenicity, margin, shape, bilateral refraction sign and echotexture were the significant factors for tumors 1.1-2 cm. On multiple regression analysis, margin was the only significant factor for tumors < or = 1 cm.

CONCLUSION

Tumor margin is the most important sonographic feature in evaluating breast lesions in any size group. With the combination of significant factors and emphasis on specific features according to size of lesion, the diagnostic accuracy of ultrasound for the differential diagnosis of malignant and benign tumors may be improved.

Sonographic differentiation of invasive and intraductal carcinomas of the breast

The purpose of this study is to evaluate the diagnostic ability of ultrasound and define the sonographic features of symptomatic intraductal and invasive breast carcinoma. To achieve this the ultrasound features of 488 invasive carcinomas and 65 non-screening detected intraductal carcinomas were compared retrospectively. The features included size, AP/W (anteroposterior diameter/width) ratio, shape, margin, internal echogenicity, internal echotexture, posterior acoustic transmission, bilateral edge shadowing sign and calcifications. The sensitivity and specificity of the detection of calcifications by ultrasound in comparison with mammography were also studied. The accuracy of ultrasound diagnosis is 92.0% for invasive carcinoma of breast and 84.8% for intraductal carcinoma. Differentiation of ultrasound features of intraductal and invasive carcinoma can be based on the internal hypoechogenicity, loss of bilateral edge shadowing, posterior acoustic transmission, irregular shape and non-uniform internal echotexture with odds ratio of 0.3, 0.3, 0.4, 0.5 and 0.5, respectively. Internal echogenicity was the only significant differentiating factor on multiple logistic regression analysis. Non-comedo type ductal carcinoma in situ can be differentiated from comedo type by irregular shape with odds ratio of 0.3. The sensitivity, specificity and accuracy rate for the detection of calcifications in invasive carcinomas by ultrasound were 65.1%, 61.9% and 63.2%; in comedo type intraductal carcinoma 62.5%, 66.7% and 63.6%, and in non-comedo type intraductal carcinoma 30.0%, 86.7% and 64.0%, respectively. The ultrasound appearance of non-screening detected intraductal carcinoma is relatively isoechoic in comparison with invasive carcinoma. More than 60% of microcalcifications in comedo type intraductal carcinoma can be accurately demonstrated by ultrasound. However, the role of ultrasound in detecting symptomatic intraductal carcinoma warrants further study.

Cryotherapy of breast cancer under ultrasound guidance: initial results and limitations

The aim of this study was to investigate the potential and feasibility of ultrasound-guided cryotherapy in breast cancer. Fifteen female patients with 16 breast cancers (mean tumour diameter 21+/-7.8 mm) were treated. A 3-mm cryo probe was placed in the tumour under ultrasound guidance. Two freeze/thaw cycles with durations of 7-10 min and 5 min, respectively, were performed. The size of the iceballs was measured sonographically in 1-min intervals. The patients underwent surgery within 5 days and the specimens were evaluated histologically. The mean diameter of the iceball was 28+/-2.7 mm after the second freezing cycle. No severe side effects were observed. Five tumours with a diameter below 16 mm did not show any remaining invasive cancer after treatment. Two of these had ductal carcinoma in situ (DCIS) in the surrounding tissue. In 11 patients cryotherapy of tumours reaching diameters of 23 mm or more resulted in incomplete necrosis. This study shows that the invasive components of small tumours can be treated using cryotherapy. Remnant DCIS components which may not be detected preinterventionally represent a challenging problem for complete ablation. In tumours larger than 15 mm two or more cryo probes should be used to achieve larger iceballs.

[Criteria of dignity in ultrasound mammography using a 10-MHz-transducer, also with regard to tumor size]

AIM

Ongoing technical progress has increased the accuracy of imaging in ultrasound mammography. Using a 10-MHz-transducer, eight different criteria of dignity were evaluated for validity, also with regard to the size of a tumor.

MATERIALS AND METHODS

Over a period of three years, 446 breast tumors were ultrasonographically examined by two experienced medical doctors. The study comprised only suspicious lesions detected by mammography and/or manual palpation. Diagnostic validity was quantified by means of sensitivity, specificity, positive and negative predictive value, as well as the ODDS-ratio.

