[Ultrasound examination of the breast with 7.5 MHz and 13 MHz-transducers: scope for improving diagnostic accuracy in complementary breast diagnostics?]. / Mamma-Sonographie mit 7.5 MHz versus 13 MHz: Ist eine Verbesserung der diagnostischen Sicherheit im Rahmen der komplementären Mammadiagnostik möglich?

AIM: Complementary diagnostic methods in early diagnosis of breast cancer are used to increase diagnostic accuracy and minimize unnecessary invasive diagnostic procedures. Aim of the following prospective, open multicenter clinical study was to define the value of high-frequency breast ultrasound with 13 MHZ transducers compared to standard breast ultrasound with 7.5 MHz. METHOD: Data of 810 female patients, aged 45 to 60 years, with 819 suspicious breast lesions evaluated by four participating centres between October 1996 and December 1997. Standardised breast ultrasound was performed uniformly using a AU4 IDEA diagnostic ultrasound system by Esaote-Biomedica in addition to a standardised procedure of clinical examination and standard-2view-mammography. Analysis of all aquired data and the correlating histopathological findings was done by means of descriptive statistics on the basis of an access datafile (Version 2.0). RESULTS: The histopathological evaluation showed 435 benign and 384 malignant findings. Overall sensitivity and specificity of the clinical examination were 71.1 % and 88.9 % and for mammography 84.7 % and 76.5 %, respectively. Standard ultrasound with 7,5 MHz reached a sensitivity of 82,6 % and a specificity of 80.8 % high-frequency ultrasound with 13 MHz came to 87.2 % and 78.4 %, respectively. Regarding tumour size, mammography gave the highest sensitivity in detection of pre-invasive cancers (DCIS). High-frequency breast ultrasound (13 MHz) proved to have a higher diagnostic accuracy compared to standard breast ultrasound (7,5 MHz) regardless of tumour size. Sensitivity was especially improved in case of small invasive tumours (pT1a) with 78 % versus 56 %, respectively. CONCLUSIONS: We conclude that high-frequency ultrasound is a valueable additive tool especially in the diagnosis of small tumours, improving diagnostic safety and reducing unnecessary invasive diagnostic procedures.

[3D ultrasound in core breast biopsy]. / Einsatz des 3D Ultraschalls bei der Stanzbiopsie unklarer Mammaläsionen.

AIM: To evaluate the potential of three-dimensional ultrasound (3D US) in core biopsy of suspicious breast lesions. METHOD: 3D US controlled core biopsy was performed in 107 breast masses in 100 women by using an automated biopsy system (11G coaxial needle, 12 G biopsy needle). Mean diameter of the lesions was 1.55 cm (0.5 - 3.5 cm). A linear 3D US volume scanner was used for the procedure. Localization of the lesion and placement of the needle were initially done under 2D US guidance. After core needle stroke a 3D US volume acquisition was performed to correlate lesion and needle position. In the case of eccentric needle position the needle was repositioned under 3D control. 5 specimens were taken from each lesion. The histological results from the specimens were correlated with the results from surgery or clinical follow-up (> 2.5 years). RESULTS: Biopsy was taken from 59 probably benign (BI-RADS 3 - 4) and 48 malignant (BI-RADS 5) lesions. 3D US revealed 61 central, 44 eccentric and 2 marginal needle positions after the initial 2D guidance. Central repositioning of the needle was achievable under 3D guidance in all patients. Histological examination of the specimens revealed 41 invasive carcinomas and one in-situ carcinoma (DCIS). In one lesion, the carcinoma was missed in the core biopsy, despite central hits of the biopsy needle. This led to a sensitivity of 98 %, specificity of 100 %, PPV of 100 %, NPV of 98.5 % and accuracy of 99 % for the diagnosis of a malignant lesion. CONCLUSION: 3D US improves needle positioning as well as the depiction of correct needle placement in freehand core biopsy.

[Experimental investigations at the new digital mammographic system]. / Experimentelle Untersuchungen an einem neuen digitalen Mammographiesystem.

PURPOSE: Experimental investigations of a new digital mammography system. MATERIALS AND METHODS: The digital mammography system SenoScan (Fischer Imaging) is based on 4 charged coupled devices (CCD) (slot detector). The pixel size is 50 micro m, field of view 21 x 29 cm (2), effective quantum efficiency (DQE) (0) 50 %, spatial resolution 10 lp/mm, and memory depth 12 bit. The object of investigation was the Wisconsin Mammographic Random Phantom, Model 152 A (Radiation Measurements Inc., Wisconsin). The radiograms were acquired using the digital mammography system. RESULTS: The digital mammography detected 225 of 225 possible details. The surface dose was 6.95 mGy. CONCLUSIONS: These experimental results support the use of the digital mammography in practice. This has to be confirmed in further clinical trials.

