2008 update of the guideline: early detection of breast cancer in Germany

Breast imaging in focus: A bibliometric overview of visual quality, modality innovations, and diagnostic performance

INTRODUCTION

Breast imaging plays a crucial role in the early detection and management of breast cancer, with visual quality, modality innovation and diagnostic performance being key factors in achieving accurate diagnoses and optimal patient outcomes. This paper presents a comprehensive bibliometric analysis of the literature on the three above elements focusing on breast imaging, aiming to uncover publication trends, identify influential works and authors, and highlight future research directions.

METHODS

We employed a methodical bibliometric approach, making use of Scopus and Web of Science (WoS) databases for gathering literatures. We planned our search strategy, concentrating on terms linked to "breast imaging," "image quality," and "diagnostic accuracy" to ensure a systematic examination of the subject. The enhanced search functions in these databases enabled us to narrow down and improve our findings, choosing only the articles, conference papers, and book sections that are most relevant. After conducting a thorough screening process to remove duplicates and evaluate significance, we utilized ScientoPy and VOSviewer software for an in-depth bibliometric analysis. This helped to explore trends in publications, patterns of citations, and thematic groups, giving us a better understanding of how the field has changed and where it currently stands. Our approach prioritized assessing methodological quality and bias in the studies we included, guaranteeing the reliability of our findings.

RESULTS

We reviewed 2984 relevant publications, revealing a consistent annual growth rate of 2.8% in breast imaging research, with the United States and Europe leading in contributions. The study found that advancements in radiological technologies and international collaboration are driving forces behind the field's expansion. Key subject areas such as 'Radiology, Nuclear Medicine, and Medical Imaging' dominated, underscoring their impact on diagnostic quality. Notable authors and institutions have been identified for their influential research, characterized by high citation metrics and significant scholarly impact.

CONCLUSION

The study shows a continuous increase in research on breast imaging, considered by new technologies and teamwork defining the present time. The assessment highlights a key move towards utilizing digital imaging methods and computational analysis, affecting the improvement of future diagnostic procedures and patients' results. The study highlights the importance of continued international collaborations to tackle the new barriers in breast imaging and make the most of technological progress.

IMPLICATIONS FOR PRACTICE

This study shows a focus on using interdisciplinary methods and cutting-edge technology in breast imaging to help healthcare professionals improve their performance and accuracy in diagnosis. Recognizing vital research and emerging trends should guide clinical guidelines, radiology training, and patient care plans to encourage the use of effective techniques and stimulate innovation in diagnostic approaches.

miR-125 in Breast Cancer Etiopathogenesis: An Emerging Role as a Biomarker in Differential Diagnosis, Regenerative Medicine, and the Challenges of Personalized Medicine

Breast Cancer (BC) is one of the most common cancer types worldwide, and it is characterized by a complex etiopathogenesis, resulting in an equally complex classification of subtypes. MicroRNA (miRNA or miR) are small non-coding RNA molecules that have an essential role in gene expression and are significantly linked to tumor development and angiogenesis in different types of cancer. Recently, complex interactions among coding and non-coding RNA have been elucidated, further shedding light on the complexity of the roles these molecules fulfill in cancer formation. In this context, knowledge about the role of miR in BC has significantly improved, highlighting the deregulation of these molecules as additional factors influencing BC occurrence, development and classification. A considerable number of papers has been published over the past few years regarding the role of miR-125 in human pathology in general and in several types of cancer formation in particular. Interestingly, miR-125 family members have been recently linked to BC formation as well, and complex interactions (competing endogenous RNA networks, or ceRNET) between this molecule and target mRNA have been described. In this review, we summarize the state-of-the-art about research on this topic.

Mammography in combination with breast ultrasonography versus mammography for breast cancer screening in women at average risk

BACKGROUND

Screening mammography can detect breast cancer at an early stage. Supporters of adding ultrasonography to the screening regimen consider it a safe and inexpensive approach to reduce false-negative rates during screening. However, those opposed to it argue that performing supplemental ultrasonography will also increase the rate of false-positive findings and can lead to unnecessary biopsies and treatments.

OBJECTIVES

To assess the comparative effectiveness and safety of mammography in combination with breast ultrasonography versus mammography alone for breast cancer screening for women at average risk of breast cancer.

SEARCH METHODS

We searched the Cochrane Breast Cancer Group's Specialised Register, CENTRAL, MEDLINE, Embase, the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), and ClinicalTrials.gov up until 3 May 2021.

SELECTION CRITERIA

For efficacy and harms, we considered randomised controlled trials (RCTs) and controlled non-randomised studies enrolling at least 500 women at average risk for breast cancer between the ages of 40 and 75. We also included studies where 80% of the population met our age and breast cancer risk inclusion criteria.

DATA COLLECTION AND ANALYSIS

Two review authors screened abstracts and full texts, assessed risk of bias, and applied the GRADE approach. We calculated the risk ratio (RR) with 95% confidence intervals (CI) based on available event rates. We conducted a random-effects meta-analysis.

