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Purpose: To evaluate the additional benefit of true geometric (air-gap) magnification views for the characterization of microcalcifications in digital mammography., Materials and Methods: After ethical approval, we retrospectively reviewed patient records to identify 100 patients with suspicious microcalcifications (35 malignant, 65 benign) who had a standard digital mammography and an additional digital magnification view in the same projection within three months. All images were obtained using an amorphous silicon-based full-field digital system (Senographe 2000 D, GE Healthcare, Chalfont St. Giles, UK). Images were independently analyzed by six board-certified radiologists. The probability of malignancy was estimated using first standard contact mammography alone (MG) and then mammography in combination with the magnification view (MG+MAG) using a modified Breast Imaging Reporting and Data System (BI-RADS) classification system and a percentage scale. Results were compared using receiver operating characteristic (ROC) analysis. In addition, readers assessed the subjective visibility of the calcifications., Results: For all six readers combined, the area under the curve (AUC) was 0.664 ± 0.052 for MG and 0.813 ± 0.042 for MG + MAG, resulting in a statistically significant improvement of 0.148 ± 0.120. Each reader had a higher AUC for MG + MAG than MG, with the improvement being statistically significant in four of the six readers. In 76.34 % of the cases, MG + MAG resulted in better visibility of calcifications compared with mammography alone. In 33 % slightly more and in 39 % significantly more calcifications were found., Conclusion: Even in digital mammography with the option of using electronic magnification (zoom) at the viewing workstation, true geometric (air-gap) magnification views remain important for the visibility and correct classification of microcalcifications and for the assessment of their extent., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objectives: To compare mammography (MG), contrast-enhanced spectral mammography (CESM), and magnetic resonance imaging (MRI) in the detection and size estimation of histologically proven breast cancers using postoperative histology as the gold standard., Methods: After ethical approval, 80 women with newly diagnosed breast cancer underwent MG, CESM, and MRI examinations. CESM was reviewed by an independent experienced radiologist, and the maximum dimension of suspicious lesions was measured. For MG and MRI, routine clinical reports of breast specialists, with judgment based on the BI-RADS lexicon, were used. Results of each imaging technique were correlated to define the index cancer. Fifty-nine cases could be compared to postoperative histology for size estimation., Results: Breast cancer was visible in 66/80 MG, 80/80 CESM, and 77/79 MRI examinations. Average lesion largest dimension was 27.31 mm (SD 22.18) in MG, 31.62 mm (SD 24.41) in CESM, and 27.72 mm (SD 21.51) in MRI versus 32.51 mm (SD 29.03) in postoperative histology. No significant difference was found between lesion size measurement on MRI and CESM compared with histopathology., Conclusion: Our initial results show a better sensitivity of CESM and MRI in breast cancer detection than MG and a good correlation with postoperative histology in size assessment., Key Points: • Contrast-enhanced spectral mammography (CESM) is slowly being introduced into clinical practice. • Access to breast MRI is limited by availability and lack of reimbursement. • Initial results show a better sensitivity of CESM and MRI than conventional mammography. • CESM showed a good correlation with postoperative histology in size assessment. • Contrast-enhanced spectral mammography offers promise, seemingly providing information comparable to MRI.

Objectives: To evaluate whether real-time elastography, a new, non-invasive method for the diagnosis of breast cancer, improves the differentiation and characterization of benign and malignant breast lesions., Methods: Real-time elastography was carried out in 108 potential breast tumor patients with cytologically or histologically confirmed focal breast lesions (59 benign, 49 malignant; median age, 53.9 years; range, 16-84 years). Tumor and healthy tissue were differentiated by measurement of elasticity based on the correlation between tissue properties and elasticity modulus. Evaluation was performed using the three-dimensional (3D) finite element method, in which the information is color-coded and superimposed on the B-mode ultrasound image. A second observer evaluated the elastography images, in order to improve the objectivity of the method. The results of B-mode scan and elastography were compared with those of histology and previous sonographic findings. Sensitivities and specificities were calculated, taking histology as the gold standard., Results: B-mode ultrasound had a sensitivity of 91.8% and a specificity of 78%, compared with sensitivities of 77.6% and 79.6% and specificities of 91.5% and 84.7%, respectively, for the two observers evaluating elastography. Agreement between B-mode ultrasound and elastography was good, yielding a weighted kappa of 0.67., Conclusions: Our initial clinical results suggest that real-time elastography improves the specificity of breast lesion diagnosis and is a promising new approach for the diagnosis of breast cancer. Elastography provides additional information for differentiating malignant BI-RADS (breast imaging reporting and data system) category IV lesions., (Copyright 2006 ISUOG. Published by John Wiley & Sons, Ltd.)

Aim: To investigate the use of iodine-based contrast media in digital full-field mammography., Methods: After performing initial phantom studies, seven patients underwent digital mammography (Senographe 2000D, GE Medical Systems, Milwaukee, USA) using a specially filtered beam before as well as 60, 120, and 180 seconds after injection of 80 ml of iodine contrast medium (Ultravist 370, Schering AG, Germany). The precontrast mammograms were then subtracted from the postcontrast mammograms and the resulting images compared with a contrast-enhanced dynamic MRI study, performed on all women., Results: Contrast medium accumulation within the tumors was visualized with a good quality in all cases. The conditions under which successful contrast-enhanced digital mammography can be performed were determined in phantom studies., Conclusions: Contrast-enhanced digital mammography has a potential for improving the visualization of breast tumors in mammography using special beam filtering, adjusted x-ray parameters, proper timing, and suitable subtraction software.