[Film-screen mammography versus digital storage plate mammography: hard copy and monitor display of microcalcifications and focal findings--a retrospective clinical and histologic analysis]. / Film-Folien-Mammographie versus digitale Mammographie mit Speicherfolien: Mikrokalzifikationen und Herdbefunde, Hartkopie- und Monitorbefundung--eine retrospektiv klinisch/histologische Analyse (n = 76).

PURPOSE: A retrospective clinical-histological study to determine the diagnostic accuracy of mammography using conventional screen-film cassettes (hard copy), high-resolution digital phosphor storage plates (hard copy) and monitor display (soft copy) for microcalcifications and focal lesions (BI-RADS (TM) category 4 or 5). MATERIALS AND METHODS: From April to November 2001, 76 patients underwent conventional film-screen mammography and, after diagnosis and preoperative wire localization, digital mammography with the same exposure parameters. Five investigators retrospectively determined the diagnosis after the operation from randomly distributed mediolateral views (hard-copy reading) and from the monitor display (soft-copy reading). These results were correlated with the final histology. RESULTS: The accuracy of conventional screen-film mammography, digital mammography and monitor-displayed mammography was 67%, 65% and 68% for all findings, (n = 76), 59%, 59% and 68% for microcalcifications (n = 44) and 75%, 72% and 63% for focal lesions (n = 32). The overall results showed no difference. CONCLUSION: Our findings indicate equivalence of conventional screen-film mammography, high-resolution digital phosphor storage plate mammography and monitor-displayed mammography.

[Sonographical breast biopsy: how many core biopsy specimens are needed?]. / Sonographisch gezielte Stanzbiopsie: Wie viele Biopsiezylinder sind notwendig?

PURPOSE: To determine the optimum number of specimens of a sonographically guided core biopsy of the breast. MATERIALS AND METHODS: From January 2001 to April 2001, sonographically guided core biopsies (coaxial needle: 11 G; core needle: 12 G) were performed on 106 patients with 115 BI-RADS trade mark 4-5 lesions that had corresponding sonographic findings. Five specimens were obtained in anteroposterior direction parallel to the chest wall and each specimen examined histologically. RESULTS: A total of 575 core biopsies produced 545 specimens (94.8 %), with no material obtained in 30 biopsies (5.2 %). The first and second specimen confirmed the diagnosis in 99 of 115 lesions (86 %), with subsequent specimens confirming the diagnosis in 87 % (3 rd specimen), 88 % (4 th specimen) and 82 % (5 th specimen). The additive accuracy of the five core breast specimens was 86 %, 96 %, 98 %, 99 % and 100 %. The possible volume of 78.9 mm 3 as determined by the sample notch of the core needle only furnished an average volume of 38.1 mm 3 (41.1 mm 3 for the 1 st, 40.1 mm 3 for the 2 nd, 37.5 mm 3 for the 3 rd, 36.7 mm 3 for the 4 th and 35.0 mm 3 for 5 th core specimen). CONCLUSION: Sonographically guided core breast biopsy (coaxial needle: 11 G; core needle: 12 G) may require five passes to achieve a diagnostic accuracy of more than 99 %.

[Scar or recurrence--comparison of MRI and color-coded ultrasound with echo signal amplifiers]. / Narbe oder Rezidiv? Einsatz der signalverstärkten Doppler-Sonographie im Vergleich zur MRT.

PURPOSE: MRI is the most reliable method to differentiate scar and recurrent carcinoma of the breast after surgical treatment. This study compares MRI and color-coded ultrasound with and without echo signal amplifier (ESA). MATERIALS AND METHODS: Forty-two patients with suspected recurrent tumors were enrolled in this prospective study, with 38 patients after breast conserving therapy and 4 after mastectomy. All patients had a clinical examination, mammography (n = 38), real time ultrasound (US), color-coded ultrasound without and with ESA (Levovist(R), Schering, Berlin), and dynamic MRI. The criteria used for duplex ultrasound were tumor vascularisation and flow pattern. The results were compared with histologic findings or the results of follow-up examinations for at least 12 months. RESULTS: The detection of penetrating or central vessels proved to be an accurate sign of malignancy in duplex ultrasound. With the application of ESA, additional vessels were detected within the lesions, increasing the diagnostic accuracy (83 % with ESA versus 79 % without ESA). The sensitivity of color-coded ultrasound improved from 64 % to 86 % with echo signal amplifier. The specificity was 86 % without and 82 % with echo signal amplifier. MRI was found to have a sensitivity of 100 % and a specificity of 82 %. The same 5 lesions were false positive on MRI and color-coded US after Levovist(R). No lesion without signs of vascularity within or in its vicinity was malignant. CONCLUSION: Color-coded ultrasound seems to be a promising method in the differentiation between scar and recurrence. Lesions with penetrating or central vessels have a high probability of being malignant, whereas lesions without any signs of vascularity inside or nearby have a high probability of being benign. Advantage of contrast-enhanced US is its ubiquitous availability.

