Mammographic breast glandularity in Malaysian women: data derived from radiography

A survey on mean glandular dose in mammography examination and the factors affecting it in Shahid Sadoughi Hospital, Yazd, Iran

BACKGROUND

mammography is the gold standard in the early detection of breast cancer. Due to the increase in the rate of women suffering from this malignancy all over the world, this imaging modality has been widely used. Considering the side effects caused by ionizing radiation to measure the carcinogenic risk of mammography X-rays, mean glandular dose (MGD) is the best parameter to evaluate the dose received by patients undergoing mammography. The aims of this study were to measure MGD in mammography in mammographic craniocaudal (CC) and mediolateral oblique (MLO) projections and investigate the relationship of MGD with compressed breast thickness (CBT), body mass index, age of the patient, and device exposure conditions.

MATERIALS AND METHODS

this cross-sectional analytical study was conducted on women aged 30-70 referring to the mammography unit of Shahid Sadoughi Hospital in Yazd city from May to August 2022. The TLD-GR 200 (thermoluminescence dosimeter) was placed on the breast of the patients for CC and MLO projections, and then the MGD was obtained by multiplying the entrance surface dose and the normalized glandular dose. Analysis of data (such as demographic information of patients, CBT, kVp, and mAs) was done by SPSS 23 software. The normality of the data was checked using Shapiro-Wilk tests. It was found that except for age, other variables did not have a normal distribution; therefore, equivalent parametric and nonparametric tests were used. In this regard, Spearman's correlation was used to assess the correlation between variables. P-value < .05 was considered as level of significance.

RESULTS

The mean ± standard deviation (SD) age of patients was 47.3 ± 7.1 years. The median ± IQR (the interquartile range (IQR) is a measure of statistical dispersion, which is the spread of the data. It is defined as the difference between the 75th and 25th percentiles of the data.) (mean ± SD) value of MGD per woman was 1.2 ± 0.4 mGy (1.3 ± 0.3 mGy). The median ± IQR MGD in the MLO and CC projections was 1.6 ± 0.6 mGy and 0.9 ± 0.4 mGy, respectively. Significant relationships (P-value ≤ .001) were observed between MGD with CBT (R = 0.62) and age (R = -0.85).

CONCLUSION

The results showed that the mammography unit at Shahid Sadoughi Hospital in Yazd is functioning properly. The calculated median ± IQR MGD per woman referring to this unit (1.2 ± 0.4 mGy) was clearly below the dose limit recommended by American College of Radiology and International Commission on Radiological Protection (3 mGy). Moreover, among the factors affecting MGD, the highest correlation was seen between MGD and age (R = -0.85).

Breast size in lactating women and the content of macronutrients in human milk

INTRODUCTION

Although the primary function of a woman's breast is milk synthesis, only a few studies have evaluated the relationship between breast size and human milk composition, showing equivocal results. This study aims to test if breast size during fully established lactation is related to energy density and content of macronutrients in human milk.

MATERIALS AND METHODS

Mothers of healthy, born-on-term infants at stage III of lactogenesis (N = 137) provided breast milk samples. Milk composition was analyzed using midinfrared transmission spectroscopy. The breast size index was calculated by dividing the breast by the circumference below the breast.

RESULTS

Stepwise forward linear regression showed a negative association between breast size index and lactose concentration in breast milk (β = -.242, p = .003). The final model, which includes breast size index, feeding frequency, and maternal energy intake together explained around 13% of the variance in breast milk lactose content (R2 adj = .126, p < .001). No statistically significant relationship was found between breast size index and milk's energy density, protein, and fat content.

CONCLUSION

This is the first study that shows a negative relationship between breast size during fully established lactation and lactose concentration in milk in a large sample size. No relationship between other macronutrients and breast size indicates that large breast size is not necessary for adequate milk production; however, it may contribute to an altered lactose concentration.

