Best Practice Guideline - DEGUM Recommendations on Breast Ultrasound

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

Best Practice Guideline - DEGUM Recommendations on Breast Ultrasound

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

Patient participation in multidisciplinary tumor conferences in breast and gynecological cancer care: How patient-centered is the communication?

OBJECTIVE

Patients' participation is part of patient-centeredness, but it is so far unclear whether providers in multidisciplinary tumor conferences (MTCs) with patient participation communicate in a patient-centered way. Our aim is to explore (a) to what extent providers ask questions to breast and gynecological cancer patients during case discussion in MTCs, (b) how providers respond to patients' expressions of emotions during case discussions, and (c) which patient- and context-related characteristics and responses are associated with patients' trust in the treatment team after the case discussion.

METHODS

This observational study included survey data and audio recordings of MTCs with patient participation at three breast and gynecological cancer centers. Providers' questions to patients and responses to patients' emotional expressions were coded using the Verona Coding Definitions of Emotional Sequences. The response can be explicitly or non-explicitly related to the emotion and space-reducing or space-providing. Multiple linear regression analysis was used to determine associations between providers' responses, patient- and context-related characteristics, and patients' trust in the treatment team after the case discussion.

RESULTS

We analyzed 82 case discussions (77 breast, 5 breast and gynecological cancer patients). Providers asked a total of 646 questions, of which 86% were polar (yes/no). Providers gave 303 responses to a total of 230 emotional expressions by patients. Non-explicit responses were associated with more trust when they were space-providing, but with less trust when space-reducing.

CONCLUSIONS

The frequency of providers' closed questions and space-reducing responses to emotions shows that patient-centered communication rarely takes place in MTCs with patient participation.

Patient participation in multidisciplinary tumor conferences: How is it implemented? What is the patients' role? What are patients' experiences?

Background

Prior research has shown that around 5%–7% of patients in breast cancer centers in Germany participate in the discussion of their own case within a multidisciplinary tumor conference (MTC). The PINTU study is one of the first to research this practice. The objective is to describe (a) how patient participation in MTCs is implemented, (b) what is the role of patients, and (c) how patients experience MTCs.

Methods

MTCs in six breast and gynecological cancer centers in North Rhine‐Westphalia, Germany, with and without patient participation, are studied prospectively by (non)participatory, structured observation. Breast and gynecological cancer patients completed surveys before, directly after, and 4 weeks after MTC participation. Data are analyzed descriptively.

Results

Case discussions of a sample of n = 317 patients (n = 95 with MTC participation and n = 222 without) were observed. Survey data were obtained from n = 242 patients (n = 87 and n = 155). Observational data showed heterogeneity in the ways MTC participation was practiced. Among participating patients, 89% had the opportunity to express their opinion and 61% were involved in decision‐making. Whereas most patients reported positive experiences and would recommend participation, some had negative experiences and regretted participating.

Conclusions

Due to a lack of recommendations, hospitals implement patient participation in MTCs in many different ways. So far, it is unknown which setting and procedures of MTC participation are beneficial for patients. However, existing evidence on communication in cancer care together with this exploratory study's findings can build the basis for developing recommendations for hospitals that invite their patients to MTCs.

Clinical trial registration number

German Clinical Trials Register Nr. DRKS00012552.

Correlation of Ductoscopic and Histopathological Findings and Their Relevance as Predictors for Malignancy: A German Multicenter Study

BACKGROUND/AIM

The study aimed at investigating the correlation between ductoscopic and histopathological findings and clarify whether the former allow for accurate prediction of malignancy.

PATIENTS AND METHODS

The prospective national multi-center study covered a sample of 224 patients with pathologic nipple discharge. A total of 214 patients underwent ductoscopy with subsequent extirpation of the mammary duct. The ductoscopic findings were categorized according to shape, number, color and surface structure of lesions and vascularity and compared to the histological results and analyses.

RESULTS

Ductoscopy revealed lesions in 134 of 214 patients (62.2%). The criteria "multiple versus solitary lesion" differed significantly between malignant and benign lesions. All other criteria were not statistically significant. Malignant tumors were more frequently presented as multiple lesions, benign lesions or masses as solitary lesions (80% vs. 24.8%; p=0.018).

CONCLUSION

The ductoscopic criterion "solitary vs. multiple lesion" appears to have a low diagnostic prediction of malignancy or benignity.

[Evaluation of the nationwide DEGUM breast ultrasound training program]

PURPOSE

The aim of this study was to evaluate the quality standard of the nationwide breast ultrasound training program of the German Society of Ultrasound in Medicine (DEGUM) through objective parameters.