RESULTS

Ultrasound mammography demonstrated a sensitivity of 94.0 %, specificity of 91.4 %, positive predictive value of 95.9 %, and a negative predictive value of 99.1 %. Eight different sonographic criteria were validated separately. The most important signs of malignancy were (in descending order): a highly echogenic halo, spikes, jagged contour, posterior acoustic shadowing, and discontinuity of tissue structure. Features of benign disease were: smooth edge, posterior acoustic enhancement, displacement margin, bilateral acoustic shadowing and continuity of tissue structure. Furthermore, it appeared that the size of a tumor only had consequences on posterior shadowing (p = 0.017). All other features did not show significant variation in relation to tumor size.

CONCLUSION

We were able to prove that ultrasound mammography is an excellent medium for the differentiation of benign and malignant breast lesions, when precise indication criteria were adhered to, even in cases of small tumor size.

Agreement or prediction: asking and answering the right question

INTRODUCTION

Measuring agreement and measuring predictive ability are similar but distinct problems. Failure to appreciate the conceptual and practical differences may lead clinical researchers to give the right answer to the wrong question.

METHODS

We illustrate the relation and difference between measuring agreement and predictive ability in a non-technical way. We provide a real example investigating the feasibility of using preoperative breast cancer tumour size measurements to estimate postoperative histological size. The intraclass correlation and R-squared are calculated to ascertain the level of agreement and predictive ability respectively.

RESULTS

Analysis of agreement and analysis of predictive ability serve different purposes. The optimal solution found in terms of agreement may be different from that found for prediction.

CONCLUSIONS

A careful clarification of the goal of an investigation is important. Using an inappropriate analysis can lead to misleading results, or to results that do not really answer the research question of interest.

Breast imaging reporting and data system (BI-RADS)

The Breast Imaging Reporting and Data System (BI-RADS) lexicon was developed by the American College of Radiology to standardize mammographic reporting. The BI-RADS lexicon defines terms to describe abnormalities on mammograms, and it defines final assessment categories that are predictive of the likelihood of malignancy. Although the lexicon is clinically useful and facilitates communication and research, there is still substantial interobserver variability in its application. Lexicons for breast sonography and breast MRI are in progress.

Additional value of electrical impedance scanning: experience of 240 histologically-proven breast lesions

The aim of this study was to quantify the clinical value of using electrical impedance scanning (EIS) as an adjunct to other diagnostic techniques in order to identify cancerous tissue based upon its inherent altered local dielectric properties. 210 consecutive women with 240 sonographically and/or mammographically suspicious findings were examined using EIS. All lesions were histologically-proven. 86/103 malignant and 91/137 benign lesions were correctly identified using EIS (87.8% sensitivity, 66.4% specificity). NPV and PPV of 84.3% and 65.2% were observed, respectively. Excluding cases as defined by a priori criteria, i.e. lesions located deeper than 35 mm, lesions larger than 35 mm, and retroareolar lesions, a sensitivity of 85.5% was observed, and for invasive cancers, 91.7%. The detection rate for ductal carcinoma in situ (DCIS) was poor (57.1%, n=14). By adding EIS to mammography and ultrasound, the sensitivity rose from 86.4 to 95.1%, whereas the accuracy decreased from 82.3 to 75.7%. EIS appears to be of interest as an adjunct to breast diagnostic techniques, performing with a reasonable sensitivity. Further investigations on histomorphological characteristics and the reasons for false-negative findings are essential to gain further knowledge about the bioelectricity of breast lesions, and prove the value of this new technology.

Quantitative ultrasound as a predictor of node metastases and prognosis in patients with breast cancer

BACKGROUND

A retrospective study was performed to determine whether preoperative quantitative ultrasound assessment could predict axillary lymph node metastases and prognosis in patients with breast cancer. We focused on the presence of a halo, which is one of the features of breast cancer on ultrasound and represents reflections from the invading margin around infiltrating malignancies.

