Theoretical and practical knowledge curriculum for European Breast Surgeons.

The Breast Surgery theoretical and practical knowledge curriculum comprehensively describes the knowledge and skills expected of a fully trained breast surgeon practicing in the European Union and European Economic Area (EEA). It forms part of a range of factors that contribute to the delivery of high quality cancer care. It has been developed by a panel of experts from across Europe and has been validated by professional breast surgery societies in Europe. The curriculum maps closely to the syllabus of the Union of European Medical Specialists (UEMS) Breast Surgery Exam, the UK FRCS (breast specialist interest) curriculum and other professional standards across Europe and globally (USA Society of Surgical Oncology, SSO). It is envisioned that this will serve as the basis for breast surgery training, examination and accreditation across Europe to harmonise and raise standards as breast surgery develops as a separate discipline from its parent specialties (general surgery, gynaecology, surgical oncology and plastic surgery). The curriculum is not static but will be revised and updated by the curriculum development group of the European Breast Surgical Oncology Certification group (BRESO) every 2 years.

Breast Density Assessment in Young Women with Ultrasound based on Speed of Sound: Influence of the Menstrual Cycle.

To investigate changes in breast density (BD) during the menstrual cycle in young women in comparison to inter-breast and -segment changes as well as reproducibility of a novel Speed-of-Sound (SoS) Ultrasound (US) method.SoS-US uses a conventional US system with a reflector and a software add-on to quantify SoS in the retro-mammillary, inner and outer segments of both breasts. Twenty healthy women (18-40 years) with regular menstrual cycles were scanned twice with two weeks in-between. Three of these were additionally measured twice per week for 25 days. Average SoS (m/s) and ΔSoS (segment-variation SoS; m/s) were measured. Variations between follicular and luteal phases and changes over the four-week period were assessed. Inter-examiner and inter-reader agreements were also evaluated. Variances between cycle phases, examiners and readers were compared.No significant SoS difference was observed between follicular and luteal phases for the twenty women (P = .126), and between all different days for the three more frequently measured women (P = .892). Inter-reader (ICC = 0.999) and inter-examiner (ICC = 0.990) agreements were high. The SoS variance due to menstrual variations was not significantly larger than the inter-examiner uncertainty (P = .461). Inter-reader variations were significantly smaller than menstrual and examiner variations (P < .001).SoS-US showed high inter-examiner and inter-reader reproducibility. The alterations during the menstrual cycles were not significantly larger than the confidence interval of measurements.

Transverse relaxation-based assessment of mammographic density and breast tissue composition by single-sided portable NMR.

PURPOSE: Elevated mammographic density (MD) is an independent risk factor for breast cancer (BC) as well as a source of masking in X-ray mammography. High-frequency longitudinal monitoring of MD could also be beneficial in hormonal BC prevention, where early MD changes herald the treatment's success. We present a novel approach to quantification of MD in breast tissue using single-sided portable NMR. Its development was motivated by the low cost of portable-NMR instrumentation, the suitability for measurements in vivo, and the absence of ionizing radiation. METHODS: Five breast slices were obtained from three patients undergoing prophylactic mastectomy or breast reduction surgery. Carr-Purcell-Meiboom-Gill (CPMG) relaxation curves were measured from (1) regions of high and low MD (HMD and LMD, respectively) in the full breast slices; (2) the same regions excised from the full slices; and (3) excised samples after H2 O-D2 O replacement. T2 distributions were reconstructed from the CPMG decays using inverse Laplace transform. RESULTS: Two major peaks, identified as fat and water, were consistently observed in the T2 distributions of HMD regions. The LMD T2 distributions were dominated by the fat peak. The relative areas of the two peaks exhibited statistically significant (P < .005) differences between HMD and LMD regions, enabling their classification as HMD or LMD. The relative-area distributions exhibited no statistically significant differences between full slices and excised samples. CONCLUSION: T2 -based portable-NMR analysis is a novel approach to MD quantification. The ability to quantify tissue composition, combined with the low cost of instrumentation, make this approach promising for clinical applications.

Quantitative CT Assessment of Gynecomastia in the General Population and in Dialysis, Cirrhotic, and Obese Patients.