MATERIALS AND METHODS

10 quality criteria, based on the recommendations of The National Association of Statutory Health Insurance Physicians (KBV), were defined for this study. All training units of the DEGUM received a questionnaire. The questionnaires and training material were analyzed.

RESULTS

All units met the required criteria pertaining to the trainer's qualification, duration per training course and the maximum number of participants per ultrasound machine. Only 1 course did not fulfill the required 50 % practical training time. The requirements to participate in the graduate course (200 self-made and documented cases) were not clearly conceived and a defined training log could be improved.

CONCLUSION

DEGUM breast ultrasound training offers trainees a high level of education based on the requirements of the KBV. Despite the high quality of training, the content of course announcements could be improved and an official and structured educational index could be meaningful.

[Sonoelastography usage among German DEGUM-certified breast ultrasound specialists]

PURPOSE

Sonoelastography of the breast is an emerging technology with evident data in the literature suggesting diagnostic advantages. Our study investigates the current usage of sonoelastography among German DEGUM-certified breast ultrasound specialists.

MATERIALS AND METHODS

We used a standardized questionnaire with 18 items. In 2012, the survey was sent to all members of the breast ultrasound section of the DEGUM (n = 654).

RESULTS

The group of survey participants (n = 208) performs 193 025 breast ultrasound examinations and examines 20 110 breast cancers per year. 21.2 % of the participants in the survey use sonoelastography, mainly for diagnostic purposes in BI-RADS®-US 3 and 4 lesions, less often for other categories or under study conditions. The most commonly applied criteria for the evaluation of the elastogram are the Tsukuba Elasticity Score (43.2 %), the fat-lesion ratio (29.5 %) and the determination of tissue stiffness with shear wave elastography expressed in kilopascal (25.0 %). The majority of non-users of elastography (58.6 %) would like to have the option of using sonoelastography in the future.

CONCLUSION

Sonoelastography is a feasible and helpful method in the evaluation of breast lesions. A significant number of German ultrasound specialists already apply this technology today. We expect a growing number of sonographers to perform sonoelastography in the near future, provided that they have the necessary ultrasound system and that they are trained in the method. Evidence from the literature and the recommendations of the medical societies support this development.

Abstract 1444: High-throughput four color detection and analysis of circulating epithelial cells in early and late breast cancer

The Maintrac technique (RBClysis,fluorometric detection and analysis on Olympus ScanR) detects more circulating epithelial cells (CEC) then other enrichment- based methods. In our ongoing early breast cancer study (n=177), we found >125 CEC/ml in 35% of patients. In advanced breast cancer 60% of patients had cell counts>125 cells/ml . In controls (n=98) we found 125-250 cells/ml in 2%. Extended evaluation of a non cancer control group showed >125 cells/ml in 90% of patients with liver affections such as nonalcoholic fatty liver disease(NAFLD) . Using a three colour- based technique living and dead (DAPI) EPCAM + cells coexpressing vimentin and in parallell EPCAM+ cells coexpressing Vimentin and CD44 were measured. We saw a very inhomogeneous EPCAM+ population with different expression patterns,which made analysis very tedious. Moreover, there was no detectable difference between the CEC in early and late breast cancer and in liver affections, in both situations CEC had epithelial-mesenchymal transition (EMT)- and stem cell characteristics. We aimed to perform a more comprehensive analysis of these CEC by introducing a fourth color.We modified the basic procedure of the Maintrac technique in order too allow analysis and detection of CEC on the AMNIS FlowSight. Cells are aspirated from 96 well microplates allowing four color detection and automated analysis with AMNIS IDEAS software. Total plate run is completed within 9 hours. Beside the fastness new items like detection of tumor microemboli (TME) and EPCAM- independent analysis of cells with a stem cell phenotype (CD44high,CD24 low) or metabolic markers (HIF-1,carboanhydrase 9) is possible. We currently use DAPI, EPCAMAF660, vimentin -PE and CD45-FITC as basic combination . A second run uses CD24-PE, CD45-FITC, CD44-PacBlue and EPCAM- AF660 . Double measurement of the EPCAM+CD45neg population as basic population for comparison is achieved . Comprehensive analysis of more defined circulating stem cells (CSC) is thus possible.This approach will clarify the differences between liver- and tumor-derived CEC thus avoiding false positive CTC counts in early breast cancer . Our preliminary results show detectable differences between patients with advanced cancer and NAFLD concerning highly defined CEC with with "stemness" expression (CD44high, CD24low, EPCAM+, CD45neg). Our focus is on a cell type with very high "dotted " expression of CD44, EPCAM and vimentin, seen already with three colour analysis. We are currently introducing other markers like ALDH1 and beta-catenin for better definition of CSC. Furthermore, detection of Her2 or other targets like PD-1 or phosphatidylserine are possible on this defined CEC. We will present extended data with the four color approach for CEC analysis in early and late breast cancer at the conference.