MAIN RESULTS

We included eight studies: one RCT, two prospective cohort studies, and five retrospective cohort studies, enrolling 209,207 women with a follow-up duration from one to three years. The proportion of women with dense breasts ranged from 48% to 100%. Five studies used digital mammography; one study used breast tomosynthesis; and two studies used automated breast ultrasonography (ABUS) in addition to mammography screening. One study used digital mammography alone or in combination with breast tomosynthesis and ABUS or handheld ultrasonography. Six of the eight studies evaluated the rate of cancer cases detected after one screening round, whilst two studies screened women once, twice, or more. None of the studies assessed whether mammography screening in combination with ultrasonography led to lower mortality from breast cancer or all-cause mortality. High certainty evidence from one trial showed that screening with a combination of mammography and ultrasonography detects more breast cancer than mammography alone. The J-START (Japan Strategic Anti-cancer Randomised Trial), enrolling 72,717 asymptomatic women, had a low risk of bias and found that two additional breast cancers per 1000 women were detected over two years with one additional ultrasonography than with mammography alone (5 versus 3 per 1000; RR 1.54, 95% CI 1.22 to 1.94). Low certainty evidence showed that the percentage of invasive tumours was similar, with no statistically significant difference between the two groups (69.6% (128 of 184) versus 73.5% (86 of 117); RR 0.95, 95% CI 0.82 to 1.09). However, positive lymph node status was detected less frequently in women with invasive cancer who underwent mammography screening in combination with ultrasonography than in women who underwent mammography alone (18% (23 of 128) versus 34% (29 of 86); RR 0.53, 95% CI 0.33 to 0.86; moderate certainty evidence). Further, interval carcinomas occurred less frequently in the group screened by mammography and ultrasonography compared with mammography alone (5 versus 10 in 10,000 women; RR 0.50, 95% CI 0.29 to 0.89; 72,717 participants; high certainty evidence). False-negative results were less common when ultrasonography was used in addition to mammography than with mammography alone: 9% (18 of 202) versus 23% (35 of 152; RR 0.39, 95% CI 0.23 to 0.66; moderate certainty evidence). However, the number of false-positive results and necessary biopsies were higher in the group with additional ultrasonography screening. Amongst 1000 women who do not have cancer, 37 more received a false-positive result when they participated in screening with a combination of mammography and ultrasonography than with mammography alone (RR 1.43, 95% CI 1.37 to 1.50; high certainty evidence). Compared to mammography alone, for every 1000 women participating in screening with a combination of mammography and ultrasonography, 27 more women will have a biopsy (RR 2.49, 95% CI 2.28 to 2.72; high certainty evidence). Results from cohort studies with methodological limitations confirmed these findings. A secondary analysis of the J-START provided results from 19,213 women with dense and non-dense breasts. In women with dense breasts, the combination of mammography and ultrasonography detected three more cancer cases (0 fewer to 7 more) per 1000 women screened than mammography alone (RR 1.65, 95% CI 1.0 to 2.72; 11,390 participants; high certainty evidence). A meta-analysis of three cohort studies with data from 50,327 women with dense breasts supported this finding, showing that mammography and ultrasonography combined led to statistically significantly more diagnosed cancer cases compared to mammography alone (RR 1.78, 95% CI 1.23 to 2.56; 50,327 participants; moderate certainty evidence). For women with non-dense breasts, the secondary analysis of the J-START study demonstrated that more cancer cases were detected when adding ultrasound to mammography screening compared to mammography alone (RR 1.93, 95% CI 1.01 to 3.68; 7823 participants; moderate certainty evidence), whilst two cohort studies with data from 40,636 women found no statistically significant difference between the two screening methods (RR 1.13, 95% CI 0.85 to 1.49; low certainty evidence).

AUTHORS' CONCLUSIONS

Based on one study in women at average risk of breast cancer, ultrasonography in addition to mammography leads to more screening-detected breast cancer cases. For women with dense breasts, cohort studies more in line with real-life clinical practice confirmed this finding, whilst cohort studies for women with non-dense breasts showed no statistically significant difference between the two screening interventions. However, the number of false-positive results and biopsy rates were higher in women receiving additional ultrasonography for breast cancer screening. None of the included studies analysed whether the higher number of screen-detected cancers in the intervention group resulted in a lower mortality rate compared to mammography alone. Randomised controlled trials or prospective cohort studies with a longer observation period are needed to assess the effects of the two screening interventions on morbidity and mortality.