Using Breast Tissue Information and Subject-Specific Finite-Element Models to Optimize Breast Compression Parameters for Digital Mammography

Digital mammography has become a first-line diagnostic tool for clinical breast cancer screening due to its high sensitivity and specificity. Mammographic compression force is closely associated with image quality and patient comfort. Therefore, optimizing breast compression parameters is essential. Subjects were recruited for digital mammography and breast magnetic resonance imaging (MRI) within a month. Breast MRI images were used to calculate breast volume and volumetric breast density (VBD) and construct finite element models. Finite element analysis was performed to simulate breast compression. Simulated compressed breast thickness (CBT) was compared with clinical CBT and the relationships between compression force, CBT, breast volume, and VBD were established. Simulated CBT had a good linear correlation with the clinical CBT (R2 = 0.9433) at the clinical compression force. At 10, 12, 14, and 16 daN, the mean simulated CBT of the breast models was 5.67, 5.13, 4.66, and 4.26 cm, respectively. Simulated CBT was positively correlated with breast volume (r > 0.868) and negatively correlated with VBD (r < –0.338). The results of this study provides a subject-specific and evidence-based suggestion of mammographic compression force for radiographers considering image quality and patient comfort.

The Mammary Gland: Basic Structure and Molecular Signaling during Development

The mammary gland is a compound, branched tubuloalveolar structure and a major characteristic of mammals. The mammary gland has evolved from epidermal apocrine glands, the skin glands as an accessory reproductive organ to support postnatal survival of offspring by producing milk as a source of nutrition. The mammary gland development begins during embryogenesis as a rudimentary structure that grows into an elementary branched ductal tree and is embedded in one end of a larger mammary fat pad at birth. At the onset of ovarian function at puberty, the rudimentary ductal system undergoes dramatic morphogenetic change with ductal elongation and branching. During pregnancy, the alveolar differentiation and tertiary branching are completed, and during lactation, the mature milk-producing glands eventually develop. The early stages of mammary development are hormonal independent, whereas during puberty and pregnancy, mammary gland development is hormonal dependent. We highlight the current understanding of molecular regulators involved during different stages of mammary gland development.

Methods Used in Computer-Aided Diagnosis for Breast Cancer Detection Using Mammograms: A Review

According to the American Cancer Society's forecasts for 2019, there will be about 268,600 new cases in the United States with invasive breast cancer in women, about 62,930 new noninvasive cases, and about 41,760 death cases from breast cancer. As a result, there is a high demand for breast imaging specialists as indicated in a recent report for the Institute of Medicine and National Research Council. One way to meet this demand is through developing Computer-Aided Diagnosis (CAD) systems for breast cancer detection and diagnosis using mammograms. This study aims to review recent advancements and developments in CAD systems for breast cancer detection and diagnosis using mammograms and to give an overview of the methods used in its steps starting from preprocessing and enhancement step and ending in classification step. The current level of performance for the CAD systems is encouraging but not enough to make CAD systems standalone detection and diagnose clinical systems. Unless the performance of CAD systems enhanced dramatically from its current level by enhancing the existing methods, exploiting new promising methods in pattern recognition like data augmentation in deep learning and exploiting the advances in computational power of computers, CAD systems will continue to be a second opinion clinical procedure.

Comparison of a personalized breast dosimetry method with standard dosimetry protocols

