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]. / Evaluation der DEGUM-Mammasonografiekurse nach objektivierbaren Kriterien.

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.

ShearWave™ Elastography BE1 multinational breast study: additional SWE™ features support potential to downgrade BI-RADS®-3 lesions.

PURPOSE: To determine the benefit of ShearWave™ Elastography (SWE™) in the ultrasound characterization of BI-RADS® 3 breast lesions in a diagnostic population. MATERIALS AND METHODS: 303 BI-RADS® 3 lesions (mean size: 13.2 mm, SD: 7.5 mm) from the multicenter BE1 prospective study population were analyzed: 201 (66%) had cytology or core biopsy, and the remaining 102 had a minimum follow-up of one year; 8 (2.6%) were malignant. 7 SWE features were evaluated with regard to their ability to downgrade benign BI-RADS® 3 masses. The performance of each SWE feature was assessed by evaluating the number of lesions correctly reclassified and the impact on cancer rates within the new BI-RADS® 3' lesion group. RESULTS: No malignancies were found with an E-color "black to dark blue", which allowed the downgrading of 110/303 benign masses (p < 0.0001), with a non-significant increase in BI-RADS® 3' malignancy rate from 2.6% to 4.1%. E-max ≤ 20 kPa (2.6 m/s) was able to downgrade 48/303 (p < 0.0001) lesions with a lower increase in BI-RADS® 3' malignancy rate (3.1%). No other SWE features were useful for reclassifying benign BI-RADS® 3 lesions. CONCLUSION: Applying simple reclassification rules, SWE assessment of the maximum stiffness of lesions allowed the downgrading of a sub-group of benign BI-RADS® 3 lesions. This was accompanied by a non-significant increase in the malignancy rate in the new BI-RADS® 3 class.

[Cervical vascular penetrating trauma]. / Stichverletzungen der grossen Halsgefässe.

The case of a 25 year old male with a stab wound of common carotid artery and the internal jugular vein is reported. He was admitted in severe hemorrhagic shock and immediately treated successfully by arterial reconstruction by means of a venous patch. Mild, declining neurological deficits correlated in magnetic resonance imaging with disturbances in the perfusion area of the medial cerebral artery. A survey of the literature shows that the fast repair of the carotid artery is clearly to be given preference to ligature. First can be executed successfully in exceptional emergency cases also by non-carotid surgeons, if basic vascular-surgical techniques are controlled.

Magnetic resonance imaging (MRI) for detection of active sacroiliitis--a prospective study comparing conventional radiography, scintigraphy, and contrast enhanced MRI.

OBJECTIVE: Sacroiliitis is often difficult to diagnose in the absence of radiographic alterations. For the diagnosis of active sacroiliitis, plain radiography, scintigraphy, and contrast enhanced magnetic resonance imaging (MRI) were evaluated in a prospective study. METHODS: In 44 consecutive patients with complete clinical and laboratory evaluation, plain radiographs, quantitative sacroiliac (SI) scintigraphy, and MRI were performed to evaluate the contribution of these imaging techniques to the diagnosis of active sacroiliitis. Scintiscanning and MRI were done in 20 control subjects to define the normal range of imaging findings. We determined the sensitivity and specificity for each imaging method using a reference standard based on clinical symptoms of inflammatory low back pain with or without laboratory signs, and on clinical and radiographic followup during 1.5-2.5 years to confirm diagnosis. RESULTS: MRI was most sensitive (95%) and superior to quantitative SI scintigraphy (48%) or conventional radiography (19%) for the detection and confirmation of active sacroiliitis. For the assessment of inflammatory signs, MRI had higher specificity (100%) than scintigraphy (97%) or plain radiography (47%). At repeat MRI after 2-30 months, there was persistent pathologic signal intensity in the subchondral bone area despite clinically successful antiinflammatory drug therapy. CONCLUSION: For the assessment of active changes in the synovial portion and the subchondral bone marrow, contrast enhanced MRI is superior to quantitative SI scintigraphy or conventional radiography. MRI picks up an additional 75% of early cases not diagnosed by plain radiography. Scintigraphy is only of limited value. Persistent pathologic signal intensity in the subchondral bone marrow seems to be closely associated with previous inflammatory episodes, thus limiting specificity of MRI for active sacroiliitis. Based on our findings we suggest an algorithm for the evaluation of patients with suspected active sacroiliitis.

