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.

The Potential of Shear Wave Elastography to Reduce Unnecessary Biopsies in Breast Cancer Diagnosis: An International, Diagnostic, Multicenter Trial

PURPOSE

 In this prospective, multicenter trial we evaluated whether additional shear wave elastography (SWE) for patients with BI-RADS 3 or 4 lesions on breast ultrasound could further refine the assessment with B-mode breast ultrasound for breast cancer diagnosis.

MATERIALS AND METHODS

 We analyzed prospective, multicenter, international data from 1288 women with breast lesions rated by conventional 2 D B-mode ultrasound as BI-RADS 3 to 4c and undergoing 2D-SWE. After reclassification with SWE the proportion of undetected malignancies should be < 2 %. All patients underwent histopathologic evaluation (reference standard).

RESULTS

 Histopathologic evaluation showed malignancy in 368 of 1288 lesions (28.6 %). The assessment with B-mode breast ultrasound resulted in 1.39 % (6 of 431) undetected malignancies (malignant lesions in BI-RADS 3) and 53.80 % (495 of 920) unnecessary biopsies (biopsies in benign lesions). Re-classifying BI-RADS 4a patients with a SWE cutoff of 2.55 m/s resulted in 1.98 % (11 of 556) undetected malignancies and a reduction of 24.24 % (375 vs. 495) of unnecessary biopsies.

CONCLUSION

 A SWE value below 2.55 m/s for BI-RADS 4a lesions could be used to downstage these lesions to follow-up, and therefore reduce the number of unnecessary biopsies by 24.24 %. However, this would come at the expense of some additionally missed cancers compared to B-mode breast ultrasound (rate of undetected malignancies 1.98 %, 11 of 556, versus 1.39 %, 6 of 431) which would, however, still be in line with the ACR BI-RADS 3 definition (< 2 % of undetected malignancies).

Potential of Lesion-to-Fat Elasticity Ratio Measured by Shear Wave Elastography to Reduce Benign Biopsies in BI-RADS 4 Breast Lesions

OBJECTIVES

We evaluated whether lesion-to-fat ratio measured by shear wave elastography in patients with Breast Imaging Reporting and Data System (BI-RADS) 3 or 4 lesions has the potential to further refine the assessment of B-mode ultrasound alone in breast cancer diagnostics.

METHODS

This was a secondary analysis of an international diagnostic multicenter trial (NCT02638935). Data from 1288 women with breast lesions categorized as BI-RADS 3 and 4a-c by conventional B-mode ultrasound were analyzed, whereby the focus was placed on differentiating lesions categorized as BI-RADS 3 and BI-RADS 4a. All women underwent shear wave elastography and histopathologic evaluation functioning as reference standard. Reduction of benign biopsies as well as the number of missed malignancies after reclassification using lesion-to-fat ratio measured by shear wave elastography were evaluated.

RESULTS

Breast cancer was diagnosed in 368 (28.6%) of 1288 lesions. The assessment with conventional B-mode ultrasound resulted in 53.8% (495 of 1288) pathologically benign lesions categorized as BI-RADS 4 and therefore false positives as well as in 1.39% (6 of 431) undetected malignancies categorized as BI-RADS 3. Additional lesion-to-fat ratio in BI-RADS 4a lesions with a cutoff value of 1.85 resulted in 30.11% biopsies of benign lesions which correspond to a reduction of 44.04% of false positives.

CONCLUSIONS

Adding lesion-to-fat ratio measured by shear wave elastography to conventional B-mode ultrasound in BI-RADS 4a breast lesions could help reduce the number of benign biopsies by 44.04%. At the same time, however, 1.98% of malignancies were missed, which would still be in line with American College of Radiology BI-RADS 3 definition of <2% of undetected malignancies.