RATIONALE AND OBJECTIVES: Gynecomastia is the benign enlargement of the male breast because of proliferation of the glandular component. To date, there is no radiological definition of gynecomastia and no quantitative evaluation of breast glandular tissues in the general male population. The aims of this study were to supply radiological-based measurements of breast glandular tissue in the general male population, to quantitatively assess the prevalence of gynecomastia according to age by decades, and to evaluate associations between gynecomastia and obesity, cirrhosis, and dialysis. MATERIALS AND METHODS: This retrospective study included 506 men who presented to the emergency department following trauma and underwent chest-abdominal computed tomography. Also included were 45 patients undergoing hemodialysis and 50 patients with cirrhosis who underwent chest computed tomography. The incidence and size of gynecomastia for all the study population were calculated. RESULTS: Breast tissue diameters of 22 mm, 28 mm, and 36 mm corresponded to 90th, 95th, and 97.5th cumulative percentiles of diameters in the general male population. Peaks of gynecomastia were shown in the ninth decade and in boys aged 13-14 years. Breast tissue diameter did not correlate with body mass index (r = -0.031). Patients undergoing hemodialysis and patients with cirrhosis had higher percentages (P < .0001) of breast tissue diameters above 22 mm, 28 mm, and 36 mm. CONCLUSIONS: Breast tissue diameter is a simple and reliable quantitative tool for the assessment of gynecomastia. This method provides the ability to determine the incidence of gynecomastia by age in the general population. Radiological gynecomastia should be defined as 22 mm, 28 mm, or 36 mm (90th, 95th, and 97.5th percentiles, respectively). Radiological gynecomastia is not associated with obesity, but is associated with cirrhosis and dialysis.

Understanding key performance indicators for breast support: An analysis of breast support effects on biomechanical, physiological and subjective measures during running.

To assess the effectiveness of breast support previous studies monitored breast kinematics and kinetics, subjective feedback, muscle activity (EMG), ground reaction forces (GRFs) and physiological measures in isolation. Comparing these variables within one study will establish the key performance variables that distinguish between breast supports during activities such as running. This study investigates the effects of changes in breast support on biomechanical, physiological and subjective measures during running. Ten females (34D) ran for 10 min in high and low breast supports, and for 2 min bare breasted (2.8 m·s-1). Breast and body kinematics, EMG, expired air and heart rate were recorded. GRFs were recorded during 10 m overground runs (2.8 m·s-1) and subjective feedback obtained after each condition. Of the 62 variables measured, 22 kinematic and subjective variables were influenced by changes in breast support. Willingness to exercise, time lag and superio-inferior breast velocity were most affected. GRFs, EMG and physiological variables were unaffected by breast support changes during running. Breast displacement reduction, although previously advocated, was not the most sensitive variable to breast support changes during running. Instead breast support products should be assessed using a battery of performance indicators, including the key kinematic and subjective variables identified here.

Assessment of breast absorbed doses during thoracic computed tomography scan to evaluate the effectiveness of bismuth shielding.

During a lung computed tomography (CT) examination, breast and nearby radiosensitive organs are unnecessarily irradiated because they are in the path of the primary beam. The purpose of this paper is to determine the absorbed dose in breast and nearby organs for unshielded and shielded exposures with bismuth. The experiment was done with a female anthropomorphic phantom undergoing a typical thoracic CT scan, with TLD-100 thermoluminescent detectors insert at breast, lung and thyroid positions. Results showed that dose reduction due to bismuth shielding was approximately 30% and 50% for breast and thyroid, respectively; however, the influence of the bismuth on the image quality needs to be considered.

Introduction of an automated user-independent quantitative volumetric magnetic resonance imaging breast density measurement system using the Dixon sequence: comparison with mammographic breast density assessment.

