Evolution of Imaging in Breast Cancer.

The following topics are discussed in this article. A historical review of the evolution of breast cancer imaging from thermography through digital breast tomosynthesis, molecular breast imaging, and advanced breast magnetic resonance imaging. Discussion of multiple clinical trials, their strengths, and weaknesses. Historical perspective on the Mammography Quality Standards Act and its relationship with development and implementation of the Breast Imaging-Reporting and Data System (BI-RADS).

Observer variation in the interpretation of xeromammograms.

We have examined variation in the interpretation of xeromammograms among radiologists designated to take part in a Canadian multicenter randomized controlled trial of screening for breast cancer. Radiologists read 100 xeromammograms comprising 10 histologically proved cancers, 40 benign abnormalities, and 50 normal films. Radiologists' opinions differed widely on the frequency of suspected or identified cancer. The diagnostic category "suspicion of cancer" or "cancer" was selected by radiologists for 10-55% of the films, and biopsy or aspiration was recommended for 21 to 53% of patients whose films were examined. Agreement on specific diagnostic categories was greatest for the diagnosis of cancer; agreement was least for the diagnosis of benign abnormalities and intermediate for the diagnosis of normality. Known cancers were in general correctly identified. These results indicate a need for development of methods to reduce observer variation in a interpretation of xeromammograms while preserving diagnostic sensitivity and validity. Results also emphasize the importance of developing strategies to ensure quality control in multicenter trials.

Breast cancer risk associated with reproductive factors and breast parenchymal patterns.

In a population-based study of 23,511 women 50-67 years of age at the time of first screening, a striking relationship was found between parity and age at first childbirth, on the one hand, and two radiologic aspects of breast parenchymal pattern (dysplasia and prominent duct pattern), on the other. These relationships appeared to be causal.

Temporal performance of amorphous selenium mammography detectors.

We investigated temporal performance of amorphous selenium (a-Se) detectors specifically designed for mammographic imaging. Our goal is to quantify the inherent lag and ghosting of a-Se photoconductor as a function of imaging conditions. Two small area electroded a-Se samples, one positively and the other negatively biased on the entrance side of x rays, were used in the experiments. The study of lag and ghosting was performed by delivering a number of raw exposures as experienced in screening mammography to the samples at different electric field strength E(Se) while measuring the current through the a-Se sample. Ghosting at different operational conditions was quantified as the percentage x-ray sensitivity (x-ray generated photocurrent measured from the sample) reduction compared to before irradiation. Lag was determined by measuring the residual current of a-Se at a given time after the end of each x-ray exposure. Both lag and ghosting were measured as a function of E(Se) and cumulative exposure. The values of E(Se) used in our experiments ranged from 1 to 20 V/microm. It was found that ghosting increases with exposure and decreases with E(Se) for both samples because of the dominant effect of recombination between trapped electrons and x-ray generated holes. Lag on the other hand has different dependence on E(Se) and cumulative exposure. At E(Se) < or = 10 V/microm, the first frame lag for both samples changed slowly with cumulative exposure, with a range of 0.2%-1.7% for the positively biased sample and 0.5%-8% for the negatively biased sample. Overall the positively biased sample has better temporal performance than the negatively biased sample due to the lower density of trapped electrons. The impact of time interval between exposures on the temporal performance was also investigated. Recovery of ghosting with longer time interval was observed, which was attributed to the neutralization of trapped electrons by injected holes through dark current.

Mammographic parenchymal patterns and risk of breast cancer in postmenopausal women.

A case-control study was conducted to assess whether certain "high-risk" mammographic parenchymal patterns are associated with the increased occurrence of breast cancer in postmenopausal women. Patients in the case group included 105 women with histologically confirmed breast cancer; subjects in the control group included 104 women with fibrocystic breast disease and 103 women with clinically normal breasts. All mammographic results were evaluated "blindly" by a radiologist who classified the breast parenchyma into "high-risk" and "low-risk" categories according to the criteria proposed by Wolfe. These data showed a similar proportion of allegedly "high-risk" breast parenchymal patterns among patients in all three groups. The finding that breast parenchymal patterns are not associated with an increased risk of breast cancer in women 50 years of age or older is consistent with the results of earlier studies in which the association is present only in younger, premenopausal women, and is absent in older, predominantly postmenopausal women. Consequently, it is concluded that these parenchymal patterns should not be used to select postmenopausal women for breast cancer screening programs, or to guide the evaluation of postmenopausal women with breast lumps or symptoms.

Dose reduction in mammography.