Overview of Artificial Intelligence in Breast Cancer Medical Imaging

The heavy global burden and mortality of breast cancer emphasize the importance of early diagnosis and treatment. Imaging detection is one of the main tools used in clinical practice for screening, diagnosis, and treatment efficacy evaluation, and can visualize changes in tumor size and texture before and after treatment. The overwhelming number of images, which lead to a heavy workload for radiologists and a sluggish reporting period, suggests the need for computer-aid detection techniques and platform. In addition, complex and changeable image features, heterogeneous quality of images, and inconsistent interpretation by different radiologists and medical institutions constitute the primary difficulties in breast cancer screening and imaging diagnosis. The advancement of imaging-based artificial intelligence (AI)-assisted tumor diagnosis is an ideal strategy for improving imaging diagnosis efficient and accuracy. By learning from image data input and constructing algorithm models, AI is able to recognize, segment, and diagnose tumor lesion automatically, showing promising application prospects. Furthermore, the rapid advancement of "omics" promotes a deeper and more comprehensive recognition of the nature of cancer. The fascinating relationship between tumor image and molecular characteristics has attracted attention to the radiomic and radiogenomics, which allow us to perform analysis and detection on the molecular level with no need for invasive operations. In this review, we integrate the current developments in AI-assisted imaging diagnosis and discuss the advances of AI-based breast cancer precise diagnosis from a clinical point of view. Although AI-assisted imaging breast cancer screening and detection is an emerging field and draws much attention, the clinical application of AI in tumor lesion recognition, segmentation, and diagnosis is still limited to research or in limited patients' cohort. Randomized clinical trials based on large and high-quality cohort are lacking. This review aims to describe the progress of the imaging-based AI application in breast cancer screening and diagnosis for clinicians.

The Contribution of a Solid Breast Mass Gray-Scale Histographic Analysis in Ascertaining a Benign-Malignant Differentiation

Objective:

The aim of this study was to determine the efficiency of a fat-lesion histographic analysis (FLHA) to make a benign-malignant differentiation, for patients with a breast mass. In addition, it was important to examine the relationship between FLHA rates and Breast Imaging–Reporting and Data System (BI-RADS) scoring.

Materials and Methods:

This was a retrospective study conducted by examining the breast ultrasonograms (BUS) and histopathologic data of 76 women, having at least one solid breast mass. The patients were grouped according to their histopathologic diagnoses and BUS BI-RADS scores. The recorded digital gray-scale images were transferred to a workstation to quantitatively measure tissue echogenicity. The breast masses and adjacent adipose tissue were evaluated using the ImageJ analysis program, and gray-scale histographic analysis values were generated. The FLHA rate was determined by dividing the fat tissue histographic value by the mass-lesion histographic value. Statistical analysis was performed using this value as well as the patients’ histopathologic data and BUS BI-RADS score.

Results:

A complementary effect was noted using FLHA rates with the BUS BI-RADS criteria, and a statistically significant difference was detected between benign and malignant histopathology groups ( P < .001). Similarly, the malignant histopathologic diagnosis with BI-RADS 4 and benign histopathologic diagnosis with BI-RADS 4 groups were related ( P < .001). The correlation between BI-RADS criteria and FLHA rates demonstrated a significant difference between BI-RADS 3 and BI-RADS 5 ( P < .001), and BI-RADS 4 and BI-RADS 5 for FLHA rates ( P = .002).

Conclusion:

It was determined that using the FLHA rate was a complement to the BUS BI-RADS criteria. In this cohort, there was a statistically significant difference in predicting possible malignancy in all BI-RADS classes.

Experimental optimization of the energy for breast-CT with synchrotron radiation

Breast Computed Tomography (bCT) is a three-dimensional imaging technique that is raising interest among radiologists as a viable alternative to mammographic planar imaging. In X-rays imaging it would be desirable to maximize the capability of discriminating different tissues, described by the Contrast to Noise Ratio (CNR), while minimizing the dose (i.e. the radiological risk). Both dose and CNR are functions of the X-ray energy. This work aims at experimentally investigating the optimal energy that, at fixed dose, maximizes the CNR between glandular and adipose tissues. Acquisitions of both tissue-equivalent phantoms and actual breast specimens have been performed with the bCT system implemented within the Syrma-3D collaboration at the Syrmep beamline of the Elettra synchrotron (Trieste). The experimental data have been also compared with analytical simulations and the results are in agreement. The CNR is maximized at energies around 26–28 keV. These results are in line with the outcomes of a previously presented simulation study which determined an optimal energy of 28 keV for a large set of breast phantoms with different diameters and glandular fractions. Finally, a study on photon starvation has been carried out to investigate how far the dose can be reduced still having suitable images for diagnostics.

Interpretive Performance and Inter-Observer Agreement on Digital Mammography Test Sets

Objective

To evaluate the interpretive performance and inter-observer agreement on digital mammographs among radiologists and to investigate whether radiologist characteristics affect performance and agreement.

Materials and Methods

The test sets consisted of full-field digital mammograms and contained 12 cancer cases among 1000 total cases. Twelve radiologists independently interpreted all mammograms. Performance indicators included the recall rate, cancer detection rate (CDR), positive predictive value (PPV), sensitivity, specificity, false positive rate (FPR), and area under the receiver operating characteristic curve (AUC). Inter-radiologist agreement was measured. The reporting radiologist characteristics included number of years of experience interpreting mammography, fellowship training in breast imaging, and annual volume of mammography interpretation.