Average glandular dose (AGD) in digital mammography crucially depends on the estimation of breast glandularity. In this study we compared three different methods of estimating glandularities according to Wu, Dance and Volpara with respect to resulting AGDs. Exposure data from 3050 patient images, acquired with a GE Senographe Essential constituted the study population of this work. We compared AGD (1) according to Dance et al. applying custom g, c, and s factors using HVL, breast thickness, patient age and incident air kerma (IAK) from the DICOM headers; (2) according to Wu et al. as determined by the GE system; and (3) AGD derived with the Dance model with personalized c factors using glandularity determined with the Volpara (Volpara Solutions, Wellington, New Zealand) software (Volpare AGD). The ratios of the resulting AGDs were analysed versus parameters influencing dose. The highest deviation between the resulting AGDs was found in the ratio of GE AGD to Volpara AGD for breast thicknesses between 20 and 40 mm (ratio: 0.80). For thicker breasts this ratio is close to one (1 ± 0.02 for breast thicknesses >60 mm). The Dance to Volpara ratio was between 0.86 (breast thickness 20–40 mm) and 0.99 (>80 mm), and Dance/GE AGD was between 1.07 (breast thickness 20–40 mm) and 0.98 (41–60, and >80 mm). Glandularities by Volpara were generally smaller than the one calculated with the Dance method. This effect is most pronounced for small breast thickness and older ages. Taking the considerable divergences between the AGDs from different methods into account, the selection of the method should by done carefully. As the Volpara method provides an analysis of the individual breast tissue, while the Wu and the Dance methods use look up tables and custom parameter sets, the Volpara method might be more appropriate if individual ADG values are sought. For regulatory purposes and comparison with diagnostic reference values, the method to be used needs to be defined exactly and clearly be stated. However, it should be accepted that dose values calculated with standardized models, like AGD and also effective dose, are afflicted with a considerable uncertainty budgets that need to be accounted for in the interpretation of these values.

A novel method of determining breast cancer risk using parenchymal textural analysis of mammography images on an Asian cohort

Historically, breast cancer risk prediction models are based on mammographic density measures, which are dichotomous in nature and generally categorize each voxel or area of the breast parenchyma as 'dense' or 'not dense'. Using these conventional methods, the structural patterns or textural components of the breast tissue elements are not considered or ignored entirely. This study presents a novel method to predict breast cancer risk that combines new texture and mammographic density based image features. We performed a comprehensive study of the correlation of 944 new and conventional texture and mammographic density features with breast cancer risk on a cohort of Asian women. We studied 250 breast cancer cases and 250 controls matched at full-field digital mammography (FFDM) status for age, BMI and ethnicity. Stepwise regression analysis identified relevant features to be included in a linear discriminant analysis (LDA) classifier model, trained and tested using a leave-one-out based cross-validation method. The area under the receiver operating characteristic (AUC) and adjusted odds ratios (ORs) were used as the two performance assessment indices in our study. For the LDA trained classifier, the adjusted OR was 6.15 (95% confidence interval: 3.55-10.64) and for Volpara volumetric breast density, 1.10 (0.67-1.81). The AUC for the LDA trained classifier was 0.68 (0.64-0.73), compared to 0.52 (0.47-0.57) for Volpara volumetric breast density (p   <  0.001). The regression analysis of OR values for the LDA classifier also showed a significant increase in slope (p   <  0.02). Mammographic texture features derived from digital mammograms are important quantitative measures for breast cancer risk assessment based models. Parenchymal texture analysis has an important role for stratifying breast cancer risk in women, which can be implemented to routine breast cancer screening strategies.

A new mammography dosimetric phantom

Breast phantoms produced with tissue-equivalent materials are used in an attempt to simulate glandular and adipose tissues, in terms of X-ray attenuation and density. In this work, a set of breast tissue-equivalent phantoms (BTE phantoms) with semicircular shapes of different thicknesses and compositions were produced. Such phantoms may be used in the measurement of the incident air kerma (K(i)) and the mean glandular dose (D(G)) delivered to patients undergoing mammography. To characterise the materials used to produce the phantoms, a series of 17-keV X-ray attenuation coefficient measurements were performed. The carbon-nitrogen-hydrogen elemental composition and the densities of the tissue-equivalent materials were also determined and compared with values available in the literature. Linear attenuation coefficients of 0.724 and 0.923 cm(-1) were determined, respectively, for adipose and glandular tissues. Such values agree with data available in the literature. On the basis of the results obtained in this work, it is suggested that BTE phantoms are used instead of polymethyl methacrylate phantoms to select exposure parameters (kV, mAs and target/filter combination) specific for breast glandularities from 0 to 50 % in the optimisation of doses in mammography.

Determination of equivalent breast phantoms for different age groups of Taiwanese women: an experimental approach

PURPOSE

Polymethylmethacrylate (PMMA) slab is one of the mostly used phantoms for studying breast dosimetry in mammography. The purpose of this study was to evaluate the equivalence between exposure factors acquired from PMMA slabs and patient cases of different age groups of Taiwanese women in mammography.