Intelligent multi-modal shear wave elastography to reduce unnecessary biopsies in breast cancer diagnosis (INSPiRED 002): a retrospective, international, multicentre analysis

BACKGROUND

Breast ultrasound identifies additional carcinomas not detected in mammography but has a higher rate of false-positive findings. We evaluated whether use of intelligent multi-modal shear wave elastography (SWE) can reduce the number of unnecessary biopsies without impairing the breast cancer detection rate.

METHODS

We trained, tested, and validated machine learning algorithms using SWE, clinical, and patient information to classify breast masses. We used data from 857 women who underwent B-mode breast ultrasound, SWE, and subsequent histopathologic evaluation at 12 study sites in seven countries from 2016 to 2019. Algorithms were trained and tested on data from 11 of the 12 sites and externally validated using the additional site's data. We compared findings to the histopathologic evaluation and compared the diagnostic performance between B-mode breast ultrasound, traditional SWE, and intelligent multi-modal SWE.

RESULTS

In the external validation set (n = 285), intelligent multi-modal SWE showed a sensitivity of 100% (95% CI, 97.1-100%, 126 of 126), a specificity of 50.3% (95% CI, 42.3-58.3%, 80 of 159), and an area under the curve of 0.93 (95% CI, 0.90-0.96). Diagnostic performance was significantly higher compared to traditional SWE and B-mode breast ultrasound (P < 0.001). Unlike traditional SWE, positive-predictive values of intelligent multi-modal SWE were significantly higher compared to B-mode breast ultrasound. Unnecessary biopsies were reduced by 50.3% (79 versus 159, P < 0.001) without missing cancer compared to B-mode ultrasound.

CONCLUSION

The majority of unnecessary breast biopsies might be safely avoided by using intelligent multi-modal SWE. These results may be helpful to reduce diagnostic burden for patients, providers, and healthcare systems.

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.

A New Practical Decision Rule to Better Differentiate BI-RADS 3 or 4 Breast Masses on Breast Ultrasound

OBJECTIVES

The BI-RADS classification provides a standardized way to describe ultrasound findings in breast cancer diagnostics. However, there is little information regarding which BI-RADS descriptors are most strongly associated with malignancy, to better distinguish BI-RADS 3 (follow-up imaging) and 4 (diagnostic biopsy) breast masses.

METHODS

Patients were recruited as part of an international, multicenter trial (NCT02638935). The trial enrolled 1294 women (6 excluded) categorized as BI-RADS 3 or 4 upon routine B-mode ultrasound examination. Ultrasound images were evaluated by three expert physicians according to BI-RADS. All patients underwent histopathological confirmation (reference standard). We performed univariate and multivariate analyses (chi-square test, logistic regression, and Krippendorff's alpha).

RESULTS

Histopathologic evaluation showed malignancy in 368 of 1288 masses (28.6%). Upon performing multivariate analysis, the following descriptors were significantly associated with malignancy (P < .05): age ≥50 years (OR 8.99), non-circumscribed indistinct (OR 4.05) and microlobulated margin (OR 2.95), nonparallel orientation (OR 2.69), and calcification (OR 2.64). A clinical decision rule informed by these results demonstrated a 97% sensitivity and missed fewer cancers compared to three physician experts (range of sensitivity 79-95%) and a previous decision rule (sensitivity 59%). Specificity was 44% versus 22-83%, respectively. The inter-reader reliability of the BI-RADS descriptors and of the final BI-RADS score was fair-moderate.

CONCLUSIONS

A patient should undergo a diagnostic biopsy (BI-RADS 4) instead of follow-up imaging (BI-RADS 3) if the patient is 50 years or older or exhibits at least one of the following features: calcification, nonparallel orientation of mass, non-circumscribed margin, or posterior shadowing.

The importance of multi-modal imaging and clinical information for humans and AI-based algorithms to classify breast masses (INSPiRED 003): an international, multicenter analysis

OBJECTIVES

AI-based algorithms for medical image analysis showed comparable performance to human image readers. However, in practice, diagnoses are made using multiple imaging modalities alongside other data sources. We determined the importance of this multi-modal information and compared the diagnostic performance of routine breast cancer diagnosis to breast ultrasound interpretations by humans or AI-based algorithms.

