Comparison of Sonography versus Digital Breast Tomosynthesis to Locate Intramammary Marker Clips.

Introduction: This study aimed to compare the accuracy of sonography versus digital breast tomosynthesis to locate intramammary marker clips placed under ultrasound guidance. Patients and Methods: Fifty patients with suspicion of breast cancer (lesion diameter less than 2 cm [cT1]) had ultrasound-guided core needle biopsy with placement of a marker clip in the center of the tumor. Intramammary marker clips were subsequently located with both sonography and digital breast tomosynthesis. Results: Sonography detected no dislocation of intrammammary marker clips in 42 of 50 patients (84 %); dislocation was reported in 8 patients (16 %) with a maximum dislocation of 7 mm along the x-, y- or z-axis. Digital breast tomosynthesis showed accurate placement without dislocation of the intramammary marker clip in 48 patients (96 %); 2 patients (4 %) had a maximum clip dislocation of 3 mm along the x-, y- or z-axis (p < 0.05). Conclusion: The use of digital breast tomosynthesis could improve the accuracy when locating intramammary marker clips compared to sonography and could, in future, be used to complement or even completely replace sonography.

[Future of mammography-based imaging]. / Zukunft mammographiebasierter Bildgebung.

Mammography is the central diagnostic method for clinical diagnostics of breast cancer and the breast cancer screening program. In the clinical routine complementary methods, such as ultrasound, tomosynthesis and optional magnetic resonance imaging (MRI) are already combined for the diagnostic procedure. Future developments will utilize investigative procedures either as a hybrid (combination of several different imaging modalities in one instrument) or as a fusion method (the technical fusion of two or more of these methods) to implement fusion imaging into diagnostic algorithms. For screening there are reasonable hypotheses to aim for studies that individualize the diagnostic process within the screening procedure. Individual breast cancer risk prediction and individualized knowledge about sensitivity and specificity for certain diagnostic methods could be tested. The clinical implementation of these algorithms is not yet in sight.

Ultrasound elastography of pulmonary lesions - a feasibility study.

INTRODUCTION: The potential of sonography in the examination of lung tissue is extremely limited by the air-filled alveoles of the lung. Only in special circumstances like pleural adhesion lesions, atelectasis or pneumonia can lung tissue be visualized by B-mode sonography. Real-time elastography was primarily applied to detect and visualize pulmonary lesions. METHODS AND PATIENTS: 8 patients with a total of 18 histologically proven metastases of the lung were included. All pulmonary lesions were detected by computed tomography. Sonographic examination was performed with a 7.5 MHz linear transducer (Acuson Antares premium edition, Siemens, Erlangen, Germany), including B-mode and real-time elastography (RTE). The mean distance between pleura and the lesions ranged from 0 to 2.5 cm. Two lesions were located in the upper right lobe, eleven lesions in the lower right and five in the lower left lobe. RESULTS: RTE was able to detect and visualize all 18 pulmonary lesions in contrast to B-mode. The size and distance of the lesions from the pleura correlated with the CT findings. CONCLUSION: In contrast to B-mode sonography, RTE is able to detect and visualize peripheral, non-pleural adherent pulmonary lesions.

Evaluation of Newly Adapted Clip Marker System in Ultrasound-Guided Core Needle Biopsy for Suspicion of Breast Cancer.

Introduction: A newly adapted clip system for intramammary marking during ultrasound-guided core needle biopsy for suspicion of breast cancer is described and evaluated here. Material and Method: Fifty patients with suspicion of breast cancer (cT2) had ultrasound-guided core needle biopsy using a newly adapted clip marker system (HistoCore™ and O-Twist Marker™). Subsequently, ultrasound follow-up and tomosynthesis scans were done to determine the location of the marker clips. Results: No dislocation of the marker clip was detected on ultrasound in 45 of 50 patients (90 %), and 5 patients (10 %) had a maximum dislocation of 5 mm along the x-, y- or z-axis. Tomosynthesis scans demonstrated precise placement without dislocation of the clip markers in 48 patients (96 %); 2 patients (4 %) had a maximum dislocation of 3 mm along the x-, y- or z-axis. Conclusion: The newly developed clip marker system, a combination of a single-use breast biopsy needle and a precise, length-adapted intramammary marker clip, represents a further improvement in oncological therapy. This is of particular importance for patients requiring subsequent neoadjuvant chemotherapy, as in cases with complete tumour remission, there is no target point for preoperative, ultrasound-guided wire marking.