[Computerized tomography findings score in the differentiation of adrenal tumors in patients with extra-adrenal malignomas]. / Computertomographischer Befundungscore zur Differenzierung von Nebennierentumoren bei Patienten mit extraadrenalen Malignomen.

PURPOSE: In a retrospective study the diagnostic accuracy of computed tomography for the differentiation of benign from malignant adrenal masses in patients with extra-adrenal malignancies was evaluated. For this differentiation a new score system was tested. PATIENTS AND METHODS: Size, density, structure, and borders of adrenal masses in 60 patients with extra-adrenal tumours were analysed and scored. The single criteria and the total score values were correlated with the final diagnosis achieved either by histology or by follow-up CT examinations. RESULTS: Score values above 4 indicated always metastases and score values below 2 were benign lesions. An overlap occurred at score values between 2 and 3 resulting in an overall accuracy of 83.3%. CONCLUSION: Single CT criteria are not reliable enough to differentiate benign from malignant adrenal lesions: better results are achieved by using our scoring system.

HIV-related metabolic abnormalities in the brain: depiction with proton MR spectroscopy with short echo times.

PURPOSE: To analyze brain metabolite changes in human immunodeficiency virus (HIV)-positive neurologically asymptomatic patients and patients with acquired immunodeficiency syndrome (AIDS) dementia complex (ADC). MATERIALS AND METHODS: Twelve ADC patients, 11 HIV-positive asymptomatic patients, and 10 healthy control subjects underwent magnetic resonance (MR) imaging and proton MR spectroscopy with short echo times. Changes in N-acetyl aspartate (NAA), choline (Cho), myoinositol (MI), and creatine (Cr) were presented as ratios with Cr as the reference. RESULTS: Statistically significant (P < .05) differences were noted. In ADC patients, all with MR findings of brain atrophy and diffuse white matter disease, NA/Cr decreased (white matter, -31.8%; gray matter, -22.3%), MI/Cr increased (white matter, +42.5%; gray matter, +51.8%), and Cho/Cr increased (white matter, +20.6%; gray matter, +51.7%) compared with healthy control subjects. In HIV-positive asymptomatic patients, NA/Cr decreased slightly (white matter, -6.9%; gray matter, -5.1%), MI/Cr increased slightly (white matter, +13.7%; gray matter, +10.7%), and Cho/Cr did not change. CONCLUSION: ADC has a uniform pathologic metabolic pattern that affects NAA, MI, and Cho. Proton MR spectroscopy with short echo times helps detect early abnormalities in clinically asymptomatic patients.

[Phantom studies of ultrasound equipment for quality improvement in breast diagnosis]. / Phantomuntersuchungen von Ultraschallgeräten zur Qualitätsverbesserung in der Mammadiagnostik.

AIM: According to the German guidelines for quality control of ultrasonic equipment, the following conditions are required for breast ultrasound: A transducer frequency between 5-7.5 MHz and a minimum field of view of 5 cm. Satisfactory images must be obtained in a depth between 0.5 and 4 cm with a wide tolerance of the focal zones. This allows the use of poor quality equipment which does not produce satisfactory image quality and it excludes a number of high frequency and high resolution transducers with a field of view below 5 cm. This study with a test phantom was performed to define image quality objectively. METHOD: Sixteen ultrasound instruments in different price categories were used to perform standardized examinations on a breast phantom model 550 (ATS Laboratories, Bridgeport, USA). Contrast and spatial resolution in different penetration depths were investigated on cyst phantoms from 1-4 mm diameter and wire targets with defined distances between 0.5-3 mm 4 investigations reported the images. RESULTS: A positive correlation was seen between price category and image quality. CONCLUSION: This study demonstrates that transducer frequency and image geometry do not allow sufficient quality control. An improvement of ultrasound diagnosis is only possible if equipment guidelines are based on standard examinations with test phantoms.

[Ultrasound and mammography follow-up of findings after breast saving operation and adjuvant irradiation]. / Sonographischer und mammographischer Befundverlauf nach brusterhaltender Operation und Nachbestrahlung.