OBJECTIVES: The purposes of this study were to introduce and assess an automated user-independent quantitative volumetric (AUQV) breast density (BD) measurement system on the basis of magnetic resonance imaging (MRI) using the Dixon technique as well as to compare it with qualitative and quantitative mammographic (MG) BD measurements. MATERIALS AND METHODS: Forty-three women with normal mammogram results (Breast Imaging Reporting and Data System 1) were included in this institutional review board-approved prospective study. All participants were subjected to BD assessment with MRI using the following sequence with the Dixon technique (echo time/echo time, 6 milliseconds/2.45 milliseconds/2.67 milliseconds; 1-mm isotropic; 3 minutes 38 seconds). To test the reproducibility, a second MRI after patient repositioning was performed. The AUQV magnetic resonance (MR) BD measurement system automatically calculated percentage (%) BD. The qualitative BD assessment was performed using the American College of Radiology Breast Imaging Reporting and Data System BD categories. Quantitative BD was estimated semiautomatically using the thresholding technique Cumulus4. Appropriate statistical tests were used to assess the agreement between the AUQV MR measurements and to compare them with qualitative and quantitative MG BD estimations. RESULTS: The AUQV MR BD measurements were successfully performed in all 43 women. There was a nearly perfect agreement of AUQV MR BD measurements between the 2 MR examinations for % BD (P < 0.001; intraclass correlation coefficient, 0.998) with no significant differences (P = 0.384). The AUQV MR BD measurements were significantly lower than quantitative and qualitative MG BD assessment (P < 0.001). CONCLUSIONS: The AUQV MR BD measurement system allows a fully automated, user-independent, robust, reproducible, as well as radiation- and compression-free volumetric quantitative BD assessment through different levels of BD. The AUQV MR BD measurements were significantly lower than the currently used qualitative and quantitative MG-based approaches, implying that the current assessment might overestimate breast density with MG.

Characterization and assessment of hyperelastic and elastic properties of decellularized human adipose tissues.

Decellularized adipose tissue (DAT) has shown potential as a regenerative scaffold for plastic and reconstructive surgery to augment or replace damaged or missing adipose tissue (e.g. following lumpectomy or mastectomy). The mechanical properties of soft tissue substitutes are of paramount importance in restoring the natural shape and appearance of the affected tissues, and mechanical mismatching can lead to unpredictable scar tissue formation and poor implant integration. The goal of this work was to assess the linear elastic and hyperelastic properties of decellularized human adipose tissue and compare them to those of normal breast adipose tissue. To assess the influence of the adipose depot source on the mechanical properties of the resultant decellularized scaffolds, we performed indentation tests on DAT samples sourced from adipose tissue isolated from the breast, subcutaneous abdominal region, omentum, pericardial depot and thymic remnant, and their corresponding force-displacement data were acquired. Elastic and hyperelastic parameters were estimated using inverse finite element algorithms. Subsequently, a simulation was conducted in which the estimated hyperelastic parameters were tested in a real human breast model under gravity loading in order to assess the suitability of the scaffolds for implantation. Results of these tests showed that in the human breast, the DAT would show similar deformability to that of native normal tissue. Using the measured hyperelastic parameters, we were able to assess whether DAT derived from different depots exhibited different intrinsic nonlinearities. Results showed that DAT sourced from varying regions of the body exhibited little intrinsic nonlinearity, with no statistically significant differences between the groups.

Objective breast volume, shape and surface area assessment: a systematic review of breast measurement methods.

BACKGROUND: There are many methods of measuring the breast and their clinical applications are well described in the literature. However, there has been no attempt to compare these various methods to allow the user to have a broad overview of the subject. The authors have attempted to summarise all the available methods to measure the breast in this article to provide a useful reference for all. METHODS: A comprehensive literature search of PubMed was performed, and the resulting articles were screened and reviewed. The data regarding the methods' mechanism, reliability, time and cost were evaluated and compared. RESULTS: A total of 74 articles dating from 1970 to 2013 were included in this study. All of the methods can be classified into those that measure (1) volume, (2) shape and (3) surface area. Each category consists of several methods that work through different mechanisms and they vary in their reliability and feasibility. Based on their mechanism, the volume measurement methods were further grouped into the natural shape methods, the stereological method, the geometrical methods and the mathematical modelling method. CONCLUSIONS: More objective breast evaluation can be achieved if all three dimensions (volume, shape and surface area) are considered. In the volume measurements, 3D modelling and the MRI are the most reliable tools. Linear measurement (geometry) and mathematical modelling are less accurate but are more economical. In the shape measurements, besides the traditional linear measurement, 3D methods that can deliver colour-coded maps and Swanson's 2D photographic measurement system are capable of depicting and tracking breast shape changes after surgery. Although the surface area metric has not been used extensively, it has potential in clinical and research applications. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

The assessment of sensory detection thresholds on the perineum and breast compared with control body sites.