METHODS

Patients were recruited as part of a multicenter trial (NCT02638935). The trial enrolled 1288 women undergoing routine breast cancer diagnosis (multi-modal imaging, demographic, and clinical information). Three physicians specialized in ultrasound diagnosis performed a second read of all ultrasound images. We used data from 11 of 12 study sites to develop two machine learning (ML) algorithms using unimodal information (ultrasound features generated by the ultrasound experts) to classify breast masses which were validated on the remaining study site. The same ML algorithms were subsequently developed and validated on multi-modal information (clinical and demographic information plus ultrasound features). We assessed performance using area under the curve (AUC).

RESULTS

Of 1288 breast masses, 368 (28.6%) were histopathologically malignant. In the external validation set (n = 373), the performance of the two unimodal ultrasound ML algorithms (AUC 0.83 and 0.82) was commensurate with performance of the human ultrasound experts (AUC 0.82 to 0.84; p for all comparisons > 0.05). The multi-modal ultrasound ML algorithms performed significantly better (AUC 0.90 and 0.89) but were statistically inferior to routine breast cancer diagnosis (AUC 0.95, p for all comparisons ≤ 0.05).

CONCLUSIONS

The performance of humans and AI-based algorithms improves with multi-modal information.

KEY POINTS

• The performance of humans and AI-based algorithms improves with multi-modal information. • Multimodal AI-based algorithms do not necessarily outperform expert humans. • Unimodal AI-based algorithms do not represent optimal performance to classify breast masses.

The potential of combined shear wave and strain elastography to reduce unnecessary biopsies in breast cancer diagnostics - An international, multicentre trial

BACKGROUND

Shear wave elastography (SWE) and strain elastography (SE) have shown promising potential in breast cancer diagnostics by evaluating the stiffness of a lesion. Combining these two techniques could further improve the diagnostic performance. We aimed to exploratorily define the cut-offs at which adding combined SWE and SE to B-mode breast ultrasound could help reclassify Breast Imaging Reporting and Data System (BI-RADS) 3-4 lesions to reduce the number of unnecessary breast biopsies.

METHODS

We report the secondary results of a prospective, multicentre, international trial (NCT02638935). The trial enrolled 1288 women with BI-RADS 3 to 4c breast masses on conventional B-mode breast ultrasound. All patients underwent SWE and SE (index test) and histopathologic evaluation (reference standard). Reduction of unnecessary biopsies (biopsies in benign lesions) and missed malignancies after recategorising with SWE and SE were the outcome measures.

RESULTS

On performing histopathologic evaluation, 368 of 1288 breast masses were malignant. Following the routine B-mode breast ultrasound assessment, 53.80% (495 of 920 patients) underwent an unnecessary biopsy. After recategorising BI-RADS 4a lesions (SWE cut-off ≥3.70 m/s, SE cut-off ≥1.0), 34.78% (320 of 920 patients) underwent an unnecessary biopsy corresponding to a 35.35% (320 versus 495) reduction of unnecessary biopsies. Malignancies in the new BI-RADS 3 cohort were missed in 1.96% (12 of 612 patients).

CONCLUSION

Adding combined SWE and SE to routine B-mode breast ultrasound to recategorise BI-RADS 4a patients could help reduce the number of unnecessary biopsies in breast diagnostics by about 35% while keeping the rate of undetected malignancies below the 2% ACR BI-RADS 3 definition.