Two mammographic imaging systems (Xerox and Kodak Min-R) were evaluated. Three hundred consecutive mammographic examinations were performed utilizing both imaging systems. Results of these studies indicated equivalency of image detail at identical source-to-image receptor distance (SID). Patient exposure as measured by the thermoluminescent dose meter for Kodak Min-R system was approximately 25% that of Xeromammography system. Due to reduced power requirement, it is possible to increase the SID when Min-R system is employed for imaging. Improved geometric arrangement provided superior diagnostic images in 5.5% of 200 comparison cases.

Phantom evaluation of imaging modalities for silicone breast implants.

RATIONALE AND OBJECTIVES: Recent concern regarding possible adverse effects from silicone breast implants has increased the role of radiologists in assessing augmented breasts. The authors compare the commonly available imaging modalities in evaluating the intact silicone implant as well as free silicone in the adjacent tissue. METHODS: A contrast resolution phantom and breast of veal phantom were tested. Fat was used as a reference material. The phantoms were imaged with xeromammography, film-screen mammography, ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI). Proton MRI spectroscopy also was performed on fat, silicone, water, and water/gelatin samples. The consensus of two radiologists determined whether free silicone was present. RESULTS: CT and MRI provided the best images of the implant and the free silicone. Several features of MRI were useful: spin-density scans and the fast low-angle shot (FLASH) and fast imaging with steady-state precision (FISP) techniques provided excellent resolution, a consistent chemical shift artifact appeared around the silicone, and frequency selective pre-saturation techniques resulted in marked suppression of the silicone. CONCLUSION: Additional testing in a more realistic setting, breast coil design, and improvement of various MRI techniques, particularly the frequency selective pre-saturation techniques, all appear promising in evaluating breast implants, the presence of free silicone, and the adjacent tissues.

Analysis of the prognosis of minimal and occult breast cancers.

Of 296 occult breast cancers diagnosed at Kaiser-Permanente Medical Center, Los Angeles, in the last ten years, 80 were classified as minimal and 167 as nonminimal. Minimal cancers were intraductal, lobular in situ, or invasive and 0.5 cm or less in diameter. In the occult-minimal group, no woman had axillary node metastases, and there were no recurrences. In the occult-nonminimal group, 26% of the patients had axillary nodal involvement, with a recurrence rate of 13% and a mortality of 11.6%. Occult breast cancers differed significantly between minimal and nonminimal tumors in both treatment and prognosis. Nonminimal cancers should be treated as any palpable carcinoma. More conservative approaches could be considered for the minimal group, but prospective controlled studies should be done to determine the long-term risks of such treatment.

Parenchymal patterns of the breast defined by real time ultrasound.

The association of mammographic parenchymal patterns of the breast with breast cancer risk has been studied extensively but there is little information about the distribution of different patterns in populations at different risks for breast cancer. Such information could be obtained if a risk-free method of breast examination were available that could be applied to the general population. We have evaluated real time ultrasound for this application by comparing the parenchymal pattern as assessed by mammography with the extent of echogenicity in the breast on ultrasound examination in 102 subjects. Subjects were examined by both methods, the mammographic and ultrasound images independently classified, and the proportion of the breast occupied by radiological density or ductal prominence compared with the extent of echogenic areas on ultrasound. These two methods of classifying mammographic parenchymal patterns were found to be strongly correlated. Real time ultrasound may therefore be useful in the epidemiological study of mammographic pattern and breast cancer risk.

Xeromammographic image quality.

Xeroradiography is a diagnostic modality whose image-forming properties are fundamentally different from those of the conventional silver halide process. In this work, the xeromammographic process, representing the low-constrast limit of xeroradiography, is analyzed in detail. A step by step approach is taken, whereby th eimiting factors in the exposure and development stages are identified and quantified. The sensitivity of the Se layer is also computed and the concept of optimal exposure introduced. The paper concludes by considering a simple model for xeroradiographic noise.

X-ray imaging using amorphous selenium: a photoinduced discharge readout method for digital mammography.

A new digital image readout method for electrostatic charge images on photoconductive plates is described. The method can be used to read out images on selenium plates similar to those used in xeromammography. The readout method, called the air-gap photoinduced discharge method (PID), discharges the latent image pixel by pixel and measures the charge. The PID readout method, like electrometer methods, is linear. However, the PID method permits much better resolution than scanning electrometers while maintaining quantum limited performance at high radiation exposure levels. Thus the air-gap PID method appears to be uniquely superior for high-resolution digital imaging tasks such as mammography.

Radiographic information theory and application to mammography.