METHODS

This study included 3910 craniocaudal screen/film mammograms on Taiwanese women acquired on one mammographic unit. The tube loading, compressed breast thickness (CBT), compression force, tube voltage, and target/filter combination for each mammogram were collected for all patients. The glandularity and the equivalent thickness of PMMA were determined for each breast using the exposure factors of the breast in combination with experimental measurements from breast-tissue-equivalent attenuation slabs. Equivalent thicknesses of PMMA to the breasts of Taiwanese women were then estimated.

RESULTS

The average +/- standard deviation CBT and breast glandularity in this study were 4.2 +/- 1.0 cm and 54% +/- 23%, respectively. The average equivalent PMMA thickness was 4.0 +/- 0.7 cm. PMMA slabs producing equivalent exposure factors as in the breasts of Taiwanese women were determined for the age groups 30-49 yr and 50-69 yr. For the 4-cm PMMA slab, the CBT and glandularity values of the equivalent breast were 4.1 cm and 65%, respectively, for the age group 30-49 yr and 4.4 cm and 44%, respectively, for the age group 50-69 yr.

CONCLUSIONS

The average thickness of PMMA slabs producing the same exposure factors as observed in a large group of Taiwanese women is less than that reported for American women. The results from this study can provide useful information for determining a suitable thickness of PMMA for mammographic dose survey in Taiwan. The equivalence of PMMA slabs and the breasts of Taiwanese women is provided to allow average glandular dose assessment in clinical practice.

A Monte Carlo study of lung counting efficiency for female workers of different breast sizes using deformable phantoms

There are currently no physical phantoms available for calibrating in vivo counting devices that represent women with different breast sizes because such phantoms are difficult, time consuming and expensive to fabricate. In this work, a feasible alternative involving computational phantoms was explored. A series of new female voxel phantoms with different breast sizes were developed and ported into a Monte Carlo radiation transport code for performing virtual lung counting efficiency calibrations. The phantoms are based on the RPI adult female phantom, a boundary representation (BREP) model. They were created with novel deformation techniques and then voxelized for the Monte Carlo simulations. Eight models have been selected with cup sizes ranging from AA to G according to brassiere industry standards. Monte Carlo simulations of a lung counting system were performed with these phantoms to study the effect of breast size on lung counting efficiencies, which are needed to determine the activity of a radionuclide deposited in the lung and hence to estimate the resulting dose to the worker. Contamination scenarios involving three different radionuclides, namely Am-241, Cs-137 and Co-60, were considered. The results show that detector efficiencies considerably decrease with increasing breast size, especially for low energy photon emitting radionuclides. When the counting efficiencies of models with cup size AA were compared to those with cup size G, a difference of up to 50% was observed. The detector efficiencies for each radionuclide can be approximated by curve fitting in the total breast mass (polynomial of second order) or the cup size (power).

Inside the lactating breast: the latest anatomy research

Although it is well recognized that a thorough understanding of the anatomy of an organ is essential to enable assessment of any abnormalities in that organ, there has been little investigation of the anatomy of the normal lactating breast since Sir Astley Cooper performed detailed dissections of the anatomy of the breast more than 160 years ago. Many mothers recognize that breast milk provides the ultimate nutrition and protection for the infant; however, a significant proportion of women experience difficulties breastfeeding, some of which lead to weaning the infant. Recently, a small number of studies have focused on the gross anatomy of the breast, and have found that the ductal system is comprised of fewer numbers of main ducts than previously thought. In addition, the ducts are compressible and do not contain large amounts of milk, the amount of fatty tissue in the breast is variable, and a proportion is situated within the glandular tissue. These findings add to our understanding of both the physiology and pathology of the lactating breast.