Full Field Digital Mammography (FFDM) versus CMOS Technology, Specimen Radiography System (SRS) and Tomosynthesis (DBT) - Which System Can Optimise Surgical Therapy?

Aim: This prospective clinical study aimed to evaluate whether it would be possible to reduce the rate of re-excisions using CMOS technology, a specimen radiography system (SRS) or digital breast tomosynthesis (DBT) compared to a conventional full field digital mammography (FFDM) system. Material and Method: Between 12/2012 and 2/2013 50 patients were diagnosed with invasive breast cancer (BI-RADS™ 5). After histological verification, all patients underwent breast-conserving therapy with intraoperative imaging using 4 different systems and differing magnifications: 1. Inspiration™ (Siemens, Erlangen, Germany), amorphous selenium, tungsten source, focus 0.1 mm, resolution 85 µm pixel pitch, 8 lp/mm; 2. BioVision™ (Bioptics, Tucson, AZ, USA), CMOS technology, photodiode array, flat panel, tungsten source, focus 0.05, resolution 50 µm pixel pitch, 12 lp/mm; 3. the Trident™ specimen radiography system (SRS) (Hologic, Bedford, MA, USA), amorphous selenium, tungsten source, focus 0.05, resolution 70 µm pixel pitch, 7.1 lp/mm; 4. tomosynthesis (Siemens, Erlangen, Germany), amorphous selenium, tungsten source, focus 0.1 mm, resolution 85 µm pixel pitch, 8 lp/mm, angular range 50 degrees, 25 projections, scan time > 20 s, geometry: uniform scanning, reconstruction: filtered back projection. The 600 radiographs were prospectively shown to 3 radiologists. Results: Of the 50 patients with histologically proven breast cancer (BI-RADS™ 6), 39 patients required no further surgical therapy (re-excision) after breast-conserving surgery. A retrospective analysis (n = 11) showed a significant (p < 0.05) increase of sensitivity with the BioVision™, the Trident™ and tomosynthesis compared to the Inspiration™ at a magnification of 1.0 : 2.0 or 1.0 : 1.0 (tomosynthesis) (2.6, 3.3 or 3.6 %), i.e. re-excision would not have been necessary in 2, 3 or 4 patients, respectively, compared to findings obtained with a standard magnification of 1.0 : 1.0. Conclusion: The sensitivity of the BioVision™, the Trident™ and tomosynthesis was significantly (p < 0.05) higher and the rate of re-excisions was reduced compared to FFDM using a conventional detector at a magnification of 2.0 but without zooming.

Accuracy of radiological tumour size assessment and the risk for re-excision in a cohort of primary breast cancer patients.

BACKGROUND: Re-operations after breast conserving surgery (BCS) are necessary, when specimen margins are not free of breast cancer cells. This study explored the accuracy of preoperative tumour size assessment and its influence on the rate of re-excisions and mastectomies. METHODS: The study included 1591 patients with invasive breast cancer, who were planned for BCS. Patient, staging and tumor characteristics were evaluated concerning their influence on re-excision and mastectomy rates. Patient and tumor characteristics comprised histopathological tumour size, HER2 status, multifocality, in situ component, grading (G), nodal status and hormone receptor (HR) status. Staging characteristics included deviation from pathological tumour size as measured by clinical examination, sonography and mammography. RESULTS: In 1316 patients (83%) sufficient treatment was possible with one operation. 275 patients (17%) had to undergo at least one further surgery as a result of positive specimen margins. In 138 patients (9%) mastectomy was ultimately necessary. In patients with a positive HER2 status, a larger tumour size, underestimation by ultrasound, an in situ component and multifocality, the risk for a re-operation was about doubled. Tumour size deviation in the mammogram or the clinical tumour size assessment did not have significant influence to the re-excision rates. CONCLUSION: Tumour size and accurate presurgical assessment of the tumour size itself are independent predictors for the need of a second surgery or even a mastectomy in patients for whom a primary BCS was planned.