Abstract PS3-18: Differences in the diagnostic performance of breast ultrasound with or without additional patient information: A secondary analysis of an international multicenter trial

Background and objectives: The Breast Imaging Reporting and Data System (BI-RADS) has helped to standardize radiologic reports and assessment in breast cancer diagnostics. So far, BI-RADS consists of the sole, standardized description of images. Individual patient characteristics like disease and family history or age are no part of the current BI-RADS classification system but are often subjectively considered to evaluate the risk of breast cancer in the clinical setting. It is however unclear how and to which extent such additional patient information influence the evaluation of risk of malignancy. Thus, we compared the performance in the detection of breast cancer between the sole analysis of ultrasound images by physician experts and a physician actually examining and counseling a patient in the clinical setting.

Methods: This multicenter, prospective trial took place at 11 trial sites in Austria, France, Germany, Japan, Netherlands, Portugal, and the US from February 2016 to March 2019. The trial enrolled 1288 women presenting with a lesion ≥0.5 and ≤5 cm in 2D B-mode ultrasound. In the clinical setting, the examiner conducted a routine 2D B-mode ultrasound examination and had additional standard information about the patients’ disease history and family history. The final ultrasound images made in the clinical routine (annotated with size measurements) but not any other information about the patient was given to three physician experts (&gt;15 years of experience in breast cancer diagnostics). The examiner in the clinical setting and each of the three experts evaluated the ultrasound images according to BI-RADS and gave a likelihood score for malignancy according to ACR (American College of Radiology). Following the BI-RADS definition by ACR, malignancy was assumed for a likelihood of malignancy &gt;2% (BI-RADS 4 or higher). All patients underwent histopathological confirmation which was the gold standard against which the clinical examiner and the three experts were compared. AUC, sensitivity, specificity, negative-predictive value (NPV), and positive-predictive value (PPV) were the performance measures.

Results: Histopathologic evaluation showed malignancy in 368 of 1288 lesions (28.6%). AUC of the examiner in the clinical setting (AUC=0.94; 95% CI 0.92-0.95) was significantly better as for all three experts evaluating images only: expert one AUC=0.78 (95% CI 0.75-0.81); expert two AUC=0.81 (95% CI 0.78-0.84); expert three AUC=0.83 (95% CI 0.80-0.86). Sensitivity, specificity, NPV, and PPV of the examiner in the clinical setting were better as for all three experts evaluating images only. NPV of the examiner in the clinical setting was 98.6% (425 of 431), for expert one 87.8% (381 of 434), for expert two 91.2% (198 of 217), and for expert 3 84.1% (413 of 491).

Conclusion: Our findings suggest that information about individual patient characteristics (e.g. age, disease and family history) has great influence to accurately evaluate the risk of breast cancer. Future research may look into incorporating not only a standardized description of images into the BI-RADS classification system but also a standardized description of these individual patient characteristics to further standardize and objectify the risk evaluation in breast cancer diagnostics. Trial registration: NCT02638935

Performance of the examiner in the clinical setting and the three experts evaluating images onlyExaminer clinical settingImages only – Expert 1Images only – Expert 2Images only – Expert 3AUC (95% CI)0.94 (0.92-0.95)0.78 (0.75-0.81)0.81 (0.78-0.84)0.83 (0.80-0.86)Sensitivity –% (no.)98.4% (362 of 368)85.6% (315 of 368)94.8% (349 of 368)78.8% (290 of 368)Specificity –% (no.)46.2% (425 of 920)41.4% (381 of 920)21.5% (198 of 920)44.9% (413 of 920)Negative Predictive Value –% (no.)98.6% (425 of 431)87.8% (381 of 434)91.2% (198 of 217)84.1% (413 of 491)Positive Predictive Value –% (no.)42.2% (362 of 857)36.9% (315 of 854)32.6% (349 of 1071)36.4% (290 of 797)

Citation Format: André Pfob, Richard G. Barr, Volker Duda, Christopher Buesch, Joerg Heil, Michael Golatta. Differences in the diagnostic performance of breast ultrasound with or without additional patient information: A secondary analysis of an international multicenter trial [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS3-18.