INTRODUCTION: Few studies explored multiple sensory detection thresholds on the perineum and breast, but these normative data may provide standards for clinical conditions such as aging, genital and breast surgeries, pathological conditions affecting the genitals, and sexual function. AIMS: The aim of this study was to provide normative data on sensory detection thresholds of three sensory modalities on the perineum and breast. METHODS: Thirty healthy women aged between 18 and 35 years were assessed on the perineum (clitoris, labia minora, vaginal, and anal margin), breast (lateral, areola, nipple), and control body locations (neck, forearm, abdomen) for three sensory modalities (light touch, pressure, vibration). MAIN OUTCOME MEASURES: Average detection thresholds for each body location and sensory modality and statistical comparisons between the primary genital, secondary sexual, and neutral zones were the main outcome measures. RESULTS: Average detection thresholds for light touch suggest that the neck, forearm, and vaginal margin are most sensitive, and areola least sensitive. No statistical difference is found between the primary and secondary sexual zones, but the secondary sexual zone is significantly more sensitive than the neutral zone. Average detection thresholds for pressure suggest that the clitoris and nipple are most sensitive, and the lateral breast and abdomen least sensitive. No statistical difference is found between the primary and secondary sexual zone, but they are both significantly more sensitive than the neutral zone. Average detection thresholds for vibration suggest that the clitoris and nipple are most sensitive. The secondary sexual zone is significantly more sensitive than the primary and neutral zone, but the latter two show no difference. CONCLUSION: The current normative data from sensory detection threshold are discussed in terms of providing standard values for research and clinical conditions. Additional analysis from breast volume, body mass index, hormonal contraception, menstrual cycle, and sexual orientation do not seem to influence the results. Sexual abstinence and body piercing may have some impact.

Breast imaging using electrical impedance tomography: correlation of quantitative assessment with visual interpretation.

BACKGROUND: Electrical impedance tomography (EIT) is a new non-invasive, mobile screening method which does not use ionizing radiation to the human breast; allows conducting quantitative assessment of the images besides the visual interpretation. The aim of this study was to correlate the quantitative assessment and visual interpretation of breast electrical impedance tomographs and associated factors. MATERIALS AND METHODS: One hundred and fifty mammography patients above 40 years and undergoing EIT were chosen using convenient sampling. Visual interpretation of the images was carried out by a radiologist with minimum of three years experience using the breast imaging - electrical impedance (BI-EIM) classification for detection of abnormalities. A set of thirty blinded EIT images were reinterpreted to determine the intra-rater reliability using kappa. Quantitative assessment was by comparison of the breast average electric conductivity with the norm and correlations with visual interpretation of the images were determined using Chi-square. One-way ANOVA was used to compare the mean electrical conductivity between groups and t-test was used for comparisons with pre-existing Caucasians statistics. Independent t-tests were applied to compare the mean electrical conductivity of women with factors like exogenous hormone use and family history of breast cancer. RESULTS: The mean electrical conductivity of Malaysian women was significantly lower than that of Caucasians (p<0.05). Quantitative assessment of electrical impedance tomography was significantly related with visual interpretation of images of the breast (p<0.05). CONCLUSIONS: Quantitative assessment of electrical impedance tomography images was significantly related with visual interpretation.

Multilayer imaging and compositional analysis of human male breast by laser reflectometry and Monte Carlo simulation.