Results

The mean and range of interpretive performance were as follows: recall rate, 7.5% (3.3–10.2%); CDR, 10.6 (8.0–12.0 per 1000 examinations); PPV, 15.9% (8.8–33.3%); sensitivity, 88.2% (66.7–100%); specificity, 93.5% (90.6–97.8%); FPR, 6.5% (2.2–9.4%); and AUC, 0.93 (0.82–0.99). Radiologists who annually interpreted more than 3000 screening mammograms tended to exhibit higher CDRs and sensitivities than those who interpreted fewer than 3000 mammograms (p = 0.064). The inter-radiologist agreement showed a percent agreement of 77.2–88.8% and a kappa value of 0.27–0.34. Radiologist characteristics did not affect agreement.

Conclusion

The interpretative performance of the radiologists fulfilled the mammography screening goal of the American College of Radiology, although there was inter-observer variability. Radiologists who interpreted more than 3000 screening mammograms annually tended to perform better than radiologists who did not.

Optimization of the energy for Breast monochromatic absorption X-ray Computed Tomography

The limits of mammography have led to an increasing interest on possible alternatives such as the breast Computed Tomography (bCT). The common goal of all X-ray imaging techniques is to achieve the optimal contrast resolution, measured through the Contrast to Noise Ratio (CNR), while minimizing the radiological risks, quantified by the dose. Both dose and CNR depend on the energy and the intensity of the X-rays employed for the specific imaging technique. Some attempts to determine an optimal energy for bCT have suggested the range 22 keV-34 keV, some others instead suggested the range 50 keV-60 keV depending on the parameters considered in the study. Recent experimental works, based on the use of monochromatic radiation and breast specimens, show that energies around 32 keV give better image quality respect to setups based on higher energies. In this paper we report a systematic study aiming at defining the range of energies that maximizes the CNR at fixed dose in bCT. The study evaluates several compositions and diameters of the breast and includes various reconstruction algorithms as well as different dose levels. The results show that a good compromise between CNR and dose is obtained using energies around 28 keV.

Toward Improving Breast Cancer Imaging: Radiological Assessment of Propagation-Based Phase-Contrast CT Technology

RATIONALE AND OBJECTIVES

This study employs clinical/radiological evaluation in establishing the optimum imaging conditions for breast cancer imaging using the X-ray propagation-based phase-contrast tomography.

MATERIALS AND METHODS

Two series of experiments were conducted and in total 161 synchrotron-based computed tomography (CT) reconstructions of one breast mastectomy specimen were produced at different imaging conditions. Imaging factors include sample-to-detector distance, X-ray energy, CT reconstruction method, phase retrieval algorithm applied to the CT projection images and maximum intensity projection. Observers including breast radiologists and medical imaging experts compared the quality of the reconstructed images with reference images approximating the conventional (absorption) CT. Various radiological image quality attributes in a visual grading analysis design were used for the radiological assessments.

RESULTS

The results show that the application of the longest achievable sample-to-detector distance (9.31 m), the lowest employed X-ray energy (32 keV), the full phase retrieval, and the maximum intensity projection can significantly improve the radiological quality of the image. Several combinations of imaging variables resulted in images with very high-quality scores.

CONCLUSION

The results of the present study will support future experimental and clinical attempts to further optimize this innovative approach to breast cancer imaging.

Cost-effectiveness of breast cancer screening programme for women in rural China

In low and middle-income countries mammographic breast cancer screening is prohibitively expensive and a cheaper alternative option is to use ultrasound as the primary screening test. In 2009, China launched a breast cancer screening programme for rural women aged 35-64 years with clinical breast examination coupled with ultrasound as the primary tool. Our study aimed to analyse the cost-effectiveness of breast screening compared to no screening among Chinese rural women. We developed a Markov model to estimate the lifetime costs and effects for rural women aged 35 years from a societal perspective. Asymptomatic women in the intervention arm were screened every 3 years before age 64 years. Breast cancer in the non-screening arm can only be diagnosed on presentation of symptoms. Parameter uncertainty was explored using one-way and probabilistic sensitivity analyses. Compared to no screening, breast cancer screening cost $186.7 more and led to a loss of 0.20 quality-adjusted life years (QALYs). Breast screening was more expensive and did harm to health among rural women with an incremental cost-effectiveness ratio (ICER) of $-916/QALY. The sensitivity analysis identified utility loss from false positives as the factor that most influenced the results, but this did not affect the conclusions. In a rural setting with such low breast cancer incidence, screening for asymptomatic disease is not cost-effective with current screening tools. Priority should be given to ensure that symptomatic women have proper access to diagnosis and treatment at an early stage as this will lead to mortality reductions without the usual screening harms.

Cost-effectiveness of risk-based breast cancer screening programme, China

OBJECTIVE

To model the cost-effectiveness of a risk-based breast cancer screening programme in urban China, launched in 2012, compared with no screening.