Abstract PS3-16: Identifying the most relevant descriptors when evaluating ultrasound images in breast cancer diagnostics: A secondary analysis of an international multicenter trial

Background and objectives: The Breast Imaging Reporting and Data System (BI-RADS) provides a standardized way to describe ultrasound images in breast cancer diagnostics. However, there is little information which descriptors are most strongly associated with malignancy and to which extend the single descriptors (tissue composition, shape, orientation, margin of lesion, echo pattern, posterior features, and calcifications) should be considered for the final evaluation of risk of malignancy. Thus, we aimed to identify which BI-RADS descriptors are most strongly associated with malignancy when evaluating ultrasound images in breast cancer diagnostics.

Methods: This multicenter, prospective trial took place at 11 trial sites in Austria, France, Germany, Japan, Netherlands, Portugal, and the US from February 2016 to March 2019. The trial enrolled 1288 women presenting with a lesion ≥0.5 and ≤5 cm in 2D B-mode ultrasound. The examiner conducted a routine 2D B-mode ultrasound examination and had additional standard information about the patients’ disease history and family history. The examiner described the ultrasound images according to BI-RADS. All patients underwent histopathological confirmation which was the gold standard against which the clinical examiner was compared. We performed univariate and multivariate analyses using descriptive statistics, Chi-Square test, and logistic regression to identify which image descriptors are associated with malignancy.

Results: Histopathologic evaluation showed malignancy in 368 of 1288 lesions (28.6%). The descriptors most strongly associated with malignancy were spiculated margins (rate of malignancy 84.9%; 79 of 93), calcification (69.9%; 51 of 73), un-parallel orientation (65.9%; 187 of 284), angular margins (64.6%; 64 of 99), posterior shadowing (62.4%; 88 of 142), irregular shape (55.2%; 208 of 377), and indistinct margins (52.0%; 185 of 356). Different tissue compositions and echo patterns were least useful to distinguish between malign and benign lesions. Upon multivariate analysis, calcifications (OR 5.52; 95% CI 1.94-15.87) and posterior shadowing (OR 16.13; 95% CI 2.75-90.91) remained significantly (p&lt;0.05) associated with malignancy.

Conclusion: We identified which BI-RADS descriptors are most strongly associated with malignancy when evaluating ultrasound images in breast cancer diagnostics. Future research may look into providing not only a standardized image description but also a standardized final evaluation for the rate of malignancy with respect to the different predictive usefulness of the single descriptors. This may further standardize and objectify the risk evaluation in breast cancer diagnostics.

Trial registration: NCT02638935

Table 1: Association of BI-RADS descriptors with final histopathologic resultsbenign pathologymalignant pathologyp-valuetissue compositionp&lt;0.0001homogeneous background texture; fat —no. (%)185 (60.3)122 (39.74)homogeneous background texture; fibroglandular —no. (%)378 (77.3)111 (22.7)heterogeneous background texture —no. (%)356 (72.7)134 (27.4)shape of lesionp&lt;0.0001oval —no. (%)659 (86.1)106 (13.8)round —no. (%)89 (62.7)53 (37.3)irregular —no. (%)169 (44.8)208 (55.2)orientation of lesionp&lt;0.0001parallel —no. (%)806 (82.6)170 (17.42)not parallel —no. (%)97 (34.15)187 (65.9)margin of lesionp&lt;0.0001circumcised —no. (%)644 (89.0)80 (11.0)indistinct margin —no. (%)171 (48.0)185 (52.0)angular margin —no. (%)35 (35.4)64 (64.6)microlobulated margin —no. (%)117 (60.0)78 (40.0)spiculated margin —no. (%)14 (15.1)79 (84.9)echo patternp=0.02anechoic —no. (%)7 (100)0 (0.0)hyperechoic —no. (%)30 (79.0)8 (21.0)complex cystic and solid —no. (%)52 (82.5)11 (17.5)hypoechoic —no. (%)645 (71.0)264 (29.0)isoechoic —no. (%)40 (78.4)11 (21.6)heterogeneous —no. (%)136 (64.8)74 (35.2)posterior featuresp&lt;0.0001none —no. (%)590 (73.2)216 (26.8)enhancement —no. (%)249 (83.3)50 (16.7)shadowing —no. (%)53 (37.6)88 (62.4)combined pattern —no. (%)20 (58.8)14 (41.2)calcificationp&lt;0.0001no calcification —no. (%)894 (73.8)317 (26.2)calcification —no. (%)22 (30.1)51 (69.9)