Full Field Digital Mammography (FFDM) versus CMOS Technology versus Tomosynthesis (DBT) - Which System Increases the Quality of Intraoperative Imaging?

Aim: The aim of this prospective clinical study was to assess whether it would be possible to reduce the rate of re-excisions and improve the quality using CMOS technology or digital breast tomosynthesis (DBT) compared to a conventional FFDM system. Material and Methods: An invasive breast cancer (BI-RADS 5) was diagnosed in 200 patients in the period from 5/2011 to 1/2012. After histological verification, a breast-conserving therapy was performed with intraoperative imaging. Three different imaging systems were used: 1) Inspiration™ (Siemens, Erlangen, Germany), amorphous selenium, tungsten source, focus 0.1 mm, resolution 85 µm pixel pitch, 8 l/mm as the standard; 2) BioVision™ (Bioptics, Tucson, USA), flat panel photodiode array, tungsten source, focus 0.05, resolution 50 µm pixel pitch, 12 l/mm; 3) Tomosynthesis (Siemens, Erlangen, Germany), amorphous selenium, tungsten source, focus 0.1 mm, resolution 85 µm pixel pitch, 8 l/mm, range: 50°, 25 projections, scan time > 20 s, geometry: uniform scanning, reconstruction: filtered back projection. The 600 radiograms were prospectively shown to 3 radiologists. Results: Out of a total of 200 patients with histologically confirmed breast cancer (BI-RADS 6) 156 patients required no further operative therapy (re-excision) after breast-conserving therapy. A retrospective analysis (n = 44) showed an increase in sensitivity with tomosynthesis compared to the BioVision™ (CMOS technology) and the Inspiration™ at a magnification of 1.0 : 1.0 of 8 % (p < 0.05), i.e. re-excision would not have been necessary in 16 patients with tomosynthesis. Conclusions: The sensitivity of tomosynthesis for intraoperative radiography is significantly (p < 0.05) higher compared to both CMOS technology and an FFDM system with a conventional detector. Additional studies using higher magnification, e.g. 2.0 : 1.0, but no zooming will be necessary to evaluate the method further.

Percent Mammographic Density and Dense Area as Risk Factors for Breast Cancer.

Purpose: Mammographic characteristics are known to be correlated to breast cancer risk. Percent mammographic density (PMD), as assessed by computer-assisted methods, is an established risk factor for breast cancer. Along with this assessment the absolute dense area (DA) of the breast is reported as well. Aim of this study was to assess the predictive value of DA concerning breast cancer risk in addition to other risk factors and in addition to PMD. Methods: We conducted a case control study with hospital-based patients with a diagnosis of invasive breast cancer and healthy women as controls. A total of 561 patients and 376 controls with available mammographic density were included into this study. We describe the differences concerning the common risk factors BMI, parital status, use of hormone replacement therapy (HRT) and menopause between cases and controls and estimate the odds ratios for PMD and DA, adjusted for the mentioned risk factors. Furthermore we compare the prediction models with each other to find out whether the addition of DA improves the model. Results: Mammographic density and DA were highly correlated with each other. Both variables were as well correlated to the commonly known risk factors with an expected direction and strength, however PMD (ρ = -0.56) was stronger correlated to BMI than DA (ρ = -0.11). The group of women within the highest quartil of PMD had an OR of 2.12 (95 % CI: 1.25-3.62). This could not be seen for the fourth quartile concerning DA. However the assessment of breast cancer risk could be improved by including DA in a prediction model in addition to common risk factors and PMD. Conclusions: The inclusion of the parameter DA into a prediction model for breast cancer in addition to established risk factors and PMD could improve the breast cancer risk assessment. As DA is measured together with PMD in the process of computer-assisted assessment of PMD it might be considered to include it as one additional breast cancer risk factor that is obtained from breast imaging.

Pilot Study on the Detection of Simulated Lesions Using a 2D and 3D Digital Full-Field Mammography System with a Newly Developed High Resolution Detector Based on Two Shifts of a-Se.