A theoretical estimate is made for the lowest exposure necessary to record the smallest feature of interest, using various radiographic detecting surfaces and allowing for the probability of making errors to be within certain specified bounds. These calculated exposures are compared with the errors to be within certain specified bounds. These calculated exposures are compared with the actual exposures given in clinical situations in order that the smallest feature of interest can be observed by the practitioner with the same probability of error. A measure of the viewing efficiency of a radiographic process is given by the ratio of these exposures. The application of these concepts to mammography for three different recording media--film, film/screen, and xeroradiography--shows that the minimum entrance exposure necessary for recording information by each receptor varies with the energy of the x-ray beam, and that the optimal photon energy lies in the 21- to 25-keV region. All three methods with their present modes of processing use at most only a few percent of the information they actually intercept. This argues, for example, that if some more efficient method of reading xerographic plates were found, entrance exposures as low as 9 mR per exposure would suffice for a mammogram.

Resolution and noise in xeromammography.

The resolution and noise characteristics of the xeromammographic image are analyzed by means of a multistage model which considers the exposure, toner deposition, and toner transfer steps. A frequency-dependent theory of xeromammographic noise is developed and comparison is made with experimental results. Central to this theory is the concept of a toner electrode formed in the immediate vicinity of the Se layer. Comparison is also made between the imaging capabilities of xeromammography and screen/film systems. The paper concludes by addressing the question of normalization of the transfer function in an electrostatic system.

On optimizing the xeromammographic image.

This work undertakes a detailed system-based analysis of the xeromammographic process starting from basic considerations. Both the edge enhancement and wide-recording latitude, the two principal characteristics of xeroradiography, are shown to bear an intimate relationship to the electric-field distribution. Criteria and methods are formulated for optimizing xeromammographic image quality and a procedure is developed for calculating the white gap. Densitometric curves are derived for both positive- and negative-mode xeroradiography and found to be in excellent agreement with experiment. The question of image linearity is examined carefully and a threshold value of the electrostatic contrast is established, which sets a natural criterion for the application of Fourier analysis. Furthermore, it is shown that, in xeromammography with its inherently low-contrast structures, an optimal exposure exists which optimizes simultaneously all low-contrast edges. This last finding, coupled with experimental results, suggest immediately the possibility of an automatic exposure termination in xeromammography. Beam hardening is also investigated and it is shown that increased filtration combined with a lower bias potential leads to substantial dose reduction without significant loss of image quality. The paper concludes with a discussion of scattered radiation and how it affects xeromammographic image quality.

X-ray imaging with amorphous selenium: optimal spectra for digital mammography.

The optimum x-ray spectra for acquisition of digital mammographic images using an amorphous selenium (a-Se) photoconductor are investigated. The recorded images consist of latent charge distributions on the surface of an a-Se plate, which are then read out using two methods, laser discharge, or flat panel recharge. The investigation is based on a model of the breast previously developed for a phosphor-based digital readout system, and has been extended to include the effects specific to the use of photoconductors. The effects of plate thickness, x-ray scatter, readout noise, dose, and the kind of breast tissue on the nature of the optimum spectrum are explored for the two readout methods. The results indicate that use of a kilovoltage setting in the current mammographic range, and a molybdenum target spectrum is appropriate for digital readout of a-Se detectors. This conclusion contrasts with the appreciably higher kilovoltages traditionally used with the xerographic (toner) readout of latent charge images on a-Se.

Simulation of mammographic x-ray spectra.

Attempts to simulate Mo-anode spectra for film mammography by using Mo filters with W-anode tubes have been reported by several workers, and others have generated W-like continua for xeromammographic purposes by heavy Al filtration of Mo-anode tubes. In the present work the success of these simulations was tested by Si(Li) spectrometric methods that measured the spectral shapes and the exposure levels. Comparisons of Mo-anode/Al-filter with W-anode/Al-filter combinations were made, and also of W-anode/M-filter with Mo-anode/Mo-folter combinations. In certain circumstance the spectral shape is moderately well simulated but in all cases the useful output is less in the simulations than in the original spectra. The general conclusion is that simulation is always less attractive than direct use of the desired anode.

Film-screen mammography x-ray tube anodes: molybdenum versus tungsten.