Citation Format: André Pfob, Richard G. Barr, Volker Duda, Christopher Buesch, Joerg Heil, Michael Golatta. Identifying the most relevant descriptors when evaluating ultrasound images in breast cancer diagnostics: A secondary analysis of an international multicenter trial [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS3-16.

The Problem of Mammographic Breast Density - The Position of the DEGUM Working Group on Breast Ultrasound

Mammographic breast density correlates with breast cancer risk and also with the number of false-negative calls. In the USA these facts lead to the "Breast Density and Mammography Reporting Act" of 2011. In the case of mammographically dense breasts, the Working Group on Breast Ultrasound in Germany recommends explaining the advantages of adjunct imaging to women, depending on the individual breast cancer risk. Due to the particular structure of German healthcare, quality-assured breast ultrasound would be the first choice. Possible overdiagnosis, costs, potentially increased emotional stress should be addressed. In high familial breast cancer risk, genetic counselling and an intensified early detection program should be performed.

[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.

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.

3D breast ultrasound: a significant predictor in breast cancer reduction under pre-operative chemotherapy

BACKGROUND

The objective was the investigation of a possible predictive quantitative impact of initial tumor sphericity, measured by 3D sonography, on response to pre-operative chemotherapy.

PATIENTS AND METHODS

This 3D ultrasound study was conducted on 41 consecutive primary breast cancer patients who received pre-operative epirubicin and paclitaxel chemotherapy; the tumors were measured by 3D sonography and by pathology after chemotherapy. Sphericity was defined as the ratio of the smallest to the largest extent by 3D sonography.

RESULTS

A predictive impact of initial tumor sphericity on response to pre-operative chemotherapy was quantitatively identified for the first time. Sphericity was a significant predictor of pathological complete remission with a rank difference of 0.34 or about 1/3 i.e., spherical tumors were more likely to show successful remission.

CONCLUSION

Tumor sphericity as defined from 3D sonography could be predictive of response to pre-operative chemotherapy regimens; prospective investigation is suggested.

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.

Imprint cytology of core needle biopsy specimens of breast lesions. A rapid approach to detecting malignancies, with comparison of cytologic and histopathologic analyses of 173 cases

OBJECTIVE

To investigate whether imprint cytology of core needle biopsy (CNB) specimens from breast lesions is a useful method of rapidly obtaining additional diagnostic information and potentially can be used to reduce the number of biopsies needed.

STUDY DESIGN

Cytologic analysis was performed on 173 breast lesions and compared with their histopathologic diagnoses (143 malignant and 30 benign). For imprint cytology, one CNB specimen was rolled between two slides and stained with Diff-Quik and Papanicolaou stain.

RESULTS

The diagnostic overall accuracy of Diff-Quik stain (Papanicolaou stain) was 95.4% (95.9%), with a sensitivity of 96.5% (97.2%), specificity of 90% (90%), positive predictive value of 97.8% (97.8%) and negative predictive value of 84.3% (87.0%). There was no statistically significant difference between the stains. Histopathologic analysis had an overall accuracy of 97.7%, with a sensitivity of 97.2%, specificity and positive predictive value of 100% and a negative predictive value of 88.2%.

CONCLUSION

Imprint cytology of CNBs is a sensitive method of detecting malignancies in breast tumors. Diff-Quik is a rapid and reliable approach that can reduce the number of biopsies. Inadequate and suspicious cases should be evaluated based on complementary diagnostic procedures for breast lesions.

