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Alongside mammography, breast ultrasound is an important and well-established method in assessment of breast lesions. With the "Best Practice Guideline", the DEGUM Breast Ultrasound (in German, "Mammasonografie") working group, intends to describe the additional and optional application modalities for the diagnostic confirmation of breast findings and to express DEGUM recommendations in this Part II, in addition to the current dignity criteria and assessment categories published in Part I, in order to facilitate the differential diagnosis of ambiguous lesions.The present "Best Practice Guideline" has set itself the goal of meeting the requirements for quality assurance and ensuring quality-controlled performance of breast ultrasound. The most important aspects of quality assurance are explained in this Part II of the Best Practice Guideline., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

For many years, breast ultrasound has been used in addition to mammography as an important method for clarifying breast findings. However, differences in the interpretation of findings continue to be problematic 1 2. These differences decrease the diagnostic accuracy of ultrasound after detection of a finding and complicate interdisciplinary communication and the comparison of scientific studies 3. In 1999, the American College of Radiology (ACR) created a working group (International Expert Working Group) that developed a classification system for ultrasound examinations based on the established BI-RADS classification of mammographic findings under consideration of literature data 4. Due to differences in content, the German Society for Ultrasound in Medicine (DEGUM) published its own BI-RADS-analogue criteria catalog in 2006 3. In addition to the persistence of differences in content, there is also an issue with formal licensing with the current 5th edition of the ACR BI-RADS catalog, even though the content is recognized by the DEGUM as another system for describing and documenting findings. The goal of the Best Practice Guideline of the Breast Ultrasound Working Group of the DEGUM is to provide colleagues specialized in senology with a current catalog of ultrasound criteria and assessment categories as well as best practice recommendations for the various ultrasound modalities., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

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., (© Georg Thieme Verlag KG Stuttgart · New York.)

The updated 2008 German Guideline for Early Detection of Breast Cancer provides evidence-based and consensus-based recommendations of the knowledge gained by the German Society for Surgery and the German Society of Plastic, Aesthetic, and Reconstructive Surgeons together with 29 professional societies, associations, and nonmedical organizations. The guideline is meant to assist physicians, healthy women, and patients in medical decisions with recommendations regarding the diagnostic chain in early detection of breast cancer. In addition to these recommendations, the guideline also includes descriptions of quality assurance for resources, procedures, outcomes, and evaluation using a set of quality indicators. It updates the previous version from 2003. The guideline's recommendations are presented. They are described in detail in the full publication (in German) Geburtsh Frauenh 2008; 68:251-261. The long version of the Guideline, methods report, and evidence report are available on the internet at www.awmf-leitlinien.de (reg. no. 077/001) with free access.

Higher breast density leads to a higher risk of breast-cancer coming along with a reduced sensitivity of mammography, the most important method for early diagnosis of breast cancer. HRT leads to an increase in breast density in up to (1/3) of treated women. Combined regimes of estrogen-progestin show a stronger influence than estrogen only. Changes of breast density appear almost entirely within the first year of administration and seem to be reversible after suspension of treatment within a few weeks. A possible solution of the dilemma is to perform mammography in asymptomatic premenopausal women during the first half of the menstrual cycle. In women with increased breast density using HRT it is recommended to modify the combination of hormones, change the application mode, or suspend HRT for a short period of 3 weeks prior to mammography. In symptomatic women with dense breasts, additive breast ultrasound is strongly recommended to reduce the otherwise high rate of missed breast cancers.

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.

Aim: The syndrome was first described by Poland in 1841. It classically consists of unilateral muscular and osseous anomalies of the thorax and upper limb with defects of the ipsilateral breast and nipple. We report the value of panoramic-sonography in the diagnosis of this rare condition in three patients., Method: The three girls, all born in 1990, were independently introduced to our unit of children and adolescent gynaecology because of unilateral "developmental defects" of the breasts at the beginning of puberty. To discriminate a Poland-Syndrome from unilateral accentuation of thelarche standardized clinical and sonographical examinations were performed., Results: In 2 cases we found unilateral aplasia of the glandular tissue of the breast with different distinction of mamilla and pectoralis muscle. The 3 (rd) case showed a hypoplastic breast development with osseous defects of the chest wall, aplasia of the pectoralis muscle and brachydaktylia., Conclusion: The standardized panoramic sonography allowed an immediate and safe diagnosis without hazardous radiation exposure.