METHODS

We evaluated ultrasonography from 187 infiltrating breast carcinoma patients with tumors 5 cm or less in greatest dimension (T1, T2). Using computer image analysis, the halo area (H) and the sum of the area of halo and internal echo (total tumor area (T)) were measured, and the ratio of halo to entire tumor (H/T, halo ratio) was calculated and compared with lymph node status and prognosis.

RESULTS

The mean of the halo ratio was 0.38+/-0.13. Using the value of 0.42 as a cut-off, the high halo ratio group had significantly worse prognoses for both overall and disease-free survival at 49 months in median follow-up (p <0.001 and p <0.0005, respectively). The specificity of a high halo ratio in the T1 classification for predicting axillary node metastasis was 83.1%, with a negative predictive value of 86.8%. In patients with tumors 1.0 cm or smaller, the negative predictive value was 100%. In a multivariate analysis, halo ratio was an independent predictor of disease-free survival of breast carcinoma patients (p =0.0232).

CONCLUSIONS

Preoperative quantitative ultrasound may be a useful non-invasive method for predicting the presence of axillary lymph node metastases and prognosis in patients with primary breast cancer.

Audit of a one-stop breast clinic--revisited

BACKGROUND

A one-stop diagnostic service has been available for women with symptomatic breast disease at St Bartholomew's Hospital for 5 years and was originally audited in May 1993. In re-auditing the one-stop service our aim was to see if our practice had improved following the original audit and to look at the impact which these changes in practice had made to the service offered to the patient.

METHODS

A prospective audit of 4 consecutive clinics was undertaken in November 1997. A total of 300 patients (59 new and 241 follow up) were seen in clinic in this time. The primary outcome measure concerned the completeness of triple assessment in the 40 patients who required one stop investigations, including mammography, ultrasonography and fine-needle aspiration cytology. In addition, mean time to initial consultation and level of awareness of the one-stop facility and its attendant time delay were measured.

RESULTS

Of the 300 clinic attendees 40 (38 new, 2 follow-up) had one-stop investigations. As a result of the one-stop service being in practice, 36 patients (90%) had a definitive management decision made at their first outpatient visit. Of these 2 were symptomatic cancers, forming 5% of the workload. A total of 86% of the workload was benign. Four patients (10%) had equivocal results. The mean waiting time from designated appointment until surgical consultation was 36.7 minutes and was disappointingly unchanged from that of the previous audit. However this does not take into account the significant reduction in staffing levels which has occurred between the two periods of assessment.

CONCLUSIONS

The initial audit identified a significant problem with time constraints, necessitating that a large number of patients with carcinomas return at a later date for further investigations. Booking only new patients at the beginning of clinic has provided a solution. Disappointingly, our figures do not show a significant improvement in mean waiting time compared with the previous audit, despite allowing GPs greater access of referral. Encouragingly, we have been able to maintain a similar standard of provision of care despite lower staffing levels and to implement the changes suggested by the original audit (thereby closing the audit loop).

Baseline staging tests in primary breast cancer: a practice guideline

BACKGROUND

Breast cancer develops in over 7000 women each year in Ontario. These patients will all undergo some staging work-up at diagnosis. The Breast Cancer Disease Site Group of the Cancer Care Ontario Practice Guidelines Initiative reviewed the evidence and indications for routine bone scanning, liver ultrasonography and chest radiography in asymptomatic women who have undergone surgery for breast cancer.

METHODS

A systematic review of the published literature was combined with a consensus interpretation of the evidence in the context of conventional practice.

RESULTS

There were 11 studies of bone scanning reported between 1972 and 1980, involving a total of 1307 women; bone scans detected skeletal metastases in 6.8% of those with stage I breast cancer, 8.8% with stage II and 24.5% with stage III. A total of 5407 women participated in 9 studies of bone scanning reported between 1985 and 1995; in these studies, bone scans detected skeletal metastases in only 0.5% of women with stage I disease, 2.4% with stage II and 8.3% with stage III. Among 1625 women in 4 studies of liver ultrasonography reported between 1988 and 1993, hepatic metastases were detected in 0% of patients with stage I disease, 0.4% with stage II and 2.0% with stage III. Among 3884 patients in 2 studies of chest radiography published in 1988 and 1991, lung metastases were detected in 0.1% of those with stage I, 0.2% with stage II and 1.7% with stage III. False-positive rates ranged from 10% to 22% for bone scanning, 33% to 66% for liver ultrasonography and 0% to 23% for chest radiography. The false-negative rate for bone scanning was about 10%.