Citation Format: Leo Habets, Wolfgang Körber, Bettina Frenken, Ilham El Ghali, Mahmoud Danaei, Manfred Kusche, Uwe Peisker, Torsten Kroll, Katharina Pachmann. High-throughput four color detection and analysis of circulating epithelial cells in early and late breast cancer. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 1444. doi:10.1158/1538-7445.AM2013-1444

Abstract P1-07-16: Liver derived epithelial cells as source of false positive circulating tumor cells in early breast cancer

The MAINTRAC technique as introduced by our coworkers from Jena (RBC lysis, fluorometric detection and analysis on Olympius ScanR) detects more circulating epithelial cells than techniques using enrichment. Also cells with a low EPCAM expression are detected and not only the typical cells with bright expression found after immunomagnetic enrichment. The relative cheapness and reproducibility allows frequent monitoring during and after therapy Using 3 colour detection (EPCAMfitc, DAPI, Vimentin PE) living and dead circulating epithelial cells in EMT, or cells in EMT with stemcell markers (EPCAMfitc, Vimentin-PE, CD44PacBlue) can be detected. In early breast cancer (n = 135) cells can be found in 60% of patients and in 40% higher cell counts (>100 ml are detectable. A control population(n = 100) showed low numbers in 98% (e.g (<100 CECin 1 ml blood). Expression of the mesenchymal marker (vimentin) ranges between 10 and 40% with different expression. CD44 shows also a wide range of expression. Two main cell types can be distinguished: type 1 shows generalized but weaker expression patterns and a second type with very bright dotted expression. The clinical relevance of these subsets is not known and their behavior under therapy has not been analysed in depth yet. In advanced breast cancers high cell counts were detectable in most patients with a less agressive disease course. In the rapidly progressing unfavorable subtypes (TN and Her2+. HRneg) less or none cells were found. During crossvalidation in non cancer patients we found high cell numbers in several forms of liver affections (n = 108). The expression patterns of markers on these cells were not differing from those in cancer patients. So this same cell type merging EMT, stemcell an hypoxic stress markers is detectable in advanced and early breast cancer (n = 40) and in benign disease. These cells disappear or decrease after response to chemo or anti-hormonal therapy in cancer or antioxidant therapy in NAFLD. We believe that the evasion of these cells is driven by the same force in cancer as in non cancer conditions. We suggest that this are the wellknown hypoxic and hyperacidic conditions causing epithelial mesenchymal transition. Cancer cell hijack this functions occurring normally under these conditions to survive and to facilitate evasion. More comprehensive analysis (four colour analysis on the AMNIS Flowsight) is needed and should show differences in expression patterns of liver derived epithelial cells (LDEC) and real tumor derived epithelial cells (TDEC). Further clarification of these phenomena should give new insights of the biological events in early disease and the possibilities and reliability of “fluid biopsy”.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-07-16.

Interdisciplinary consensus recommendations for the use of vacuum-assisted breast biopsy under sonographic guidance: first update 2012

PURPOSE

The vacuum biopsy of the breast under sonographic guidance (VB) was introduced in Germany in the year 2000 and the first consensus recommendations were published by Krainick-Strobel et al. in 2005. Since then, many clinical studies on this technique have been published. The purpose of this publication is to update the consensus recommendations from 2005 regarding the latest literature.

MATERIALS AND METHODS

The consensus statements were the result of two preliminary meetings after the review of the latest literature by members of the Minimally Invasive Breast Intervention Study Group from the German Society of Senology. The final consensus text was review by all members of the working group. The statements listed under results obtained complete acceptance (consensus 100 %).

RESULTS

The consensus recommendations describe the indications, investigator qualifications, technical requirements, documentation, quality assurance and follow-up intervals regarding the latest literature.

CONCLUSION

The VB is a safe method for extracting breast tissue for histological workup. The technique allows the resection of breast tissue up to 8 cm3. Besides the diagnostic indications, the method qualifies for a therapeutic resection of symptomatic benign lesions (e. g. fibroadenomas). The technique should be used in specialized breast centers working in a multidisciplinary setup. This paper is an expert's recommendation for the use of VB under sonographic guidance. It is not formulated as a nationwide guideline.

Significant differentiation of focal breast lesions: raw data-based calculation of strain ratio

PURPOSE

We compared elastography, B-mode ultrasound and mammography to determine whether raw data calculation of strain ratios (SRs) can further improve the differentiation of focal breast lesions.