A tumorous type of pulmonary rhabdomyomatous dysplasia

We report an extraordinary case of tumorous type of rhabdomyomatous dysplasia without any other malformation in a fetus of 23 weeks gestation. Histologically, autopsy showed distinctive striated muscle tissue in the upper and middle lobes of the right lung. Unusual in this case, compared with previously published reports, is the absence of further malformations, the occurrence in the apical parts of the lung and the marked degree of rhabdomyomatous dysplasia. The case report is followed by a differential diagnosis, review of the literature and discussion of the pathogenesis.

The response of uterine fibroids to GnRH-agonist treatment can be predicted in most cases after one month

Twenty-seven patients with uterine fibroids were treated for 3 months with the GnRH-agonist goserelin prior to surgical myomectomy. Ovarian function was suppressed reliably in all patients. After three applications, 15 fibroids were reduced in volume by more than 50%, and one complete remission was achieved. Seven patients showed a decrease of 10-50% in volume. However, in 5 cases there was no significant reduction. Analysing the time course of the fibroid reduction, the response can be predicted in most cases as early as four weeks after the first injection. Retrospective statistical analysis showed that a 50% reduction in fibroid size due to GnRH treatment is preceded by a 35% reduction after 4 weeks in 81% of cases, and after 8 weeks in all cases. Only 2 of 12 fibroids, which showed a smaller response (less than 50%) to GnRH therapy, were reduced by more than 35% after 4 and 8 weeks. In most cases it seems to be possible to estimate the individual response to GnRH-application after the first injection, so that it is possible to stop therapy in non-responding patients.

Genetic amniocentesis in twin pregnancies: results of a multicenter study of 529 cases

To evaluate the risk of abortion after genetic amniocentesis in twin pregnancies, a retrospective study of 15 centers was performed. The spontaneous abortion rate up to 20 completed weeks of gestation was 2.3%; the abortion rate up to 28 completed weeks, as defined by WHO, was 3.7%. The abortion rate could not be correlated either with the number of needle insertions or with the type of marker dye used. There was also no correlation between the abortion rate and the gestational age at which amniocentesis was performed. A significant association was shown between congenital intestinal obstructions and the application of methylene blue intra-amniotically as a marker dye. Considering the increased natural loss rate in multiple gestations, amniocentesis in twin pregnancies seems to be a safe and reliable technique.

[Pätau syndrome without trisomy karyotype? Danger of restricted thinking in syndrome diagnosis]

By means of a case-report the problems of an uncritical usage of the terminus "syndrom" are pointed out. The report concerns with a newborn child clinically showing nearly all morphological characteristics of the "Pätau-Syndrom" without having a chromosomal aberration.

[Persistent cysts of the choroid plexus as sonographic indications of a genetic defect]

In the case of a 29-year-old woman an early SGA (small for gestational age) fetus was detected in her third pregnancy. This fact being already a possible indicator for a genetical defect, the fetus also showed permanent cysts of the Plexus choroideus as a sonographical symptom of a deletion of the chromosome 10 (10 qter). The value of Plexus choroideus cysts sonographically diagnosed during pregnancy is discussed by showing the differential diagnoses, the clinical proceedings in general and specially the indications for a chromosomal analysis.

[Vaginal sonography: pilot study for using in ovarian screening procedures]

From May to September 1987, 221 women of over 45 years of age were examined by transvaginal ultrasound at the Department of Gynaecology (Gynaecological Hospital) of the University of Marburg. Transvaginal ultrasound proved to be significantly superior to clinical examination, since palpation had resulted in "NAD" findings in all cases. The average diameter and the volume of postmenopausal ovaries, determined by transabdominal sonographic studies, were easily confirmed by the new method. In 6% of the 221 patients, pathological findings of the ovaries were clinically "NAD". Since the usefulness of transabdominal ultrasound in screening for ovarian cancer has already been confirmed by other authors, this pilot study aims at providing an opportunity to test transvaginal ultrasound also in a large ovarian cancer screening programme by furnishing the essential basic research data. Age-adapted average ovarian sizes and significant differences in size between the right and the left ovary were used to differentiate between normal and pathological findings as well as changes in the ovarian parenchymal patterns.