Purpose: Experimental study of a new system for digital 2D and 3D full-field mammography (FFDM) using a high resolution detector based on two shifts of a-Se. Material and Methods: Images were acquired using the new FFDM system Amulet® (FujiFilm, Tokio, Japan), an a-Se detector (receptor 24 × 30 cm2, pixel size 50 µm, memory depth 12 bit, spatial resolution 10 lp/mm, DQE > 0.50). Integrated in the detector is a new method for data transfer, based on optical switch technology. The object of investigation was the Wisconsin Mammographic Random Phantom, Model 152A (Radiation Measurement Inc., Middleton, WI, USA) and the same parameters and exposure data (Tungsten, 100 mAs, 30 kV) were consistently used. We acquired 3 different pairs of images in the c-c and ml planes (2D) and in the c-c and c-c planes with an angle of 4 degrees (3D). Five radiologists experienced in mammography (experience ranging from 3 months to more than 5 years) analyzed the images (monitoring) which had been randomly encoded (random generator) with regard to the recognition of details such as specks of aluminum oxide (200-740 µm), nylon fibers (0.4-1.6 mm) and round lesions/masses (diameters 5-14 mm), using special linear glasses for 3D visualization, and compared the results. Results: A total of 225 correct positive decisions could be detected: we found 222 (98.7 %) correct positive results for 2D and 3D visualization in each case. Conclusion: The results of this phantom study showed the same detection rates for both 2D and 3D imaging using full field digital mammography. Our results must be confirmed in further clinical trials.

Differentiation between phyllodes tumor and fibroadenoma using real-time elastography.

PURPOSE: Phyllodes tumors (PT) are a rare entity accounting for less than 1 % of all breast lesions. They have a malignancy rate of 25-30%. Differentiation from benign fibroadenomas is difficult using ultrasound, mammogram and MRI. The elastic characteristics of both tumors were examined using real-time elastography (RTE) to find specific patterns that make differentiation possible. MATERIALS AND METHODS: From February 2007 to May 2009, a total of 620 women were examined by RTE. Histological diagnosis was achieved using core needle biopsy. 123 of the lesions were fibroadenomas, 8 were phyllodes tumors. All patients underwent mammography and ultrasound followed by RTE. Sonography was performed by Acuson Antares, Premium Edition® (Siemens, Erlangen, Germany) with a 7 and 10 MHz transducer. RESULTS: All phyllodes tumors had a similar elastic pattern with an elastic center and inelastic outer limits, referred to as the "ring sign". It was found in 5% of all fibroadenomas. CONCLUSION: RTE provides a specific elastic pattern, which is sufficient for differentiating between a fibroadenoma and a phyllodes tumor. Therefore, the detection of the most suspicious lesion in women with the coexistence of multiple fibroadenomas and phyllodes tumors seems easier.

[A useful tool for routine radiological examinations : the iPhone application "KM Helper"]. / Sinnvoller Einsatz neuer elektronischer Medien bei radiologischen Untersuchungen : Die iPhone-Applikation "KM Helper"

Since Apple's iPhone revolutionized the smartphone market, numerous software application features (apps) for portable devices have been developed. Amongst many others, a broad range of medical assistance software, such as anatomic books or medical encyclopedias is now available. We developed an app which helps to identify patients who need medical treatment before intravenous or intra-arterial administration of iodinated contrast media. The purpose of this article is to show that novel techniques such as smartphone applications can be a useful tool in medicine.

[Transient monoparesis of the right arm after carotid artery stenting]. / Transiente Monoparese des rechten Arms nach Karotisstenting.

We report on an 80-year-old hypertensive patient with a left-sided high-grade carotid stenosis who developed transient monoparesis of the right arm after stenting of the carotid artery. Computed tomography (CT) of the brain (cranial CT) performed immediately after the symptomatic had begun showed a linear hyperdensity in the ipsilateral, precentral sulcus with a moderate, local brain swelling and edema. Transcranial doppler sonography revealed an accelerated post-interventional systolic blood flow velocity and in the ipsilateral medial cerebral artery compared to the preoperative value and an increased cerebral blood flow, so that the diagnosis of hyperperfusion syndrome with a subpial hematoma was confirmed. After strict blood pressure control and -reduction the neurological deficit regressed gradually and the hyperdensity had completely disappeared in control CCT after 15 h.

