[Sonographic criteria for the differentiation of benign and malignant breast lesions using real-time spatial compound imaging in combination with XRES adaptive image processing]. / Dignitätskriterien der Mammasonografie unter Anwendung des Real-Time Compound Image in Kombination mit dem XRES Adaptiv Image Processing.

PURPOSE: The purpose of the study was to analyze sonographic criteria for the differentiation of benign and malignant breast lesions using real-time spatial compound imaging (CT) in combination with adaptive image processing (XRES). MATERIALS AND METHODS: In a retrospective analysis of 460 patients, the sonographic criteria: shape, orientation, margin, echo pattern and posterior acoustic features were determined using CT and XRES. All investigations were performed using a 12 MHz linear transducer. The findings were classified according to the DEGUM criteria analogous to BIRADS and were histologically confirmed by core needle or vacuum biopsy. Statistical analysis was performed using a Chi-square test, logistic uni- and multivariate regression analysis and an ROC-curve analysis to detect the false-positive rate. RESULTS: All investigated diagnostic criteria were significant in the descriptive analysis (Chi-squared). The multivariate analysis showed that the criteria of irregular shape versus round, and not circumscribed margin versus circumscribed margin as well as the posterior acoustic features of enhanced versus reduced have a significant influence on the prediction of a malignant finding. The univariate analysis also showed a statistical significance using the indifferent and not parallel orientation versus parallel. To attain a detection rate of > 95 %, a false-positive rate of 60 % must be expected. CONCLUSION: This study shows that when using CT in combination with XRES, the analyzed sonographic criteria for the differentiation of benign and malignant breast lesions are still of diagnostic value. In particular, the shape, margin and posterior sonographic features are important.

[Are breast biopsies adequately funded? A process cost & revenue analysis]. / Ist die Mammabiopsie ausreichend finanziert? Eine Prozesskosten & Erlösbetrachtung.

PURPOSE: The objective of the study was to determine whether the various breast biopsy procedures specified in the S 3 guidelines are sensibly represented within the current German health system as considered from a cost evaluation perspective. MATERIALS AND METHODS: This prospectively designed multicenter study analyzed 221 breast biopsies at 7 institutions from 04/2006 to 01/2007. Core needle biopsies, vacuum-assisted biopsies and surgical open biopsies under sonographic or mammographic guidance were evaluated. During an analysis of process costs, the individual process steps were recorded in diagrammatic form and assigned to the true consumption of resources. The actual resource consumption costs were entered. A process-related breakeven analysis was conducted to check whether the reimbursement of individual biopsy types covers the costs. RESULTS: Only sonographically guided core needle biopsy and surgical open biopsy are adequately reimbursed in the current German health system. All other breast biopsies indicate a negative profit margin. The principal reasons for under-funding are found in the area of reimbursement of investment and non-personnel costs. CONCLUSION: The reimbursement of breast biopsies must be improved in order to guarantee nationwide care of the population using the breast biopsy methods recommended in the S 3 guidelines and to avoid disincentives with respect to breast biopsy indications.

[MR imaging of the breast before and after neoadjuvant treatment - enhancement characteristics and T 2 signal intensity of breast cancers and breast parenchyma]. / MR-Mammografie vor und nach neoadjuvanter Systemtherapie - Enhancementcharakteristika und T 2-Signalinintensität von Mammakarzinomen und Drüsenparenchym.

PURPOSE: Analysis of enhancement characteristics and T 2 signal intensity (SI) of breast cancers and normal breast parenchyma on MR imaging (MRI) before and after neoadjuvant treatment (NT) to improve the assessment of therapy response. MATERIALS AND METHODS: Retrospective data analysis of 43 consecutive patients (mean age 49.9 years) with invasive breast cancers (T2 /T3) who received NT. Evaluation of breast MRI before and after NT with assessment of therapy response according to RECIST criteria as well as calculation of the maximum initial enhancement (Enh (max)), delayed enhancement (Enh (post)) and T 2 SI by ROI analyses of breast cancers and breast parenchyma. Comparison of therapy response and enhancement characteristics. RESULTS: Therapy response on MRI: 16.3 % (n = 7) complete remission (CR (MRT)), 53.5 % (n = 23) partial remission (PR (MRT)), 27.9 % (n = 12) stable disease (SD (MRT)) und 2.3 % (n = 1) progressive disease (PD (MRT)). Breast cancers showed a significant decrease in Enh (max) and T 2 SI as well as a significant increase in Enh (post) after NT (p < 0.01). Not any SI parameter of normal breast parenchyma showed a significant change after NT (p > 0.05). All cases with CR (MRT) had wash out or plateau shape of the SI time curve before NT and showed continuous enhancement thereafter. CONCLUSION: Breast MRI shows significant changes in enhancement characteristics and T 2 SI of breast cancers after NT, whereas normal breast parenchyma remains unchanged. SI data could possibly help to improve the assessment of therapy response by MRI. Prospective trials with larger study cohorts and MRI monitoring during NT are necessary to validate these results.