AIM: The aim of our controlled retrospective study was to assess the diagnostic value of sonography for detection and characterisation of changes compared to mammography and palpation. METHOD: In 80 patients sonographic and clinical follow-up examinations were performed every 3 to 6 months, mammography examinations were performed every 6 to 12 months during the first 2 years after breast-preserving therapy (BPT) and irradiation. Extension, echogenicity, and configuration of lesions in sonography, and semiquantitiative description of diffuse or circumscribed changes in mammography were the basis of comparative follow-up observation. RESULTS: Postoperative seromas and haematomas, initially presenting echo-free or as hypoechoic lesions, showed an increase in echogenicity within 18 months after irradiation. Fat necrosis occurred in 9.5% of patients, lymph cysts developed in 4%, granuloma in 3%, recurrence of neoplasma in 1.6%. The diffuse loss of transparency in mammography that was associated with radiation therapy, showed a peak 6-12 months after irradiation. CONCLUSION: Sonography and sonographic guided puncture are mandatory tools to characterise circumscribed unclear lesions after breast-conserving therapy and irradiation in specialised centers. We recommend a 6-month interval for combined sonography, palpation, and mammography within the first 2 years after BPT and irradiation, because shorter control intervals did not result in relevant diagnostic advantages.

Digital optical card. A promising technology for documentation and communication of images.

PURPOSE: To assess a patient-oriented digital optical card (OC) for documentation and communication of images using the analysis of breast microcalcifications to illustrate its resolution power. METHODS: Fifty film mammograms with histologically proved clustered microcalcifications were digitized using a 5 lp/mm CCD-scanner. A region of interest containing the cluster was selected for documentation on an OC as an overview OC-image and as a magnified OC-image (5 lp/mm). The shape (spherical/nonspherical) as well as the total number of microcalcifications were quantitatively analyzed by 2 radiologists. RESULTS: The detection rate for total number of overall and spherical microcalcifications using digital media was significantly reduced (p < 0.01) compared to analog mammography. There were no significant differences in the detection rate of nonspherical microcalcifications between film mammograms (100%) and magnified section OC-images (92.7%). The overview OC-image revealed 72% of those calcifications (p < 0.01). CONCLUSION: According to our results, this technology is not appropriate for diagnosis of breast microcalcifications, but may be a promising communication digital medium for transmitting an image/report unit to referring physicians.

Differential diagnosis of breast lesions by color Doppler.

Color Doppler allows flow detection in small tumor vessels. Due to the vascularity associated with the growth of malignancies, this method can be used to differentiate between benign and malignant breast lesions. In order to study the typical flow characteristics, we investigated multiple Doppler flow parameters. A UM9 HDI (ATL) was used with a linear transducer L 10-5. The number of tumor vessels and the mean, maximum and total flow velocity were measured in 325 benign and 133 malignant lesions and showed highly significant differences (p < 0.0001). Flow profiles (resistance index and systolic/diastolic frequency ratio) showed a large overlap and did not allow accurate tumor differentiation when mean and minimum values were analyzed. Surprisingly, the maximum resistance index and systolic/diastolic frequency ratio were significantly higher in carcinomas than in benign lesions, but the overlap of the values was wider than the flow velocity measurements. Using the vessel number and the total tumor vascularity, 90% of all lesions could be differentiated. A difficulty that we encountered was that a few cancers have very low flow values and some of the proliferative benign lesions can have increased flow.

[Value of high resolution sonography in breast cancer screening]. / Einsatz der hochauflösenden Sonographie zur Brustkrebsvorsorge.

Breast ultrasound has mainly been used for differentiation of cystic and solid lesions. With high resolution technique, which was introduced several years ago, early cancers can now be detected by ultrasound. In this study, 1016 women were examined within 3 months. Mammography was used independently. According to the expected prevalence, 4 nonpalpable carcinomas were detected by sonography. The study proves that high-quality ultrasound equipment allows a primary detection of subclinical breast cancers. In premenopausal patients the sensitivity of mammography is reduced. Therefore, ultrasound should be used complementary to mammography in this age group. Widespread use is not possible due to a deficiency in experienced staff. However, in experienced centres, ultrasound could be used as a supplement to mammographic screening to prove if breast cancer mortality in premenopausal women can be reduced.