Quantitative assessment of breast density from digitized mammograms into Tabar's patterns

We describe a semi-automated technique for the quantitative assessment of breast density from digitized mammograms in comparison with patterns suggested by Tabar. It was developed using the MATLAB-based graphical user interface applications. It is based on an interactive thresholding method, after a short automated method that shows the fibroglandular tissue area, breast area and breast density each time new thresholds are placed on the image. The breast density is taken as a percentage of the fibroglandular tissue to the breast tissue areas. It was tested in four different ways, namely by examining: (i) correlation of the quantitative assessment results with subjective classification, (ii) classification performance using the quantitative assessment technique, (iii) interobserver agreement and (iv) intraobserver agreement. The results of the quantitative assessment correlated well (r2 = 0.92) with the subjective Tabar patterns classified by the radiologist (correctly classified 83% of digitized mammograms). The average kappa coefficient for the agreement between the readers was 0.63. This indicated moderate agreement between the three observers in classifying breast density using the quantitative assessment technique. The kappa coefficient of 0.75 for intraobserver agreement reflected good agreement between two sets of readings. The technique may be useful as a supplement to the radiologist's assessment in classifying mammograms into Tabar's pattern associated with breast cancer risk.

Strategies for shimming the breast

There is evidence in the literature indicating a significant static field inhomogeneity in the human breast. A nonhomogenous field results in line broadening and frequency shifts in MRS and can cause intensity loss and spatial errors in MRI. Thus, there is a clear rationale for determining the regional variations in the static field homogeneity in the breast and providing strategies to correct them. Herein, the nature and extent of the static magnetic field at 3 T were measured in central planes of the human breast using both phase maps and multivoxel MRS techniques. In addition, the effect of first- and high-order shimming and of spatial saturation pulses on the static field inhomogeneity was evaluated. Both the theoretical and the measured field were found to be primarily linear in nature, with a reduction of 300 Hz from the nipple to the chest wall. First-order shimming reduced this inhomogeneity by 65%. Interestingly, the combination of spatial saturation pulses and first-order shimming was more effective than high-order shim alone. Since many clinical scanners do not have either higher-order shim or automated higher shimming algorithms that work in the presence of fat, the suggested combination provides an effective means to correct inhomogeneities in the breast.

Anatomy of the lactating human breast redefined with ultrasound imaging

The aim of this study was to use ultrasound imaging to re-investigate the anatomy of the lactating breast. The breasts of 21 fully lactating women (1-6 months post partum) were scanned using an ACUSON XP10 (5-10 MHz linear array probe). The number of main ducts was measured, ductal morphology was determined, and the distribution of glandular and adipose tissue was recorded. Milk ducts appeared as hypoechoic tubular structures with echogenic walls that often contained echoes. Ducts were easily compressed and did not display typical sinuses. All ducts branched within the areolar radius, the first branch occurring 8.0 +/- 5.5 mm from the nipple. Duct diameter was 1.9 +/- 0.6 mm, 2.0 +/- 90.7 mm and the number of main ducts was 9.6 +/- 2.9, 9.2 +/- 2.9, for left and right breast, respectively. Milk ducts are superficial, easily compressible and echoes within the duct represent fat globules in breastmilk. The low number and size of the ducts, the rapid branching under the areola and the absence of sinuses suggest that ducts transport breastmilk, rather than store it. The distribution of adipose and glandular tissue showed wide variation between women but not between breasts within women. The proportion of glandular and fat tissue and the number and size of ducts were not related to milk production. This study highlights inconsistencies in anatomical literature that impact on breast physiology, breastfeeding management and ultrasound assessment.

Optimization of tube potential–filter combinations for film-screen mammography

This study evaluated how tube potential-filter combinations [with a molybdenum (Mo) anode and either an Mo or a rhodium (Rh) filter] influence image quality and radiation dose to breasts of different thicknesses in film-screen mammography using a new mammography phantom (CDMAM Phantom Type 3.4). A 28-kVp/Mo tube potential-filter combination is recommended for a breast (phantom) thickness of 40 mm or less, 28 kVp/Rh for a breast (phantom) thickness of 60 mm or less, and 30 kVp/Rh for a breast (phantom) thickness greater than 60 mm.