Selective microdochectomy after ductoscopic wire marking in women with pathological nipple discharge.

BACKGROUND: To investigate the diagnostic reliability of selective microdochectomy after direct ductoscopic wire marking of suspect lesions in patients with pathological nipple discharge. METHODS: Selective microdochectomy due to pathological discharge was performed in 33 patients with mean age of 51.7 years. Ductoscopes of 0.9 and 1.1 mm in diameter with a channel for wire marking were used. Only patients without sonographic or mammographic correlation for the discharge were included. The pathologic mammary duct was wire marked and extirpated under direct visual guidance via the ductoscope. The histological results were compared with cytology, galactography and ductoscopy. RESULTS: In 24 out of 33 cases (72%) an intraductal, epithelial proliferation was found histologically. The following sensitivities for intraductal, epithelial proliferations could be determined: cytology 4%, galactography 74%, and ductoscopy 78%. CONCLUSION: The method allows selective microdochectomy of the pathological duct and the intraductal proliferation under visual guidance. The resection volume can be reduced in contrast to the unselective ductectomy after injection of methylene blue.

[Diagnostic value of a breast MRI score for the prediction of malignancy of breast lesions detected solely with MRI]. / Diagnostische Wertigkeit des Göttinger Scores zur Malignitätsvorhersage von ausschliesslich in der MRT darstellbaren Mammaläsionen.

PURPOSE: To determine whether lesion scoring allows valid BI-RADS ((R)) classification and prediction of malignancy of breast lesions detectable solely with MRI. MATERIALS AND METHODS: Retrospective analysis of 86 patients who underwent MRI-guided localization and excisional biopsy of 100 breast lesions detectable only with MRI. Breast MRI was performed at 1.5 Tesla by means of a T 1w dynamic GE sequence. The positive predictive value (PPV) for malignancy was calculated for each score criterion separately, for the total score, and for corresponding BI-RADS classes. The PPV was correlated with histology. RESULTS: 31% (31/100) of breast lesions detectable only with MRI were malignant. Of the single score criteria only the lesion morphology criterion was significantly correlated with malignancy. The malignancy rate according to the breast MRI score was 0% for score 3, 18.2% for score 4, 32.1% for score 5 and each 50% for lesions of score 6 and 7. After translation into BI-RADS the malignancy rates were 0% for BI-RADS 3, 24.6% for BI-RADS 4 and 48.5% for BI-RADS 5 lesions. The thus defined BI-RADS classes were significantly correlated with malignancy. CONCLUSION: The combination of different lesion criteria to form a total breast MRI score and its translation into BI-RADS is useful in case of lesions detectable only with MRI. It enables standardized BI-RADS classification with satisfying PPV of malignancy for each BI-RADS class. Because of their low malignancy rate (18.2%), we suggest classifying lesions with a breast MRI score of 4 points as BI-RADS 4a.

Risk-benefit analysis of preoperative breast MRI in patients with primary breast cancer.

AIM: To analyse and compare the risks and benefits of preoperative breast MRI (BMRI) in patients with primary breast cancer (PBC), and to determine the influence of mammographic breast density (BD) and histological tumour type (TT). MATERIALS AND METHODS: One hundred and nineteen patients who underwent preoperative bilateral breast MRI for staging of PBC during a 1-year period from July 2005 to August 2006 were prospectively evaluated. Changes in clinical management due to BMRI findings were recorded. MRI-detected lesions were correlated with histology. Additional MRI-detected malignant lesions and spared additional biopsies because of negative MRI in case of unclear ultrasound findings were determined as beneficial for the patient. Biopsies of benign MRI detected lesions were defined as disadvantageous. The influence of BD (ACR 1-4) and TT on the change in clinical management and patient benefit was evaluated. RESULTS: The findings of the BMRI examinations changed the clinical management in 48 patients (40.3%). Seventeen women underwent mastectomy instead of breast conservation, eight patients underwent extended excision, 21 additional lesions were clarified by MRI intervention, and two ultrasound-detected lesions were not biopsied because of negative MRI. Histologically malignant additional or extended biopsies (n=34) and two cases of spared biopsies resulted in 36 (30.3%) women who benefited from preoperative BMRI. Twelve patients (10.1%) had additional biopsies of MRI-detected benign lesions, and therefore, had an unfavourable outcome due to BMRI. The change in clinical management and patient benefit were independent of BD and TT (p>0.05). CONCLUSION: Preoperative BMRI was beneficial for 30.3% of 119 patients with PBC. The percentage of additional biopsies of benign lesions (10.1%) seems acceptable.