RECOMMENDATIONS

The following recommendations apply to women with newly diagnosed breast cancer who have undergone surgical resection and who have no symptoms, physical signs or biochemical evidence of metastases. Routine bone scanning, liver ultrasonography and chest radiography are not indicated before surgery. In women with intraductal and pathological stage I tumours, routine bone scanning, liver ultrasonography and chest radiography are not indicated as part of baseline staging. In women who have pathological stage II tumours, a postoperative bone scan is recommended as part of baseline staging. Routine liver ultrasonography and chest radiography are not indicated in this group but could be considered for patients with 4 or more positive lymph nodes. In women with pathological stage III tumours, bone scanning, liver ultrasonography and chest radiography are recommended postoperatively as part of baseline staging. In women for whom treatment options are restricted to tamoxifen or hormone therapy, or for whom no further treatment is indicated because of age or other factors, routine bone scanning, liver ultrasonography and chest radiography are not indicated as part of baseline staging.

Correlation between ultrasound characteristics, mammographic findings and histological grade in patients with invasive ductal carcinoma of the breast

AIM

To investigate the relationship between ultrasound characteristics, mammographic findings and histological grade in cases of invasive ductal carcinoma which produce a mass on ultrasound.

MATERIAL AND METHODS

A retrospective review was performed of the imaging findings in 120 patients diagnosed with invasive ductal carcinoma of the breast between January 1996 and December 1997. Imaging findings were correlated with the histological grade of tumour.

RESULTS

High-grade tumours were significantly larger both on ultrasound and mammography (P < 0.016). A spiculated margin on mammogram was documented in 72% of low-grade tumours compared with only 24% of high-grade tumours (P = 0.001). Twenty-two per cent of low-grade tumours had a poorly defined margin on mammography compared with 66% of high-grade tumours (P = 0.001). At ultrasound, 16% of high-grade tumours (95% confidence limits 7-29%) had a well-defined margin. Acoustic enhancement was seen in 36% of high-grade tumours compared with only 9% of low and intermediate-grade tumours (P = 0.003): 22% of all tumours showed acoustic enhancement. Acoustic shadowing was seen in 71% of low-grade tumours compared with only 28% of high-grade tumours (P = 0.003). Malignant-type microcalcification was seen on mammogram in 6% of low-grade tumours compared with 31% of high-grade tumours (P = 0.045).

CONCLUSION

The classical appearance of a malignant breast mass as a spiculated mass on mammogram associated with acoustic shadowing on ultrasound is more typical of a low-grade tumour. In comparison, high-grade tumours are more likely to demonstrate posterior acoustic enhancement, and a proportion has a well-defined margin on ultrasound. Therefore, high-grade invasive ductal carcinoma may paradoxically display similar imaging features to a benign breast mass.

A study testing the routine use of ultrasound measurements when selecting the electron energy for breast boost radiotherapy

The determination of the depth of the tumour bed within the breast requiring an electron therapy boost dose is generally judged clinically and can be inconsistent between individual radiotherapists. High frequency ultrasound provides a reproducible, safe and quick method of measuring this depth. In order to improve current working practice at the Royal Marsden NHS Trust the routine use of ultrasound when planning breast boost radiotherapy was established. Fifty-three early stage postoperative breast cancer patients had both clinical and ultrasound assessments of boost depth performed. These measurements were converted into electron energy and compared. Measurements ranged from 0.8 cm to 4.9 cm and electron energy from 4 MeV to 15 MeV. As a direct result of the ultrasound measurements taken, 60% of patients had their electron energy changed from that chosen by the clinically assessed measurement. Overall, the energy was as likely to be increased as decreased. Breast size did not influence the need for change but patients with small breasts never required an increase in the energy from that chosen clinically. It was concluded that the use of ultrasound, once integrated into the planning process, can improve accuracy when selecting electron energy for patients receiving breast boost irradiation.