[Experiences with phantom measurements in different mammographic systems]. / Erfahrungen mit Phantommessungen bei verschiedenen Mammographiesystemen.

PURPOSE: Determination of image quality between conventional film screen system, digital phosphor storage plate mammography (high resolution) and digital mammography. MATERIALS AND METHODS: Mammograms of the Wisconsin Mammographic Random Phantom, Model 152 A (Radiation Measurements Inc., Wisconsin) were acquired using a conventional film-screen system, a digital storage phosphor plate system and a digital system. RESULTS: Of 225 possible details, 191/a 38.2, 193/a 38.6, and 202/a 40.4 details were detected with conventional film-screen system, digital phosphor storage plate mammography and digital mammography, respectively. There was no significant difference (p < 0,058). The entrance surface air kerma was 9.64 mGy, 7.60 mGy and 7.02 mGy, respectively. CONCLUSIONS: Based on these results, conventional film-screen system can be replaced with both digital phosphor storage plate mammography and digital mammography, to be confirmed with further clinical trials.

Clinical value of MRC in the follow-up of liver transplant patients with a choledochojejunostomy.

BACKGROUND: We investigated the clinical value of magnetic resonance cholangiography (MRC) in liver transplant patients receiving choledochojejunostomy (CDJ). METHODS: Twenty-five MRCs were performed in 23 initially asymptomatic patients 19 months (mean) after liver transplantation with biliary reconstruction via CDJ. The images were evaluated by consensus (two investigators) for bile duct strictures and dilatations. As a standard of reference, clinical follow-up (including laboratory analysis) was used in 20 cases and direct cholangiography or surgery in three cases. RESULTS: Fourteen pathologic findings were observed in 11 patients (anastomotic strictures in four, left or right bile duct strictures in three, and peripheral segmental dilatations with or without strictures in seven). Patients with pathologic MRC findings had significantly higher levels of alkaline phosphatase (p < 0.05) and more frequently had histories of cholangitis than did patients with normal MRC. Four of six patients with stenoses of the central bile ducts subsequently developed biliary complications requiring treatment (three confirmed by direct cholangiography). In patients with unremarkable bile ducts or only peripherally located changes on MRC, no bile duct complications or relevant changes in the cholestasis parameters occurred during follow-up (mean = 30 months). CONCLUSION: MRC can noninvasively detect pathologic biliary tract changes in liver transplant patients in the asymptomatic stage and provide information for planning invasive therapeutic procedures.

[Galactoscopy--is it a new interventional method for breast diagnosis?]. / Galaktoskopie - eine neue interventionelle Methode in der Mammadiagnostik?

Based on experimental studies with animals we examined 22 patients with pathological (bloody) nipple discharge by cytology, ultrasonography, galactography and the newly developed galactoscopy [Endoscopic-System EndoGnost(R) (Polydiagnost)]. The duct's cannula has an outer/inner diameter of 0.45 mm/0.36 mm and a working length of 30 mm, the endoscope a length of 1200 mm, adapted to a CCD-camera (2500 pixel). All patients underwent surgery and histo-pathological diagnosis. The best diagnostic results were received with galactoscopy (21/22). By using an additional cutter it is possible to obtain a histological sample for diagnosis endoscopically. Galactoscopy is an emerging technique and will expand the spectrum of interventional methods in breast diagnosis.

[Value of CAD systems]. / Der Stellenwert von CAD-Systemen.