New diagnostic criteria in real-time elastography for the assessment of breast lesions.

PURPOSE: Elastography is a new ultrasonographic method that has been examined as a diagnostic tool for breast lesions. This study was intended to create and define new elastographic criteria allowing assessment of whether breast lesions are malignant or benign. MATERIALS AND METHODS: 217 patients with a total of 245 breast lesions of unknown malignancy underwent ultrasound examination. The new eSie Touch Elasticity Imaging technology (Siemens, Erlangen, Germany) was used with a 10-MHz linear transducer (Acuson Antares). Lesions were examined using B-mode and real-time elastography (RTE). Each lesion was histologically assessed by core biopsy. Five RTE characteristics were examined: elasticity proportion (EP), different location on RTE in comparison with B-mode (MV), different contrast patterns (SOS), dorsal lesion limitation visibility and different size on RTE in comparison with B-mode. RESULTS: 54 malignant lesions (54 %) appeared inelastic, in contrast to the benign control group (34.5 %; P = 0.001). A completely elastic pattern was visible in 10 malignant (10 %) and 39 benign lesions (26.9 %). MV was identified in 23 cases, with 22 of the lesions being malignant and one benign. The SOS was negative in 89 malignant lesions (89 %) and positive in 100 benign lesions. The dorsal lesion limitation was visible on RTE without B-mode in 88 malignant lesions (88 %) and 27 benign lesions (18.6 %). The size was assessed as larger in 45 malignant lesions (45 %) and seven benign lesions (4.8 %). CONCLUSION: SOS and a larger tumor size on RTE are specific characteristics of malignant breast lesions. EP, MV and distal mass border are further helpful signs to assess the malignancy of tumors.

[Comparison of dignity determination of mammographic microcalcification with two systems for digital full-field mammography with different detector resolution: a retrospective clinical study]. / Vergleich der Dignitätsbestimmung von mammographischem Mikrokalk mit zwei Systemen zur digitalen Vollfeldmammographie unterschiedlicher Detektorauflösung : Eine retrospektive klinische Studie.

PURPOSE: The aim of this retrospective clinical study was to compare the diagnostic accuracy of the novel 50 µm FFDM (full-field digital mammography) system (DR) with an established 70 µm system (DR) in the differential diagnosis between benign and malignant clusters of microcalcification (n=50) (BI-RADS™ classification 4/5) and to assess the possible incremental value of the 50 µm pixel-pitch on specificity. MATERIAL AND METHODS: From March 2009 to September 2009, 50 patients underwent full-field digital mammography (FFDM) (detector resolution 70 µm) (Novation, Siemens, Erlangen, Germany). As there were suspicious signs of microcalcification classified with BI-RADS™ 4/5 after diagnosis and preoperative wire localization, control images were made with the new FFDM system (detector: resolution 50 µm) (Amulet, Fujifilm, Tokyo, Japan) with the same exposure parameters. The diagnosis was determined after the operation by five radiologists with different experience in digital mammography from randomly distributed mediolateral views (monitor reading) whose results were correlated with the final histology of all lesions. RESULTS: Histopathology revealed 19 benign and 31 malignant lesions in 50 patients after open biopsy. The results of the five readers showed a higher sensitivity of the new FFDM system (80.0%) in the ability to recognize malignant microcalcification in comparison to the established system (74.8%). The specificity (75.8 versus 71.6%) was slightly higher for the new system but these results were not statistically significant (p<0.001). Considering the diagnostic accuracy, the new system (detector: resolution 50 µm) was also slightly superior to the well-known system (detector: resolution 70 µm) (80.1% versus 76.4%). CONCLUSIONS: Our study has shown that the new full-field digital mammography system using the novel detector compared with the already established FFDM system with respect to the assessment of microcalcification is at least equivalent.

Use of Tomosynthesis in Intraoperative Digital Specimen Radiography - Is a Reduction of Breast Re-excision Rates Possible?