MATERIALS AND METHODS

201 women with histologically proven focal breast lesions (85 benign, 116 malignant) were included at two German breast centers. Patients underwent a standardized ultrasound procedure using high-end ultrasound system with a 9-MHz broadband linear transducer. Two experienced readers analyzed the B-mode scans and mammograms using the BI-RADS criteria, while elastograms were analyzed using the Tsukuba score. SRs were calculated from a tumor-adjusted ROI and a comparable ROI placed in the lateral fatty tissue. The sensitivity, specificity, and cutoff values were calculated for SRs (ROC analysis).

RESULTS

The median age was 53 years. The sensitivity and specificity were 85 %/ 60 % for B-mode scanning, 85 %/ 68 % for elastography, 78 %/ 62 % for mammography, and 95 %/ 74 % for SRs. An SR cutoff value of 2.27 (AUC 0.907) allowed significant differentiation (p < 0.001) between malignant and benign lesions. The quantitative SR calculation was superior to subjective interpretation of B-mode scans and sonoelastograms with a positive predictive value of 83 % versus 78 % and 74 %, and equal to mammograms.

CONCLUSION

Strain ratio calculation contributes to the standardization of sonoelastography with high sensitivity and allows significant differentiation between benign and malignant breast lesions with a higher specificity compared to B-mode, subjective evaluation of elastography and mammography.

A circulating epithelial cell type merging stem cell, EMT, and hypoxic stress markers in early and advanced breast cancer

10600

Background: MAINTRAC as developed by our coworkers from Jena finds more CETC. They found CETC in 90% of high risk patients. Circulating cells in epithelial mesenchymal transition (EMT+) should be detectable in early disease. Methods: 2 colours (7AAD, EP-FITC) detected living and dead cells. Cells in EMT (EP-FITC, Vim-PE) were analysed in paralell. Complex marker expression urged us to introduce a three colour technique. 1. EPCAM-FITC, Vimentin-PE and DAPI , marking living or dead cells in EMT. 2. EP-FITC, Vim-PE and CD44 PB for stemness. ACA9 (hypoxia) and PARP-1 expression (genotox) were used too. Results: In the 2 colour phase we examined CEC in 110 patients with early disease and 44 patients with metastasis. Cells were detectable in both disease situations in 50 and 60% of patients, in a control population only in few patients low numbers were found. In non cancer situations e.g liver disease high numbers of EMT+cells were found.The results of 3 colour analysis are shown in the table. No clear differences between the classical risk groups are found, other subgroups are too small yet to be considered. Conclusions: Our findings show that in both disease situations cells merging EMT, stemcells ( EP+,Vim+.CD44+) and other markers are detectable. This cell type however is found also in non cancer conditions.We hypothesize that hypoxia is the common driver. Metastasis gives different patterns. Highly aggressive cancers show often none or few cells. In less agressive disease high cell numbers are found. We need to characterize the "benign" EMT phenomenon, as it could mingle with "real" CTC. Definitely liver is the source of these benign cells. Multi colour analysis will reveal the differences. Nevertheless monitoring of this special cell type could give new insights in the metastatic process in early and late disease. [Table: see text]

Complete extirpation of benign breast lesions with an ultrasound-guided vacuum biopsy system

OBJECTIVES

To investigate whether ultrasound-guided vacuum biopsy (VB) with curative intent is suitable for the complete extirpation of selected sonographically detectable benign lesions of the breast, and to establish the limitations of the method with regard to lesion size and complications, the extent of scar formation and the prognostic value.

METHODS

One hundred and nine patients underwent hand-held, ultrasound-guided VB (8G or 11G needle) between June 2000 and September 2003. Of these, 45 (41%) women underwent ultrasound-guided extirpation of 46 lesions, and 42 women with 43 lesions were followed up clinically and sonographically for an average of 5.9 months. The complete extirpation rate, residual lesions, and patient satisfaction with the intervention were evaluated.

RESULTS

Removal of all sonographic evidence of lesions (median diameter, 13 mm) was achieved in 86% of cases (8G needle, 80%; 11G needle, 89%). 19% of the patients had suspected scar formation at the biopsy site. A palpable lesion in the breast could be removed by VB in 90% of cases. None of the patients developed infections and there were no hemorrhages requiring intervention, or damage to the skin or chest wall. A total of 95% of the patients stated that they would prefer this approach to open excision for possible future intervention.

CONCLUSIONS

VB is an ambulatory procedure associated with a low degree of pain. It has a high degree of patient acceptance and, as a minimally invasive biopsy technique for benign lesions, is a good alternative to open excision. The rate of complications is low and is similar to that observed with conventional microbiopsy.