METHODS

We developed a Markov model to estimate the lifetime costs and effects, in terms of quality-adjusted life years (QALYs), of a breast cancer screening programme for high-risk women aged 40-69 years. We derived or adopted age-specific incidence and transition probability data, assuming a natural history progression between the stages of cancer, from other studies. We obtained lifetime direct and indirect treatment costs in 2014 United States dollars (US$) from surveys of breast cancer patients in 37 Chinese hospitals. To calculate QALYs, we derived utility scores from cross-sectional patient surveys. We evaluated incremental cost-effectiveness ratios for various scenarios for comparison with a willingness-to-pay threshold.

FINDINGS

Our baseline model of annual screening yielded an incremental cost-effectiveness ratio of US$ 8253/QALY, lower than the willingness-to-pay threshold of US$ 23 050/QALY. One-way and probabilistic sensitivity analyses demonstrated that the results are robust. In the exploration of various scenarios, screening every 3 years is the most cost-effective with an incremental cost-effectiveness ratio of US$ 6671/QALY. The cost-effectiveness of the screening is reduced if not all diagnosed women seek treatment. Finally, the economic benefit of screening women aged 45-69 years with both ultrasound and mammography, compared with mammography alone, is uncertain.

CONCLUSION

High-risk population-based breast cancer screening is cost-effective compared with no screening.

Differentiating vacuum-assisted breast biopsy from core needle biopsy: Is it necessary?

Needle biopsy has replaced excisional biopsy as a definitive diagnostic technique for breast tumours, although excisional biopsy is still used for complete tumour removal for therapeutic and/or diagnostic purposes. Many vacuum-assisted breast biopsy (VAB) systems have been made available by several manufacturers since the release of the Mammotome (MMT) by Johnson & Johnson in 1995. Several recent discussions have been conducted to identify whether core needle biopsy (CNB) or VAB, is more appropriate. However, currently available VAB systems differ from the conventional system (i.e. articulate arm type 11-gauge(G) MMT), and the characteristics of both CNB and VAB have been improved. In CNB, a 14-G needle is frequently used to obtain a larger sample. By contrast, VAB is considered easier to perform because it uses a thinner needle and a lighter, non-tethered system. When differentiating CNB from VAB, the type of VAB should also be defined. In this review, we discuss the characteristics of ultrasonography-guided VAB and CNB with a focus on practical issues such as the number of samples and volume of tissue obtained during ultrasonography-guided needle biopsy.

Inter-rater reliability and double reading analysis of an automated three-dimensional breast ultrasound system: comparison of two independent examiners

PURPOSE

Breast ultrasound could be a valuable tool complementary to mammography in breast cancer screening. Automated 3D breast ultrasound (ABUS) addresses challenges of hand-held ultrasound and could allow double reading analysis of ultrasound images. This trial assesses the inter-rater reliability and double reading analysis of an ABUS system.

METHODS

To assess the reproducibility and diagnostic validity of the ABUS system, SomoV™, a blinded double reading analysis, was performed in 1019 patients (2038 breasts) by two examiners (examiner A/B) and compared to single reading results, as well as to the reference standard regarding its diagnostic validity. Cohen's kappa coefficients were calculated to measure the inter-rater reliability and agreement of the different diagnostic modalities. Patient comfort and time consumption for image acquisition and reading were analyzed descriptively as secondary objectives.

RESULTS

Analysis of inter-rater reliability yielded agreement in 81.6% (κ = 0.37; p < 0.0001) showing fair agreement. Single reading analysis of SomoV™ exams (examiner A/examiner B) compared to reference standard showed good specificity (examiner A: 88.3%/examiner B: 84.5%), fair inter-rater agreement (examiner A: κ = 0.31/examiner B: κ = 0.31), and adequate sensitivity (examiner A: 53.1%/examiner B: 64.2%). Double reading analysis yielded good sensitivity and specificity (73.7 and 77.7%). Mammography (n = 1911) alone detected 160 of 176 carcinomas (sensitivity 90.1%). Adding SomoV™ to mammography would have detected 12 additional carcinomas, resulting in a higher sensitivity of 97.7%.

CONCLUSION

SomoV™ is a promising technique with good sensitivity, high patient comfort, and fair inter-examiner reliability. It allows double reading analysis that, in combination with mammography, could increase detection rates in breast cancer screening.

Willingness of Patients with Breast Cancer in the Adjuvant and Metastatic Setting to Use Electronic Surveys (ePRO) Depends on Sociodemographic Factors, Health-related Quality of Life, Disease Status and Computer Skills

Introduction: Because of the often unfavorable prognosis, particularly for patients with metastases, health-related quality of life is extremely important for breast cancer patients. In recent years, data on patient-relevant endpoints is being increasingly collected electronically; however, knowledge on the acceptance and practicability of, and barriers to, this form of data collection remains limited. Material and Methods: A questionnaire was completed by 96 patients to determine to what extent existing computer skills, disease status, health-related quality of life and sociodemographic factors affect patients' potential willingness to use electronics methods of data collection (ePRO). Results: 52 of 96 (55 %) patients reported a priori that they could envisage using ePRO. Patients who a priori preferred a paper-based survey (pPRO) tended to be older (ePRO 53 years vs. pPRO 62 years; p = 0.0014) and typically had lower levels of education (p = 0.0002), were in poorer health (p = 0.0327) and had fewer computer skills (p = 0.0003). Conclusion: Barriers to the prospective use of ePRO were identified in older patients and patients with a lower quality of life. Given the appropriate conditions with regard to age, education and current health status, opportunities to participate should be provided to encourage patients' willingness to take part and ensure the validity of survey results. Focusing on ease of use of ePRO applications and making applications more patient-oriented and straightforward appears to be the way forward.