[Preoperative reduction of uterine leiomyoma by the GnRH-analog goserelin (zoladex)]

The administration of GnRH analogues is expected to improve treatment by avoiding hysterectomy, since problems connected with the surgical removal of leiomyomata are correlated with their size. In this study the GnRH analogue goserelin in its depot formulation (Zoladex, ICI, Plankstadt) was used for treating isolated leiomyomata of the uterus. All patients were treated for 3 months before myomectomy was performed. The complete regression of a large myoma (206 cm3) was observed in 1 of 11 patients. In 5 cases a reduction in volume of more than 50% was achieved. Ovarian function was suppressed by goserelin, after a short-term stimulation, within 7 +/- 3 days. Serum levels of 17 beta-oestradiol were found to be generally less than 25 pg/ml. All patients reported climacteric complaints, but in no case had therapy to be discontinued. After cessation of goserelin, restoration of ovarian function was observed in all patients.

[New possibilities for differentiated therapy of leiomyoma of the uterus using the GnRH agonist zoladex]

In a 28-year-old patient with a large uterine leiomyoma, complete tumor regression was achieved by the LHRH agonist Zoladex (ICI 118.630) when administered three times. During the follow-up period of three months, new myoma growth did not occur. On the basis of this case study, it is necessary to discuss a new therapy concept for the differentiated treatment of uterine leiomyomata in young women with a desire for pregnancy.

[Differential diagnosis of the axillary lymph node]

The authors report on clinically abnormal palpatory findings in the axilla. The radiology and sonography of these findings is described, as well as differential diagnosis between normal findings and benign as well as malignant changes. If it is not possible to confirm a benign aspect even by means of examination via relevant equipment, histological clarification must be sought whenever there is a new palpatory finding or if changes are noted.

[Initial clinical experiences with grid mammography]

The article reports on a comparison between 100 x-ray films (preparation radiographies, mammographies) with grid and a film/foil combination on the one hand, and conventional x-ray technique with material testing x-ray film on the other. The clear superiority of grid mammography is demonstrated by means of case examples.

[Ultrasound mammography: development, current status and limits]

Starting with a survey of the historical development of ultrasound-mammography the current status of this method within other diagnostic procedures of the breast is defined. Basing on over 1000 examinations since 1975 we report the sonographic possibilities in demonstrating different normal and pathologic breast structures. Pathologic structures are: Dudectasy, Cysts, Mastitis, Fibroadenoma, Carcinoma and Gynaecomasty. Own results are reported and the future of ultrasound mammography is discussed.

[Ultrasound mammography:special applications (author's transl)]

Clinical observations on more than 700 patients between September 1979 and October 1980 are reported. If cysts are suspected clinically, ultrasound mammography provides the most reliable diagnosis and is superior to all other methods for localization, fine-needle biopsy and follow-up. Since it is difficult to assess (due to summation effects), the radiologically dense breast (DY) is a further indication for sonography. In case of excentrically located palpatory findings, pregnant or immobile patients, ultrasound mammography can provide valuable diagnostic information.

[New aspects in ultrasound mammography (author's transl)]

We report about 239 ultrasound examinations of the breast using a new water-tank scanner (U.I.Octoson, Ausonics, Sydney, Australia). A very good tissue differentiation of the brease is caused by a special technique and a high resolution. Beside benign results, typical findings in 49 malignancies are demonstrated ("shadowing", "christmastree-sign") and its value discussed. All ultrasound examinations are correlated to X-ray mammography, thermography, needle-biopsy and patho-histology.