The laser backscattering from biological tissues depends on their composition and blood flow. The onset of abnormalities in tissues is associated with the change in composition at a specific location which may affect laser backscattering. The objective of this work is to study the point-to-point compositional variation of male breast tissues as this site has been prone to cancer development. The normalized backscattered intensity (NBI) profiles at various locations of human chest region of five subjects by multi-probe laser reflectometer are obtained. Based on these data the images of tissue composition, showing the point-to-point changes at various depths from the tissue surface, are reconstructed. The analysis of data shows that the maximum NBI variation is at the pectoralis major muscle and minimum variation is observed at the sternum. The optical parameters, based on the NBI data obtained for five human subjects, show the maximum increase in absorption (p < 0.0001) and minimum change in scattering (p < 0.0001) coefficients compared to that as observed at the sternum. Also the minimum absorption and maximum scattering coefficients are observed at the pectoralis major muscles. The regional variations of NBI and optical parameters further support these findings. The variations in the NBI and optical parameters may indicate the compositional change in tissues, which could be used for diagnostic and therapeutic applications of laser.

Can compression be reduced for breast tomosynthesis? Monte carlo study on mass and microcalcification conspicuity in tomosynthesis.

PURPOSE: To assess, in a voxelized anthropomorphic breast phantom, how the conspicuity of breast masses and microcalcifications may be affected by applying reduced breast compression in tomosynthesis. MATERIALS AND METHODS: A breast tomosynthesis system was modeled by using a Monte Carlo program and a voxelized anthropomorphic breast phantom. The Monte Carlo program created simulated tomosynthesis projection images, which were reconstructed by using filtered back-projection software. Reconstructed images were analyzed for mass and microcalcification conspicuity, or the ratio of the lesion contrast to the anatomic and quantum noise surrounding the lesion. This analysis was performed at two compression levels (standard and 12.5% reduction) and for two breast compression thicknesses (4 and 6 cm). The change in conspicuity was analyzed for significance by using a bootstrap method and a paired Student t test. RESULTS: While keeping the glandular radiation dose constant with respective standard and reduced compression levels, the mean mass conspicuities were 1.39 +/- 0.15 (standard error of the mean) and 1.46 +/- 0.22 for a 4-cm breast compression phantom and 1.26 +/- 0.15 and 1.22 +/- 0.20 for a 6-cm breast phantom, and the mean microcalcification conspicuities were 16.2 +/- 2.87 and 18.6 +/- 2.63 for a 4-cm breast phantom and 11.4 +/- 1.11 and 10.6 +/- 1.18 for a 6-cm breast compression phantom. CONCLUSION: For constant glandular dose, mass and microcalcification conspicuity remained approximately constant with decreased compression. Constant conspicuity implies that reduced compression would have a minimal effect on radiologists' performance, which suggests that there is justification for a measured reduction of breast compression for breast tomosynthesis, increasing the comfort of women undergoing the examination.

Monte Carlo simulations to assess the effects of tube current modulation on breast dose for multidetector CT.

Tube current modulation was designed to reduce radiation dose in CT imaging while maintaining overall image quality. This study aims to develop a method for evaluating the effects of tube current modulation (TCM) on organ dose in CT exams of actual patient anatomy. This method was validated by simulating a TCM and a fixed tube current chest CT exam on 30 voxelized patient models and estimating the radiation dose to each patient's glandular breast tissue. This new method for estimating organ dose was compared with other conventional estimates of dose reduction. Thirty detailed voxelized models of patient anatomy were created based on image data from female patients who had previously undergone clinically indicated CT scans including the chest area. As an indicator of patient size, the perimeter of the patient was measured on the image containing at least one nipple using a semi-automated technique. The breasts were contoured on each image set by a radiologist and glandular tissue was semi-automatically segmented from this region. Previously validated Monte Carlo models of two multidetector CT scanners were used, taking into account details about the source spectra, filtration, collimation and geometry of the scanner. TCM data were obtained from each patient's clinical scan and factored into the model to simulate the effects of TCM. For each patient model, two exams were simulated: a fixed tube current chest CT and a tube current modulated chest CT. X-ray photons were transported through the anatomy of the voxelized patient models, and radiation dose was tallied in the glandular breast tissue. The resulting doses from the tube current modulated simulations were compared to the results obtained from simulations performed using a fixed mA value. The average radiation dose to the glandular breast tissue from a fixed tube current scan across all patient models was 19 mGy. The average reduction in breast dose using the tube current modulated scan was 17%. Results were size dependent with smaller patients getting better dose reduction (up to 64% reduction) and larger patients getting a smaller reduction, and in some cases the dose actually increased when using tube current modulation (up to 41% increase). The results indicate that radiation dose to glandular breast tissue generally decreases with the use of tube current modulated CT acquisition, but that patient size (and in some cases patient positioning) may affect dose reduction.