[Diagnostic imaging during pregnancy]. / Radiologische Untersuchungen in der Schwangerschaft.

If diagnostic imaging during pregnancy is performed, potential risks not only for the mother but also for the fetus have to be considered. Ultrasonography should be performed primarily because it is harmless for the fetus. Other imaging modalities like x-ray, computed tomography (CT) and magnetic resonance imaging (MRI) should be reserved for cases in which results of ultrasonography are inconclusive and patient care depends on further imaging. If pulmonary disease is suspected (e. g. pneumonia) chest x-ray should be performed. CT should be considered if chest x-ray is nondiagnostic or inadequate (e. g. suspicion of pulmonary embolism). In patients with abdominal symptoms the indication either for CT or MRI depends on the presumed disease. Every abdominal CT during pregnancy should include an estimation of radiation dose. Dose estimation is not necessary after CT of the chest. In case of pelvic disease in particular concerning the ovaries and the uterus as well as fetal imaging MRI is the method of choice. Contrast media should only given intravenously when a compelling clinical indication exists and the potential benefit to the patient outhweights the potential risk to the fetus.

[Performance of a newly developed clip (Tumark Professional) for MRI-guided lesion localization after MRI-guided vacuum-assisted biopsy--first results]. / Einsatz eines speziellen Clips (Tumark Professional) zur postinterventionellen Markierung suspekter Mammaläsionen nach MRT-gestützter Vakuumbiopsie--erste Ergebnisse.

PURPOSE: Evaluation of a newly developed Clip (Tumark Professional) for MRI-guided lesion localization after MRI-guided vacuum-assisted biopsy (VAB) with regard to the exactness of positioning, migration, and visibility on mammography (MG), ultrasound (US) and MR imaging (MRI). MATERIALS AND METHODS: 27 consecutive patients with 29 suspicious breast lesions detected with MRI were prospectively evaluated. The location of the lesion was determined with Tumark (Somatex, Teltow, Germany) after MRI-guided VAB. The distance between the clip and lesion was measured via MRI. The qualitative visibility of the clip was assessed by means of a 5-point scale from very good (1 point) to not visible (5 points). The analysis was performed for MG, US and MRI separately. Clip movement was measured via MG. RESULTS: 9 lesions were malignant (31%). All but one lesion (96%) were able to be localized exactly with a clip-lesion distance of < or = 10 mm. The Tumark was visible in 27 cases (93.1%) in US and in 25 cases (86.2%) in MRI. The visibility of the clip was moderate for both modalities (mean 3.2 points). Its visibility in MG was always very good (1 point). The clip position was stable at the time of short term follow-up (1 - 7 months; mean deviation 4.5 mm). CONCLUSION: Precise positioning of the Tumark Professional is usually possible. The clip is mostly visible in US. At the time of short-term follow-up, there was no relevant movement. Therefore, Tumark seems to be suitable for MRI-guided lesion localization after MRI-guided VAB of suspicious breast lesions. Further improvement of US visibility would be beneficial.

Management of late recurrence of a low-grade endometrial stromal sarcoma (LGESS): treatment with letrozole.

Low grade endometrial stromal sarcoma (LGESS) is a rare disease. LGESS usually expresses steroidal receptors and is regarded to be hormone-sensitive. Due to the rarity of the tumor, only few case series have been published so far. Here, we report the case of a 36-year-old woman who underwent an abdominal hysterectomy with bilateral salpingo-oophorectomy and adjuvant radiotherapy for a G1 LGESS in 1991. Twelve years later she presented to us with pelvic and peritoneal masses. The patient was treated with letrozole achieving a partial response which is lasting 39 months. Treatment is ongoing. Aromatase inhibitors represent an interesting treatment option for LGESS.

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.

Comparison of full-field digital mammography and film-screen mammography: image quality and lesion detection.