Vacuum-assisted breast biopsy with 7-gauge, 8-gauge, 9-gauge, 10-gauge, and 11-gauge needles: how many specimens are necessary?

BACKGROUND

Published national and international guidelines and consensus meetings on the use of vacuum-assisted biopsy (VAB) give different recommendations regarding the required numbers of tissue specimens depending on needle size and imaging method.

PURPOSE

To evaluate the weights of specimens obtained with different VAB needles to facilitate the translation of the required number of specimens between different breast biopsy systems and needle sizes, respectively.

MATERIAL AND METHODS

Five different VAB systems and seven different needle sizes were used: Mammotome® (11-gauge (G), 8-G), Vacora® (10-G), ATEC Sapphire™ (9-G), 8-G Mammotome® Revolve™, and EnCor Enspire® (10-G, 7-G). We took 24 (11-G) or 20 (7-10-G) tissue cores from a turkey breast phantom. The mean weight of a single tissue core was calculated for each needle size. A matrix, which allows the translation of the required number of tissue cores for different needle sizes, was generated. Results were compared to the true cumulative tissue weights of consecutively harvested tissue cores.

RESULTS

The mean tissue weights obtained with the 11-G / 10-G Vacora® / 10-G Enspire® / 9-G / 8-G Original / 8-G Revolve™ / 7-G needles were 0.084 g / 0.142 g / 0.221 g / 0.121 g / 0.192 g / 0.334 g / 0.363 g, respectively. The calculated required numbers of VAB tissue cores for each needle size build the matrix. For example, the minimum calculated number of required cores according to the current German S3 guideline is 20 / 12 / 8 / 14 / 9 / 5 / 5 for needles of 11-G / 10-G Vacora® / 10-G Enspire® / 9-G / 8-G Original / 8-G Revolve™ / 7-G size. These numbers agree with the true cumulative tissue weights.

CONCLUSION

The presented matrix facilitates the translation of the required number of VAB specimens between different needle sizes and thereby eases the implementation of current guidelines and consensus recommendations into clinical practice.

Magnetic resonance imaging: the evolution of breast imaging

INTRODUCTION AND AIMS

To provide an overview of the principle of current breast MRI, the available evidence concerning its indications and optimum use and future potentials.

METHODS AND RESULTS

To date sensitivities of 90-91% have been achieved with a specificity of 72-75%. MRI is the most sensitive method for detecting invasive carcinoma and comparable to mammography concerning detection of DCIS. The achievable specificity, false positive and biopsy rates, however, are much lower than for screening mammography thus do not allow its use for screening of the general population. Indications with proven advantages concern screening of women at high risk and special diagnostic problems that cannot be solved by conventional imaging and percutaneous biopsy: search for primary tumour in CUP syndrome, differentiation of nipple retraction, differentiation of scarring versus recurrence and selected difficult cases. There is no proven benefit for its general use for preoperative staging. One major problem may concern the imperfect interface between imaging and surgery. Further research is also needed for the use of MRI in women at intermediate risk. In women at low risk MRI screening is not recommended. Novel possibilities of MRI concern diffusion weighted imaging as well as MR spectroscopy. Their value for improved lesion differentiation is not yet fully established. Their main potential appears to concern an improved and earlier prediction of response to neoadjuvant therapy. Future developments might address development of more specific contrast agents, replacement of vascular enhancing agents by special MR techniques, testing of sodium MRI or image fusion with other imaging modalities.

DISCUSSION/CONCLUSION

MRI allows new patho-physiological information and thus can complement the information available by conventional methods. Present research should concentrate on improving specificity, improving the interface of imaging and surgery and has to include outcome analyses. Due to issues of specificity the responsible use of MRI should be limited to appropriate indications.

Mammography in combination with breast ultrasonography versus mammography for breast cancer screening in women at average risk

BACKGROUND

Breast cancer is the most common malignant disease diagnosed in women worldwide. Screening with mammography has the ability to detect breast cancer at an early stage. The diagnostic accuracy of mammography screening largely depends on the radiographic density of the imaged breasts. In radiographically dense breasts, non-calcified breast cancers are more likely to be missed than in fatty breasts. As a consequence, some cancers are not detected by mammography screening. Supporters of adjunct ultrasonography to the screening regimen for breast cancer argue that it might be a safe and inexpensive approach to reduce the false negative rates of the screening process. Critics, however, are concerned that performing supplemental ultrasonography on women at average risk will also increase the rate of false positive findings and can lead to unnecessary biopsies and treatments.

OBJECTIVES

To assess the comparative effectiveness and safety of mammography in combination with breast ultrasonography versus mammography for breast cancer screening for women at average risk of breast cancer.

