Imaging-led symptomatic breast clinics: a case for direct access to radiology.

Radiologists play a pivotal role in patient management in modern hospital medicine and more so with regard to breast imaging. The diagnosis of breast pathology hinges predominantly on mammography and ultrasound imaging. With reduced clinician confidence in clinical examination alone, virtually all patients with breast symptoms are being referred for imaging. The traditional 'one-stop' clinics are victims of their own success and demand outstrips availability. This article makes a case for imaging-led breast clinics to increase efficiency, reduce duplication of work and cost, and increase throughput of patients.

Digital breast tomosynthesis within a symptomatic "one-stop breast clinic" for characterization of subtle findings.

OBJECTIVE: The aim of the study was to evaluate the diagnostic accuracy of combination of full-field digital mammography [two dimension (2D)] and digital breast tomosynthesis [DBT, three dimension (3D)] by comparing the combination with 2D imaging in a symptomatic setting. METHODS: A retrospective analysis was conducted involving 103 patients who attended symptomatic breast clinics between March 2012 and September 2012. All had subtle signs on 2D images or ultrasound. Mammographic score distribution was compared between 2D imaging and 2D + 3D imaging, followed by comparison with the gold-standard histopathology. Receiver operative characteristic curves and area under curve (AUC) were calculated for 2D imaging and the combination imaging (2D + 3D). SPSS(®) v. 21 (IBM Corp., New York, NY; formerly SPSS Inc., Chicago, IL) was used for data analysis with p < 0.05 as statistically significant. RESULTS: M3 lesions were reduced from 91 (85.8%) to 18 (16.9%) with the combination imaging. The mean AUC ± 95% confidence interval for 2D images alone was 0.721 (0.662-0.905) and for combined 2D and 3D images was 0.901 (0.765-1.00). The difference in AUCs between the two modalities was 0.180. CONCLUSION: DBT (3D imaging) increases diagnostic accuracy in a symptomatic breast clinic setting and reduces the number of M3 mammograms, when used as an adjuvant to 2D images. Therefore, DBT has the potential to increase workflow efficiency in a symptomatic setting by reducing benign biopsies. ADVANCES IN KNOWLEDGE: DBT reduces the number of M3 mammograms when used in the symptomatic breast setting and has the potential to reduce benign biopsies.

How does semi-automated computer-derived CT measure of breast density compare with subjective assessments to assess mean glandular breast density, in patients with breast cancer?

OBJECTIVES: (a) To compare radiologists' breast mammographic density readings with CT subjective measures. (b) To correlate computer-derived measurement of CT density with subjective assessments. (c) To evaluate density distributions in this cohort of patients with breast cancer. METHODS: A retrospective review of mammograms and CT scans in 77 patients with breast cancer obtained within 1 year of each other was performed. Two radiologists independently reviewed both CT and mammograms and classified each case into four categories as defined by the breast imaging-reporting and data system of the American College of Radiology. Inter-reader agreements were obtained for both mammographic and CT density subjective evaluations by using the Cohen-weighted kappa statistic and Spearman correlation. The semi-automated computer-derived measurement of breast density was correlated with visual measurements. RESULTS: Inter-reader agreements were lower for subjective CT density grades than those for mammographic readings 0.428 [confidence interval (CI), 0.24-0.89] vs 0.571 (CI, 0.35-0.76). There was moderately good correlation between subjective CT density grades and the mammographic density grades for both readers (0.760 for Reader 1 and 0.913 for Reader 2). The semi-automated CT density measurement correlated well with the subjective assessments, with complete agreement of the density grades in 84.9% of patients and only one level difference in the rest. CONCLUSIONS: Semi-automated CT density measurements in the evaluation of breast density correlated well with subjective mammographic density measurement. ADVANCES IN KNOWLEDGE: There is good correlation between CT and mammographic density, but further studies are needed on how to incorporate semi-automated CT breast density measurement in the risk stratification of patients.

Screen-detected breast cancer: does presence of minimal signs on prior mammograms predict staging or grading of cancer?

AIM: To investigate whether the presence of minimal signs on prior mammograms predict staging or grading of cancer. MATERIALS AND METHODS: The previous mammograms of 148 consecutive patients with screen-detected breast cancer were examined. Women with an abnormality visible (minimal signs) on both current and prior mammograms formed the study group; the remaining patients formed the control group. Age, average size of tumour, tumour characteristic, histopathology, grade, and lymph node status were compared between the two groups, using Fisher's exact test. Cases in which earlier diagnosis would have made a significant prognostic difference were also evaluated. RESULTS: Eighteen percent of patients showed an abnormality at the site of the tumour on previous mammograms. There was no statistically significant difference between the two groups with respect to age, average size of tumour, histopathology, grade or lymph node status with p-values being 0.609, 0.781, 0.938, and 0.444, respectively. The only statistically significant difference between the two groups was tumour characteristics with more microcalcifications associated with either mass or asymmetrical density seen in the study group (p=0.003). Five patients in the study group showed lymph node positivity and were grade 3, and therefore, may have had possible gain from earlier diagnosis. CONCLUSION: The present study did not demonstrate a statistical difference in grading or staging between the group that showed "minimal signs" on prior mammograms versus normal prior mammograms. Microcalcification seems to be the most common characteristic seen in the missed cancer and a more aggressive management approach is suggested for breast microcalcifications.

Digital radiography. A comparison with modern conventional imaging.

The development of computed radiography over the past two decades has transformed radiological imaging. The radiology departments in the 21st century will look very different from those in the preceding period. In this review, the development of digital radiography is presented with a description of its various forms and a comparison with screen film radiography.