The objective of this study is to compare image quality and lesion detection for full field digital mammography (FFDM) and film-screen mammography (FSM). In 200 women we performed digital mammography of one breast and film-screen mammography of the other breast. Imaging parameters were set automatically. Image quality, visualization of calcifications and masses were rated by three readers independently. Mean glandular dose was calculated for both systems. We found no significant difference in mean glandular dose. Image quality was rated by reader A/B/C as excellent for FFDM in 153/155/167 cases and for FSM in 139/116/114 cases (p<0.03/0.001/0.001). Microcalcifications were detected by FFDM in 103/89/98 and by FSM in 76/76/76 cases (p<0.01/0.06/0.01). Detection of masses did not differ significantly. FFDM provided significantly better visibility of skin and nipple-areola region (p<0.01). FFDM demonstrated improved image quality compared with film-screen mammography. Microcalcification detection was also significantly better with the digital mammography system for two of the three readers.

Microcalcifications of the breast: how does radiologic classification correlate with histology?

PURPOSE: To assess the correlation between the pre-biopsy classification of microcalcifications and the underlying histology. MATERIAL AND METHODS: Using the morphology and distribution patterns according to the Breast Imaging-Reporting and Data System (BI-RADS) lexicon, the microcalcifications of 199 lesions in 163 consecutive patients scheduled to undergo 11 G vacuum core biopsy were classified within the BI-RADS categories. The correlation between BI-RADS assessment categories 3, 4, and 5 and the final histological results was statistically evaluated with the chi2 test. The diagnostic indices were calculated. RESULTS: The prospectively classified BI-RADS 3/4/5 findings revealed a malignant histology in 5.9%/17.6%/90.9% of all lesions, respectively. The relationship between BIRADS categories 3, 4, and 5 and histology was statistically highly significant (P<0.0001). The sensitivity, specificity, positive and negative predictive values were 95.7%/21.2%,/37.8%/94.3%, respectively. CONCLUSION: The BI-RADS lexicon describes microcalcifications of the breast and provides diagnostic categories that lead to standardized biopsy recommendations. Nevertheless, how to link description to classification of microcalcifications is still a difficult diagnostic task. The evaluation of microcalcifications as proposed in this article may help to set standards in the clinical routine and in the comparability of scientific data.

[Radiologic-histopathologic correlation of microcalcifications from 11g vacuum biopsy: analysis of 3196 core biopsies]. / Radiologisch-histopathologische Korrelation von Mikrokalzifikationen in 11-G-Vakuumbiopsaten - eine Analyse von insgesamt 3196 Proben.

PURPOSE: To perform a statistical evaluation of microcalcifications (MC) from suspicious breast lesions detected by radiography and histopathology. MATERIALS AND METHODS: Histological and radiological detection of calcifications were compared from 116 biopsies in 96 women. Lesions with identical description of calcifications detected in histopathology and radiography were considered concordant, patients with obvious discrepancies discordant. If histological and radiological groups of calcifications were identical in number but differed in location, the case was considered pseudo-concordant. RESULTS: Histopathology classified 24 of 116 lesions as malignant and 92 as benign. A total of 3196 core biopsies were examined, 851 of these contained groups of calcifications or single calcifications. Both modalities detected 579 calcifications, with 169 exclusively detected by radiography and 103 exclusively by histopathology. In 35 cases (30 %) radiologic and pathologic results were concordant, in 6 cases pseudo-concordant (4 %) and in 75 cases (65 %) discordant. The case-based Kappa coefficient was - 0.09 (- 0.24 to 0.07). The 122 calcifications not detected by histopathology were few or single calcifications at the edge of the core that were probably lost during processing, 18 were possible artefacts. Six cores contained calcium oxalate, 3 contained milk of calcium. In 6 cases malignant disease was found after the first examination, hence the cores were not searched thoroughly for the missing calcifications. In the remaining 14 cases, no calcifications were found despite complete processing of the tissue. In 49 of 103 cases of radiologically undetected microcalcifications, the retrospect analysis showed dense tissue areas that probably contained the calcification. The remaining 54 cases contained calcifications, which were too small to be detected radiologically. SUMMARY: Discordant results from pathological and radiological examinations of biopsies can mainly be explained by calcifications at the edge of the specimen lost during processing, which are therefore not detected in histopathology, and calcifications too small to be visualized radiologically.

[Stereotactic vacuum-assisted breast biopsy--success, histologic accuracy, patient acceptance and optimizing the BI-RADSTM-correlated indication]. / Stereotaktische Vakuumbiopsie mammographisch detektierter Läsionen - Erfolg, histologische Sicherheit, Patientenakzeptanz und BI-RADS trade mark -korrelierte Indikationsoptimierung.