Relationship of estrogen and progesterone receptor protein levels in carcinomatous and adjacent non-neoplastic epithelium of the breast: a histopathologic and image cytometric study.

BACKGROUND: Results of a previous study demonstrating a correlation between steroid hormone receptor concentrations in benign and tumor tissue in patients with breast carcinoma suggest that receptor levels in breast epithelium undergoing malignant transformation may play a role in determining the receptor levels in the resulting carcinoma. Data used in that study were derived from ligand binding assays and may reflect shortcomings inherent in this methodology, particularly the dilution of receptor proteins from benign and malignant epithelial cells by stromal components. METHODS: We performed a correlation study of steroid hormone receptor expression in benign and malignant breast epithelial cells using computerized image cytometry and histologic sections stained for estrogen (ER) and progesterone receptor (PR), avoiding the problems of contribution of stromal cells to the measurements and uncertainty about the histologic composition of the sample. Sections which contained both tumor and non-neoplastic breast elements were obtained from surgical specimens from 50 patients with breast carcinoma. RESULTS: Positive area (PA) scores for ER in benign and malignant epithelium showed direct correlation that was significant (r = 0.46, p < 0.001), whereas those for PR, although trended in the same direction, did not (r = 0.17, p > 0.2). PA levels for both receptor proteins were higher in benign breast epithelium with proliferative features, compared to non-proliferative benign epithelium, and in tumors when the associated benign tissue had proliferative changes, but neither of these differences were statistically significant, suggesting that the correlation of ER levels in benign and malignant epithelium was not simply a function of proliferative change. CONCLUSION: Our results provide support for the concept that ER expression in breast carcinoma depends partially on epithelial cell receptor levels in the breast in which it arises, but not for the analogous hypothesis for PR. When costs and benefits of tamoxifen chemoprevention are weighed for a patient at risk for breast carcinoma, and when cyto- or histopathologic breast tissue specimens are available, it may be reasonable to include breast epithelial ER levels among the factors considered in making the treatment decision.

Evaluation of triple touch. An assessment of program delivery.

Triple Touch is a breast health education program developed by the Florida Division of the American Cancer Society in 1994. The program reaches more Florida women each year, and has a larger group of volunteers, than any other breast cancer program sponsored by this American Cancer Society division. The purpose of the evaluation of Triple Touch was to assess and evaluate the program delivery methods of the program. The specific objectives were to identify and describe instructor characteristics, program delivery patterns, and satisfaction with the program. Results will be used for the following purposes: 1) for the future development and implementation of the Triple Touch program; and 2) for building greatly needed research-based knowledge on program implementation and delivery methods. Last, important lessons were learned from using the Collaborative Evaluation Fellows Project model to conduct evaluation research from all perspectives, including those of the evaluation fellow, the evaluation faculty, and the evaluation facilitator.

Dosimetric implications of age related glandular changes in screening mammography.

The UK National Health Service Breast Screening Programme is currently organized to routinely screen women between the ages of 50 and 64, with screening for older women available on request. The lower end of this age range closely matches the median age for the menopause (51 years), during which significant changes in the composition of the breast are known to occur. In order to quantify the dosimetric effect of these changes, radiographic factors and compressed breast thickness data for a cohort of 1258 women aged between 35 and 79 undergoing breast screening mammography have been used to derive estimates of breast glandularity and mean glandular dose (MGD), and examine their variation with age. The variation of mean radiographic exposure factors with age is also investigated. The presence of a significant number of age trial women within the cohort allowed an extended age range to be studied. Estimates of MGD including corrections for breast glandularity based on compressed breast thickness only, compressed breast thickness and age and for each individual woman are compared with the MGD based on the conventional assumption of a 50:50 adipose/glandular composition. It has been found that the use of the conventional 50:50 assumption leads to overestimates of MGD of up to 13% over the age range considered. By using compressed breast thickness to estimate breast glandularity, this error range can be reduced to 8%, whilst age and compressed breast thickness based glandularity estimates result in an error range of 1%.