SEARCH METHODS

We searched the Cochrane Breast Cancer Group's Specialised Register, MEDLINE (via OvidSP) and EMBASE up until February 2012.To detect ongoing or unpublished studies, we searched the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov and the National Cancer Institute's clinical trial database until June 2012. In addition, we conducted grey literature searches using the following sources: OpenGrey; National Institute of Health RePORTER; Health Services Research Projects in Progress (HSRPROJ); Hayes, Inc. Health Technology Assessment; The New York Academy of Medicine's Grey Literature Index and Conference Papers Index.

SELECTION CRITERIA

For efficacy, we considered randomised controlled trials (RCTs), with either individual or cluster randomisation, and prospective, controlled non-randomised studies with a low risk of bias and a sample size of at least 500 participants.In addition to studies eligible for efficacy, we considered any controlled, non-randomised study with a low risk of bias and a study size of at least 500 participants for the assessment of harms.Our population of interest were women between the ages of 40 and 75 years who were at average risk for breast cancer.

DATA COLLECTION AND ANALYSIS

Two review authors screened abstracts and full-text publications against the inclusion criteria. None of the studies met our inclusion criteria.

MAIN RESULTS

Our review did not detect any controlled studies on the use of adjunct ultrasonography for screening in women at average risk for breast cancer. One ongoing randomised controlled trial was identified (J-START, Japan).

AUTHORS' CONCLUSIONS

Presently, there is no methodologically sound evidence available justifying the routine use of ultrasonography as an adjunct screening tool in women at average risk for breast cancer.

Digital mammography screening: how many breast cancers are additionally detected by bilateral ultrasound examination during assessment?

OBJECTIVE

To assess the positive predictive values of incremental breast cancer detection (PPV1) in relation to the mammographic breast density and of performed biopsies (PPV3) resulting from supplemental bilateral physician-performed whole-breast ultrasound (US) at recall of a population-based digital mammography screening programme.

METHODS

A total of 2,803 recalled screening participants (50-69 years), who had additional bilateral US with prospectively completed documentation [grading of breast density (ACR 1-4), biopsy recommendation related to US and mammography], were included.

RESULTS

The PPV1 of supplemental cancer detection only by US was 0.21 % (6/2,803) compared to 13.8 % (386/2,803) by mammography. The PPV1 of US-only cancer detection was 0 %, 0.16 % (2/1,220), 0.22 % (3/1,374) and 1.06 % (1/94) for women with breast density of ACR 1, ACR 2, ACR 3 and ACR 4, respectively. The PPV3 of US-only lesion detection was 33.3 % (9/27) compared to 38.0 % (405/1,066) by mammography. The proportion of invasive cancers no larger than 10 mm was 37.5 % (3/8) for US-only detection compared to 38.4 % (113/294) for mammographic detection.

CONCLUSION

Bilateral ultrasound at recall, in addition to the assessment of screen-detected mammographic abnormalities, resulted in a low PPV of incremental cancer detection only by US, without a disproportional increase of false-positive biopsies.

High-resolution breast tomography at high energy: a feasibility study of phase contrast imaging on a whole breast

Previous studies on phase contrast imaging (PCI) mammography have demonstrated an enhancement of breast morphology and cancerous tissue visualization compared to conventional imaging. We show here the first results of the PCI analyser-based imaging (ABI) in computed tomography (CT) mode on whole and large (>12 cm) tumour-bearing breast tissues. We demonstrate in this work the capability of the technique of working at high x-ray energies and producing high-contrast images of large and complex specimens. One entire breast of an 80-year-old woman with invasive ductal cancer was imaged using ABI-CT with monochromatic 70 keV x-rays and an area detector of 92×92 µm² pixel size. Sagittal slices were reconstructed from the acquired data, and compared to corresponding histological sections. Comparison with conventional absorption-based CT was also performed. Five blinded radiologists quantitatively evaluated the visual aspects of the ABI-CT images with respect to sharpness, soft tissue contrast, tissue boundaries and the discrimination of different structures/tissues. ABI-CT excellently depicted the entire 3D architecture of the breast volume by providing high-resolution and high-contrast images of the normal and cancerous breast tissues. These results are an important step in the evolution of PCI-CT towards its clinical implementation.

Genetic testing for familial/hereditary breast cancer-comparison of guidelines and recommendations from the UK, France, the Netherlands and Germany

In this review, the national guidelines and recommendations for genetic testing for familial/hereditary breast cancer from the UK, France, the Netherlands and Germany were evaluated as to the inclusion criteria for genetic testing. In all four countries, access to genetic testing relies basically on the family history of breast and ovarian cancer. Similarities are obvious for most selection criteria. All four guidelines recommend embedding genetic testing within a framework of genetic counselling, and all agree to perform genetic testing first in an affected person. However, there are differences regarding the thresholds based on certain familial constellations, detailed description of selection criteria, the degree of relatedness between affected individuals and the counsellee, the age of diagnosis, the individual history of early onset breast cancer, bilateral breast cancer, the tumour morphology or the access to intensified surveillance. These differences and open questions not covered by the guidelines, e.g. on how to deal with phenocopies, unclassified variants, genetic variants in newly identified breast cancer susceptibility genes or with family constellations not fitting the criteria, are discussed. New evidence is usually slowly integrated into the guidelines. An exchange process towards the harmonization of the guidelines will ensure high quality health care across Europe.