PURPOSE: Early detection of breast cancer enables for the reduction of mortality. The purpose of this article is to describe commercially available systems for computer-aided diagnosis (CAD) for mammograms and to analyze their diagnostic potential and utility. MATERIALS AND METHODS: Up to now, there are three CAD-systems available, the Image Checker M 1000 (R2-Technology, USA), the Second Look-system (CADx Medical Systems) and the Mammex TR (Scanis Inc., USA). Most of the present studies are done with the R2-system. The mammographies have been digitalized secondarily. Different algorithms recognized microcalcifications and masses. The connection between full field digital mammography systems and DICOM-networks is possible. RESULTS: In retrospective and one large prospective study with 12.860 patients it could be shown that sensitivity of the investigator with CAD could be improved up to 19%, microcalcifications are yielded with CAD in 100%, masses in up to 80%. CONCLUSION: Double-reading with CAD-systems can increase early breast cancer detection effectively. Regarding the development of full field digital mammography we are looking forward to further innovations.

[Do tissue marker clips after sonographically or stereotactically guided breast biopsy improve follow-up of small breast lesions and localisation of breast cancer after chemotherapy?]. / Verbessert die Clipmarkierung im Rahmen der sonographischen oder stereotaktischen Brustbiopsie die Verlaufsbeurteilung kleiner Mammaläsionen und Lokalisation von Tumoren nach Chemotherapie?

PURPOSE: We wanted to determine if tissue marker clips after sonographically or stereotactically guided breast biopsy improve the follow-up of small breast lesions classified BI-RADS 4/5 and the localisation of breast cancer (TNM stage 2 or 3) after neoadjuvant chemotherapy. MATERIAL AND METHODS: Prospective analysis was performed of 108 breast lesions 1 cm or smaller mammographically classified as BI-RADS 4/5 and 14 breast lesions larger than 2 cm mammographically classified as BI-RADS 5. 33 of the 108 breast lesions 1 cm or smaller underwent sonographic core cut breast biopsy (group 1) and 75 stereotactic vacuum-assisted breast biopsy (group 2). All 14 lesions greater than 2 cm were stereotactically vacuum-assisted breast biopsied (group 3). The centre of the lesion was marked by a clip after the biopsy. Mammographies were performed in all patients of group 1 and 2 with a histologically benign finding (n = 31, n = 69, respectively) and in all patients of group 3 directly after clip placement and after 6 and 12 months. Clip localisation and possible divergence from the original position were verified by a grid. RESULTS: Two patients of group 1 and 6 patients of group 2 had breast conservative surgery (BET) because of the histological diagnosis of a ductal carcinoma in situ or invasive breast cancer. The tissue marker clips of the remaining 31 patients of group 1 and 69 patients of group 2 diverged with a mean value of 0.4 cm (standard deviation +/- 0.23 cm; range 0.1 cm to 0.9 cm) from their placement position after 6 months. After 12 months the marker clips deviated with a mean value of 0.4 cm (standard deviation +/- 0.21 cm; range 0.1 cm to 0.9 cm) in 94 patients and 0.8 cm (standard deviation +/- 0.25 cm; range 0.1 cm to 0.9 cm) in 6 patients from their original location. No tumour progression of the benign lesions in group 1 and 2 was diagnosed in follow-up mammograms. In all patients of group 3 the tissue marker clips were the only possibility to localize the tumour after neoadjuvant chemotherapy as all other diagnostic methods showed inconsistent results. CONCLUSION: Positioning a tissue marker clip in the tumour centre seems to be reasonable after interventional biopsy of breast lesions of 1.0 cm or smaller and before neoadjuvant chemotherapy.

[Mammography/stereotactically controlled vacuum excisional biopsy. Interventional methods in breast diagnosis]. / Mammographisch/stereotaktisch gezielte Vakuum-/Exzisionsbiopsie. Interventionelle Methoden in der Mammadiagnostik.

As well as in the complementary mamma diagnosis (clinical examination, mammography, sonography) including the dynamic MRI and the mammography screening projects the interventional methods like mammographically/stereotactically guided vacuumbiopsy/excisional biopsy are established methods to avoid unnecessary open operations and they are integrated in the clinical routine. By using strict criterias it is a way to improve the specificity and the negative predictive value in the mamma diagnosis. In addition the interventional methods requires less costs, less time and reduces the morbidity in comparison to an open operation.

[Radiation exposure in x-ray mammography]. / Die Strahlenexposition bei der Röntgen-Mammographie.