Gridless screen-film mammography at 23 kVp with a W anode (inherent filtration: 0.1 mm A1, added filtration: 0.025 mm Mo) can achieve contrast identical to that achieved with gridless film-screen mammography at 27 kVp with a Mo anode (inherent filtration: 1.0 mm Be, added filtration: 0.025-mm Mo). However, W-anode film-screen mammograms obtained at 23 kVp require more radiation than Mo-anode film-screen mammograms obtained at 27 kVp. The lack of contrast of W-anode film-screen images produced at the same kVp as Mo-anode images was verified clinically and with a low contrast test object imaged over a range of densities. A step wedge test object was then used to match contrast between Mo- and W-anode gridless film-screen images at various kVp. The low contrast test object images verified the contrast equivalence of images obtained at 23 kVp for a W anode and 27 kVp for a Mo anode. A comparison of the two kVp for different anode materials was tested clinically on ten patients. The clinical and low contrast test object experiments were reviewed by three radiologists specializing in mammography.

History and recent developments in xeroradiography of the breast.

The article deals in very broad terms with the development of xeroradiography. The imaging process is a by-product of the search by Chester Carlson for a method to copy documents. The early experimental work was done at Battelle Memorial Institute, Columbus, Ohio. Clinical trials followed the fabrication of a machine by the Xerox Corporation. The machine as we know it today was introduced to the market in 1970-1971.

Mammography equipment: principles, features, selection.

1. Three-phase and constant potential generators may offer advantages over single-phase generators. These include shorter exposure times with less chance for motion unsharpenss, more adequate exposure and possible lower dose, and longer tube life. 2. Control of tube voltage in increments of 1 kVp are desirable for screen-film mammography and 2 kVp for xeromammography. 3. Tube loading limitations should be capable of allowing an adequate mA and mAs output. A mammography unit with a lower mA output may require longer exposure times with consequent motion unsharpness and/or higher dose. The maximum mA output is limited by the power rating of the tube and not by the power rating of the generator, which is usually much higher. Thus, tube rating charts rather than generator power rating should be used to compare the mA output of different mammography units. 4. Phototimer capability can reduce exam time, facilitate proper exposure, and reduce radiation dose. Units with a greater number of density steps and three or more photocell locations, one of which is near the edge of the film holder, provide better phototimer results. 5. A molybdenum target, beryllium window tube with 0.03 mm molybdenum added filtration is presently preferred for screen-film mammography. A tungsten target tube with 1 to 2 mm added aluminum filtration is advised for xeromammography. 6. Effective local spot size for contact mammography should be in the range of 0.2 to 0.5 mm. However, high resolution also requires sufficiently long source-to-image-receptor distances. Using measured focal spot size and source-to-image-receptor distance, it has been shown that some mammography units do not fully utilize the resolution capabilities of some available screen-film systems. On the other hand, a focal spot that is too small may limit the field size and lead to uneven energy distribution in the x-ray field. 7. In order to perform standard and supplementary mammographic projections, the C arm assembly must be capable of being located at multiple positions within a 180 degrees rotation. Greater degrees of rotation are not required. 8. The heat dissipation capability should be adequate to accommodate the anticipated work-load in terms of number of patients and patient scheduling. A mammographic unit with an anode heat capacity of 90,000 heat units or more should be adequate for most practices. A mammography unit with a heat capacity of 20,000 heat units or less may require waiting time between exposures or studies in a high-volume mammography practice. 9. The compression plate should be made of plastic, usually 1 to 4 mm thick.(ABSTRACT TRUNCATED AT 400 WORDS)

Cassette-based digital mammography.

Over the past several years, digital mammography systems have been installed clinically across North America in small but growing numbers. A photostimulable phosphor-based full-field digital mammography image was evaluated in this investigation. Commonly known as computed radiography (CR), its use closely mimics the screen-film mammography paradigm. System performance using modulation transfer function (MTF) and detective quantum efficiency (DQE) metrics show MTF(2.5 mm(-1)) = 0.5, DQE(2.5 mm(-1)) = 0.3, and MTF(5.0 mm(-1)) = 0.2, DQE(5.0 mm(-1)) = 0.05, for a 26 kVp beam, 0.03 mm molybdenum tube filtration, 4.5 cm tissue attenuation, and 15 mR incident exposure to the detector. Slightly higher DQE values were measured at 32 kVp with 0.025 mm rhodium tube filtration. CR mammography advantages include the ability to use existing mammography machines, where multiple rooms can be converted to "digital" operation, which allows overall cost savings compared to integrated digital mammography systems. Chief disadvantages include the labor-intensive handling of the cassettes prior to and after the imaging exam, lack of a direct interface to the x-ray system for recording technique parameters, and relatively slow processing time. Clinical experience in an IRB-approved research trial has suggested that digital mammography with photostimulable storage phosphors and a dedicated CR reader is a viable alternative to conventional screen-film mammography.