Aim: The implementation of diagnostic standards enhances quality assurance. The American College of Radiology's Breast Imaging-Reporting and Data System (BI-RADS(TM)) is intended to standardize terminology in the mammography report, the assessment of the findings, and the recommendation af action to be taken. The purpose of this study was to assess the value of the standardized system for clinically apparent male breast tumors. Do the special male anatomy and physiology limit the applicability of an evaluation system designed for female screening mammograms?, Methods: 4 investigators with different degrees of experience retrospectively evaluated 160 male mammograms. Our study was based on the 36 cases which could be correlated to histopathological findings: gynecomastia in the majority of cases, but also 4 invasive ductal carcinoma, 1 leiomyosarcoma and 1 ductal carcinoma in situ., Results: Assessment of the mammograms by BI-RADS(TM) (3(rd) Edition 1998) correctly placed all cases of malignancy into categories 4 and 5 without respect to the investigators's level of experience., Conclusion: Therefore, we conclude that the BI-RADS(TM)-classification can successfully be used to classify male mammograms with a high positive predictive value for malignancy. Knowledge of gender-specific imaging characteristics increases the specificity at a constant high level of sensitivity.

Aim: Lactating adenoma are circumscribed benign breast lesions developing during pregnancy or lactation due to overall enhanced proliferation of steroid hormone dependent tissue. Sonography is the method of choice for imaging mainly because of the physiologically dense breast tissue. Which is the predictive value of sonography in the diagnosis of lactating adenoma? Are sonographic characteristics dependent on age of gestation or time of lactation? Which diagnostic procedure should be recommended?, Method: We report the long time course of four patients with histologically proven (core-needle biopsy, 16 Gauge) lactating adenoma, first diagnosed during pregnancy, which were followed up sonographically (1997-2000) with real-time B-mode, panorama-mode (Siescape) and colour-sonography., Results: Demonstrating a high inter- and intraindividual variability the tumors were biggest around parturitation. Despite ongoing lactation tumors regressed in size, but did not vanish completely even after definite termination of breast feeding. Evaluation of sonographical characteristics did not allow to rule out malignancy., Conclusion: Three percent of all breast cancers at childbearing age coincide with pregnancy and lactation, therefore, an early histologic diagnosis is absolutely necessary. Sonographically guided core-needle biopsies allow to exclude malignancy without negative effects on breast feeding.

By means of a case-report the problems of an uncritical usage of the terminus "syndrom" are pointed out. The report concerns with a newborn child clinically showing nearly all morphological characteristics of the "Pätau-Syndrom" without having a chromosomal aberration.

In the case of a 29-year-old woman an early SGA (small for gestational age) fetus was detected in her third pregnancy. This fact being already a possible indicator for a genetical defect, the fetus also showed permanent cysts of the Plexus choroideus as a sonographical symptom of a deletion of the chromosome 10 (10 qter). The value of Plexus choroideus cysts sonographically diagnosed during pregnancy is discussed by showing the differential diagnoses, the clinical proceedings in general and specially the indications for a chromosomal analysis.