When discussing the radiation risk of X-ray mammography, the magnitude of the dose applied has decisive importance. The radiation exposure of the breast is the predominant factor in risk considerations, since it contributes more than 98% to the effective dose of this examination. At present, it is generally assumed that, with regard to cancer induction by ionizing radiation, the glandular tissue is the most vulnerable part in the breast. Therefore, the average glandular dose, i.e., the mean value of the absorbed dose in the glandular tissue, is used for a description of the radiation risk. The average glandular dose cannot be measured directly, but is calculated under certain assumptions from the experimentally determined entrance surface air kerma or entrance surface dose by the use of a so-called conversion factors. During the seventies, i.e., in the era of the industrial type X-ray film, the mean value of the average glandular dose per exposure for a larger sample of patients (n > 100) was about 20 mGy. Due to the progress in radiographic technique such as, for example, the use of sensitive film-screen systems, optimized radiation qualities and modern automatic exposure control units this value has now decreased to about 1 mGy. Further dose reductions seem possible by the introduction of digital image receptors.

Experimental investigations of image quality in X-ray mammography with conventional screen film system (SFS), digital phosphor storage plate in/without magnification technique (CR) and digital CCD-technique (CCD).

Comparison of image quality in X-ray mammography between conventional film screen film system (SFS), digital phosphor storage plate in and without magnification technique (CR) and digital CCD-technique (CCD). Radiograms of an RMI-mammography phantom were acquired using a conventional screen film system, three digital storage plate systems and two digital systems in CCD-technique. Additionally, the radiograms of one digital phosphor storage plate system were post-processed regarding contrast and included in the comparison. The detectability of details was best with the digital mammography in CCD-technique. After confirming these promising results in clinical studies, digital mammography should be able to replace conventional screen film technique.

[Experimental studies on image quality in conventional film screen system, digital phosphor storage plate mammography in mangnification technique and digital mammography in CCD-technique]. / Experimentelle Untersuchungen zur Bildgüte konventioneller Film-Folien-Mammographie, digitaler Mammographie mit Speicherfolien in Vergrösserungstechnik und voll digitaler Mammographie in CCD-Technik.

UNLABELLED: Comparison of image quality between conventional film screen system, digital phosphor storage plate mammography in magnification technique and digital mammography in CCD-technique. MATERIALS AND METHODS: Radiograms of a RMI-mammography phantom were acquired using a conventional film screen system, two digital storage plate systems and two digital systems in CCD-technique. Additionally, the radiograms of one digital phosphor storage plate system were postprocessed emphasizing contrast and included in the comparison. RESULTS: The detectability of details was the best with the digital mammography in CCD-technique in comparison with the conventional film screen technique resp. digital phosphor storage plate in magnification technique. CONCLUSIONS: Based on these results there is the possibility to replace the conventional film screen system by further studies--this has to be confirmed.

[Image quality and radiation exposure in digital mammography with storage phosphor screens in a magnification technic]. / Bildgüte und Strahlenexposition bei der digitalen Mammographie mit Speicherfolien in Vergrösserungstechnik.

PURPOSE: Comparison of image quality between digital phosphor storage plate mammography in magnification technique and a conventional film screen system regarding the special aspect of radiation exposure. MATERIALS AND METHODS: Radiograms of a RMI-mammography phantom were acquired using a conventional film screen system and two digital storage plate systems. Additionally, the radiograms of one digital system were post-processed emphasizing contrast and included in the comparison. RESULTS: The detectability of details in storage plate mammographies with magnification technique is almost equal to that of film screen mammographies. Thereby, lower radiation exposures were necessary using the digital systems. CONCLUSIONS: Based on these results, storage plate mammography in magnification technique is used in clinical routine at our institution. The correct parameters in image postprocessing are of elementary importance for detail detectability. Future studies must show, whether the lower radiation exposure in digital radiograms of the breast, revealing much higher background noise, will allow the same detail detectability as film screen mammographies.

[Is the use of hyperosmolar oral contrast media still justifiable today?]. / Ist der Einsatz hyperosmolarer oraler Kontrastmittel heute noch gerechtfertigt?

The application of oral hyperosmolar contrast media, as they are used for the control of anastomoses after operations on the upper intestinal tract and for the diagnosis of ileus, is still controversial today because of possible side effects. We examined 53 patients postoperatively, after abdominal operations and within the framework of the diagnosis of ileus, to find out whether there were any problems with the fluid and electrolyte balance, and whether side-effects such as nausea, vomiting, pain and diarrhoea were still tolerable. The patients did not classify their subjective complaints as very serious. None of our patients showed clinically manifest disorders of the fluid and electrolyte balance. The increased frequency of bowel movement, caused by the contrast agent, was required for the treatment of postoperative bowel atonia and the condition of ileus or sub-ileus, if present. We still think the application of hyperosmolar contrast media can be justified, and hence we restrict the use of the much more expensive iso-osmolar contrast agents to patients who are at risk in respect to aspiration and unfit to cooperate.