PURPOSE: To evaluate success, histologic accuracy, patient acceptance and BI-RADS TM-correlated malignancy rate of stereotactic vacuum-assisted breast biopsies in order to optimize the indication. MATERIALS AND METHODS: In 132 patients with mammographically detected breast lesions 166 stereotactic vacuum- assisted 11 gauge core biopsies were performed. All lesions were classified according to the BI-RADS TM categories of the ACR. Removal of the lesion was radiographically assessed as complete, representative or not representative. Patient acceptance was evaluated. RESULTS: Of the 166 lesions, 54 (32.5 %) lesions were judged completely removed, 110 (66.3 %) representatively removed and 2 (1.2 %) not representatively removed. Malignancy was found in 38 (22.9 %) lesions. The rate of malignancy increased from 6.3 % (2/32) for BI-RADS TM category 3 to 16.7 % (19/114) for BI-RADS TM category 4 and increased further to 85 % (17/20) for BI-RADS TM category 5 (p < 0.001). The histology of a sufficient vacuum-assisted biopsy was underestimated in 6 (15 %) of the 40 lesions that were subsequently excised surgically. Most patients (98.5 %; 130/132) stated they would undergo a vacuum-assisted biopsy again. CONCLUSION: Vacuum-assisted breast biopsy is accurate, has a justifiable rate of histologic underestimation and is well accepted by patients. Patients with BI-RADS TM category 4 microcalcification benefit the most. Lesions of BI-RADS TM category 3 and BI-RADS TM category 5 should be biopsied only under special circumstances (family risk of breast cancer; assessment of lesions extension).

Large-core needle biopsy for diagnosis and treatment of breast lesions.

PURPOSE: Large-core needle biopsy (LCNB) has become a more widely used technique in the evaluation of breast lesions. This study was undertaken to access the accuracy of percutaneous LCNB on breast lesions and the impact on further proceeding. METHODS: A retrospective review of imaging-guided LCNB of 159 breast lesions was done. 143 LCNB were taken with ultrasound guided automated spring gun biopsy and 16 stereotactic-guided with vacuum-assisted biopsy device. Histology and morphobiological parameters were compared with subsequent material from surgery. RESULTS: In 113 core biopsies (71%), an infiltrating breast cancer was diagnosed, 5 biopsies (3%) yielded in-situ/atypical lesions and a benign lesion was shown in 38 cases (24%). In 3 cases, insufficient/necrotic material was obtained. 108 patients underwent subsequent surgery. In 100/108 cases (93%), histology on LCNB and surgery was identical. LCNB was false negative in 5 core biopsies (5%). Immunhistochemical stains of hormone receptors, bcl-2, c-erbB-2, p53 and MIB-1 was comparable on LCNB and on surgical material. Based on the results of LCNB, 17/113 patients (15%) with infiltrating carcinoma were primarily treated with hormones or with neoadjuvant therapy. 32/38 patients (84%) with benign lesions were followed up by imaging control. CONCLUSIONS: In patients with benign lesions on imaging, open biopsies can be avoided by LCNB. In patients with biopsy proven carcinoma, therapy planning is improved. The addition of morphobiological parameters allows early individual treatment.

Density and Fractal-like Dimension of Particles from a Laminar Diffusion Flame.

The evolution of the size distribution in a normal and in a ferrocene (Fe(C(5)H(5))(2))-doped laminar diffusion flame is measured with a scanning mobility particle sizer. Measurements with a low-pressure impactor and a differential mobility analyzer allow the determination of the density (rho) and the fractal-like dimension (d(f)) of particles sampled from a laminar diffusion flame. Various fuels are used and in the case of CH(4), the flame is doped with ferrocene. In all cases the particle densities are low, typically below 700 kg/m(3). The data acquired from the doped flame support previous studies with ferrocene and enable us to propose a further refinement. Copyright 1999 Academic Press.

Monoclonal antibodies specific for Sendai virus. II. Production of monoclonal anti-idiotypic antibodies.

The monoclonal antibodies A and B specific for the HN molecule of Sendai virus were used to induce polyclonal and monoclonal anti-idiotypic antibodies. No response was observed in allogeneic Lewis rats, low responses in syngeneic LOU rats, and high responses in allogeneic BN rats and xenogeneic Balb/c mice. The monoclonals A and B share a similar or identical idiotype, since polyclonal anti-idiotypic antisera to antibody A cross-reacted completely with antibody B and vice versa. The same was found with the three monoclonal anti-idiotypes 1, 2, and 3 elicited in a BN rat or in Balb/c mice. None of the polyclonal or monoclonal anti-idiotypes reacted with other monoclonal antibodies specific for Sendai virus, even when these recognized the same epitope as antibodies A and B. The monoclonal anti-idiotypic antibodies could be used to induce anti-Sendai antibodies in BN rats.