From May to September 1987, 221 women of over 45 years of age were examined by transvaginal ultrasound at the Department of Gynaecology (Gynaecological Hospital) of the University of Marburg. Transvaginal ultrasound proved to be significantly superior to clinical examination, since palpation had resulted in "NAD" findings in all cases. The average diameter and the volume of postmenopausal ovaries, determined by transabdominal sonographic studies, were easily confirmed by the new method. In 6% of the 221 patients, pathological findings of the ovaries were clinically "NAD". Since the usefulness of transabdominal ultrasound in screening for ovarian cancer has already been confirmed by other authors, this pilot study aims at providing an opportunity to test transvaginal ultrasound also in a large ovarian cancer screening programme by furnishing the essential basic research data. Age-adapted average ovarian sizes and significant differences in size between the right and the left ovary were used to differentiate between normal and pathological findings as well as changes in the ovarian parenchymal patterns.

The administration of GnRH analogues is expected to improve treatment by avoiding hysterectomy, since problems connected with the surgical removal of leiomyomata are correlated with their size. In this study the GnRH analogue goserelin in its depot formulation (Zoladex, ICI, Plankstadt) was used for treating isolated leiomyomata of the uterus. All patients were treated for 3 months before myomectomy was performed. The complete regression of a large myoma (206 cm3) was observed in 1 of 11 patients. In 5 cases a reduction in volume of more than 50% was achieved. Ovarian function was suppressed by goserelin, after a short-term stimulation, within 7 +/- 3 days. Serum levels of 17 beta-oestradiol were found to be generally less than 25 pg/ml. All patients reported climacteric complaints, but in no case had therapy to be discontinued. After cessation of goserelin, restoration of ovarian function was observed in all patients.

The authors report on clinically abnormal palpatory findings in the axilla. The radiology and sonography of these findings is described, as well as differential diagnosis between normal findings and benign as well as malignant changes. If it is not possible to confirm a benign aspect even by means of examination via relevant equipment, histological clarification must be sought whenever there is a new palpatory finding or if changes are noted.

The article reports on a comparison between 100 x-ray films (preparation radiographies, mammographies) with grid and a film/foil combination on the one hand, and conventional x-ray technique with material testing x-ray film on the other. The clear superiority of grid mammography is demonstrated by means of case examples.

Starting with a survey of the historical development of ultrasound-mammography the current status of this method within other diagnostic procedures of the breast is defined. Basing on over 1000 examinations since 1975 we report the sonographic possibilities in demonstrating different normal and pathologic breast structures. Pathologic structures are: Dudectasy, Cysts, Mastitis, Fibroadenoma, Carcinoma and Gynaecomasty. Own results are reported and the future of ultrasound mammography is discussed.

According to the general development in breast diagnosis the positions of the single modalities are described by showing the development of breast diagnosis at the X-ray department of the UFK Marburg. In this context special emphasis is placed on ultrasound mammography and its clinical application at the UFK Marburg during the past 10 years. Automated water coupling and hand held real-time ultrasound are compared with another and the effects of ultrasound mammography on invasive breast diagnostic modalities and on breast surgery are pointed out by means of statistical results.

We report about 239 ultrasound examinations of the breast using a new water-tank scanner (U.I.Octoson, Ausonics, Sydney, Australia). A very good tissue differentiation of the brease is caused by a special technique and a high resolution. Beside benign results, typical findings in 49 malignancies are demonstrated ("shadowing", "christmastree-sign") and its value discussed. All ultrasound examinations are correlated to X-ray mammography, thermography, needle-biopsy and patho-histology.

Clinical observations on more than 700 patients between September 1979 and October 1980 are reported. If cysts are suspected clinically, ultrasound mammography provides the most reliable diagnosis and is superior to all other methods for localization, fine-needle biopsy and follow-up. Since it is difficult to assess (due to summation effects), the radiologically dense breast (DY) is a further indication for sonography. In case of excentrically located palpatory findings, pregnant or immobile patients, ultrasound mammography can provide valuable diagnostic information.

In a 28-year-old patient with a large uterine leiomyoma, complete tumor regression was achieved by the LHRH agonist Zoladex (ICI 118.630) when administered three times. During the follow-up period of three months, new myoma growth did not occur. On the basis of this case study, it is necessary to discuss a new therapy concept for the differentiated treatment of uterine leiomyomata in young women with a desire for pregnancy.