Adopting Guidelines into Clinical Practice: Implementation of Trastuzumab in the Adjuvant Treatment of Breast Cancer in Lower Saxony, Germany, in 2007

SUMMARY: BACKGROUND: Few studies have assessed the quality of medical care in breast cancer patients outside clinical studies and certified centres in German-speaking countries. We used ONkeyLINE, a voluntary tumour registry, to evaluate the rate of adoption into clinical practice of guidelines on the adjuvant use of trastuzumab and to estimate the reliability of ONkeyLINE in assessing quality of care. MATERIAL AND METHODS: Data from ONkeyLINE were analysed to answer questions on the quality of breast cancer care in daily practice in 2007. The influence of age and area (rural/urban) on treatment patterns was also evaluated. RESULTS: Data from approximately 85% of patients diagnosed with breast cancer in Lower Saxony in 2007 were documented in ONkeyLINE. Within 1 year, more than 77% of patients received adjuvant trastuzumab according to the updated guidelines. Variations in chemotherapy and trastuzumab according to age were evident, in part but not fully attributable to comorbidities in the elderly. Access to trastuzumab therapy in rural areas was as high as in urban areas. CONCLUSIONS: Adoption of national guidelines into clinical practice was observed at a reasonable but still unsatisfactory rate in Lower Saxony. Although voluntary, ONkeyLINE covered most breast cancer cases and proved to be a reliable tool for assessing quality of care.

B3 Lesions: Radiological Assessment and Multi-Disciplinary Aspects

B3 lesions comprise different histopathological entities that are considered benign but 'of unknown biological potential'. These entities may act as risk indicators (for both breasts) or as non-obligatory precursors of malignancy. Being diagnosed at percutaneous breast biopsy, an additional risk of underestimate exists. Imaging appearances, histopathological appearance and risk of associated malignancy are presented. B3 lesions of high risk, which thus should usually be excised, include atypical ductal hyperplasia (ADH), pleomorphic or necrotic type of lobular neoplasia (LIN 3), and papillary lesions with atypias. Intermediate risk may be associated with classic lobular carcinoma in situ (LIN 2) or flat epithelial atypia (FEA), and low risk with radial sclerosing lesions (RSLs) and papillary lesions without atypias. LIN 1 is mostly an incidental finding acting as risk indicator. Follow-up is adequate if the initial diagnostic problem is solved. According to international guidelines, risk and subsequent recommendations should be discussed for each individual patient, taking into account biological risk, representative sampling, lesion size, lesion extent, percentage of lesion removal, other individual risks, and the possibility of surveillance. With vacuum-assisted breast biopsy (VABB), surgery may be avoided for more of the small lesions at low risk. Further data collection and diligent evaluation may help to better assess the individual risk, to better adapt treatment recommendations and avoid overtreatment.

Magnetic resonance imaging of the breast: recommendations from the EUSOMA working group

The use of breast magnetic resonance imaging (MRI) is rapidly increasing. EUSOMA organised a workshop in Milan on 20-21st October 2008 to evaluate the evidence currently available on clinical value and indications for breast MRI. Twenty-three experts from the disciplines involved in breast disease management - including epidemiologists, geneticists, oncologists, radiologists, radiation oncologists, and surgeons - discussed the evidence for the use of this technology in plenary and focused sessions. This paper presents the consensus reached by this working group. General recommendations, technical requirements, methodology, and interpretation were firstly considered. For the following ten indications, an overview of the evidence, a list of recommendations, and a number of research issues were defined: staging before treatment planning; screening of high-risk women; evaluation of response to neoadjuvant chemotherapy; patients with breast augmentation or reconstruction; occult primary breast cancer; breast cancer recurrence; nipple discharge; characterisation of equivocal findings at conventional imaging; inflammatory breast cancer; and male breast. The working group strongly suggests that all breast cancer specialists cooperate for an optimal clinical use of this emerging technology and for future research, focusing on patient outcome as primary end-point.

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.

Breast Centers in Germany

A decrease in medical practice variations in national breast cancer care has been shown to improve survival and the negative impact of the disease on affected women and their families. The following report describes the concert of efforts undertaken by the medical societies to optimize national breast cancer care by organizational centralization of multidisciplinary medical competence in certified breast centers (CBC), aiming to attain continual quality of health care by implementation of evidence-and consensus-based guidelines. Centralization and the systematic pursuit of organizational development by tracking guideline adherence using performance quality indicators over time demonstrate the feasibility and practicability of the implementation concept to bridge the gap between determined scientific best evidence and applied best practice. However, the proof of concept will remain pending until the data of the population-based cancer registries are analyzed for survival estimates.