Aim: A prospective clinical study was done to see whether it is possible to reduce the rate of re-excisions using digital breast tomosynthesis (DBT) compared commercial FFDM. Material and Method: Between 1/2011 and 5/2011 we diagnosed an invasive breast cancer (BI-RADS 5) in 100 patients. After histological verification we performed breast-conserving therapy with intraoperative imaging using one of 2 different systems: 1. Tomosynthesis (Siemens, Erlangen, Germany), amorphous selenium, Tungsten source, focus 0.1 mm, resolution 85 µm, pixel pitch, 8 l/mm, range: 50°, 25 projections, time for scanning > 20 s, geometry: same scanning scope, reconstruction: filtered back projection; or 2. Inspiration™ (Siemens, Erlangen, Germany), amorphous selenium, tungsten source, focus 0.1 mm, resolution 85 µm, pixel pitch, 8 l/mm as the standard. The 100 radiograms obtained with both systems were prospectively shown on a monitor to 3 radiologists. Results: Out of a total of 100 patients with histologically proven breast cancer (BI-RADS 6) no re-excision was necessary in 78 patients. A retrospective analysis (n = 22) demonstrated an increase in sensitivity of tomosynthesis compared to the Inspiration™ at a magnification of 1.0 : 1.0 of 8 % (p < 0.05), i.e., in 8 patients re-excision would not have been necessary with tomosynthesis. Conclusion: Tomosynthesis has a significant higher sensitivity (p < 0.05) compared with a commercial FFDM system. Studies with higher numbers of patients will be necessary to evaluate this method.

[Ehlers-Danlos syndrome and bilateral, dystrophic breast calcifications]. / Ehlers-Danlos-Syndrom und bilaterale, dystrophe Brustkalzifikationen.

Diagnostic investigations of mammary glands, which are routinely undertaken prior to a planned liver transplantation, can place high demands on the radiologist. The article describes a case of known Ehlers-Danlos syndrome, where it was essential that the radiologist was sufficiently informed over the past history, possible previously made images and typical presentation forms of microcalcification for corresponding findings from the breast diagnostics.

[Computer-assisted navigation system for interventional CT-guided procedures: results of phantom and clinical studies]. / Computergestütztes Navigationssystem für CT-gesteuerte Interventionen: Ergebnisse am Phantom und im klinischen Einsatz.

PURPOSE: To evaluate the technical applicability and accuracy of a navigation system for CT-guided interventional procedures in a phantom and a patient study. MATERIALS AND METHODS: A novel navigation tool (CAPPA IRAD, CAS innovations AG, Erlangen, Germany) was employed for CT-guided biopsies in a phantom and in patients. The entire system consists of a PC, navigation software, an optical tracking system and a patient frame. For the phantom study, a spine phantom in wax was used. The phantom as well as the patients were placed on the CT table in a stable position and fixed within a double vacuum device. The patient frame equipped with optical and CT markers was placed above the target region, followed by acquisition of a planning scan. All data were transferred to the navigation system inside the scanning room, and with the aid of the above mentioned navigation software, the biopsy pathway was planned. Hereafter, the needle holder was aligned accordingly, and a coaxial biopsy needle was pushed forward to the planned target. An additional control scan confirmed needle position, and the navigation software was used to evaluate the distance between the target and needle tip. RESULTS: In the phantom study (n = 60) the average deviation between the planned and documented needle tip position was 1.1 mm. In the clinical study (n = 15), we performed biopsies of the lung, the mediastinal area, the pancreas and liver and some bone biopsies as well as a therapeutic nerve root infiltration. 12 of 15 cases required oblique needle access. In 9 / 15 cases merely a single planning and control scan were required, whereas in 5 / 15 cases additional safety or correction scans were performed. In the case of pancreas biopsy, the lesion (diameter 1 centimeter) visible during the arterial phase only could not be punctured even following repeated corrections due to severe breathing artifacts and pronounced peristaltic movement of the adjacent bowel. The time between planning CT and correct needle position was about 30 minutes. CONCLUSION: The navigation system allows for safe interventions in case of angulated needle access with high accuracy and little tissue trauma. However, insufficient corrections for respiration movement constitute a substantial limitation of the tool.