Purpose: To evaluate the conspicuity of microcalcifications in magnified mammographic views of preparations obtained with full field digital mammography (FFDM), film-screen mammography (FSM), and the DIMA technique., Material and Methods: Twelve preparations were examined by FFDM and FSM using 1.8 x magnification and DIMA using 7 x magnification. Parameter settings were identical for all three techniques. The number of visible microcalcifications was then determined for each modality by three radiologists. As far as possible, all preparations were X-rayed at 22 kV and 10 mAS., Results: Altogether 9705 calcifications were counted (DIMA: 1609/1542/1534; FFDM: 1020/753/881; FSM: 901/643/822). The total number of microcalcifications identified with the DIMA technique was 4685 as compared to 2654 with FFDM and 2366 with FSM. The calcifications counted with FFDM and FSM thus corresponded to 56.6 % and 50.5 %, respectively, of those identified with DIMA. The differences between the groups were statistically significant (F-Test, p < 0.05)., Conclusion: Significantly more calcifications are identified when magnified mammographic views of preparations containing microcalcifications are obtained with the DIMA technique compared to FFDM or FSM. FFDM depicts markedly more calcifications than FSM. This means one should increase spatial resolution. Digital mammography offers the potential for improved visualization of microcalcifications with advanced applications.

Purpose: A procedure for performing intraoperative digital radiography of diagnostic breast specimens directly in the operating suite with teleradiologic assessment by a radiologist is presented. The efficiency of this procedure is compared with that of conventional magnification mammography performed in the radiology department., Material and Methods: Thirty-six specimen radiographs obtained by conventional magnification mammography were compared with 38 intraoperative digital magnification radiographs (DIMA Soft P42 prototype, Feinfocus Inc., Garbsen). The radiographs were assessed for lesion conspicuity and time savings for the surgeon, anesthesiologist, and radiologist., Results: The new procedure identified all 38 labeled pathological lesions, and the conventional technique likewise had a detection rate of 100% (36/36). The new technique resulted in considerable time savings for the surgeon and the radiologist. The duration of surgery was shorter and the time interval from removal of the specimen to reporting of the results was reduced from about 23 min to about 13 min. A single radiograph was sufficient for complete visualization of the specimen in all cases., Conclusion: Digital intraoperative specimen radiography considerably reduces the time of surgery depending on the local conditions and is highly accurate in locating a suspicious area within the tissue.

Objective: Digital full-field mammography has been used at the Department of Radiology of Charité Medical Center in Berlin since June 1999. This study compares the new digital technique with conventional mammography including a survey of its value in breast imaging and an outline of future prospects., Material and Methods: More than 1,000 of a total of over 5,000 mammographies performed between June 1999 and April 2000 have been obtained using the digital full-field mammography system Senographe 2000D (GE Medical Systems). The digital mammograms were compared with previous conventional films and conventional mammographies performed during the same period (Philips UC Diagnost, Senographe DMRplus)., Results: Digital mammographies were equal to conventional ones in all cases and seemed to be superior in detecting microcalcifications in dense glandular tissue. Adequate assessment was possible despite the lower spatial resolution compared to conventional mammography. Additional magnified images were obtained with both techniques for differentiating microcalcifications., Conclusions: Digital full-field mammography appears to be at least equal to the conventional technique and even superior in some respects. In our experience, the lower spatial resolution of digital mammography has no major disadvantages. The digital system provides new options for electronic storage of mammograms, telemammography, and computer-aided diagnosis.

Purpose: A prospective study on the differentiation of breast lesions was carried out using experimental combination schemes of mammography and automatic sonography., Materials and Methods: X-ray mammograms and a B image from automatic sonography of 39 malignant and 41 benign lesions as well as 40 cases without lesions were separately examined by four experienced diagnosticians. The observers differentiated the findings mammographically and by measurement in the B images., Results: For two examiners the combination of mammography and automatic sonography gave with regard to the differentiation of breast lesions an improvement in sensitivity of 3 or 5% and in specificity of 31 and 18%, respectively, as compared to mammography alone while for the other two examiners an improved specificity of 21 and 36%, respectively, was accompanied by an 8 and 10% decrease in sensitivity as compared to mammography alone., Conclusions: The differentiating criteria from automatic sonography and mammography can, in principle, be used to evaluate the dignity of breast lesions. However, an optimization is necessary since the improvement in specificity does not compensate the loss in sensitivity.

For non-palpable lesions detected radiographically alone, lumpectomy after needle-localization is currently performed. Specimen radiography provides an indirect proof of complete excision of the mammographic abnormality. Up to now, intraoperative mammography of the operated breast has not been possible. Digital intraoperative mammography is now possible with the ABBI-system, which will be introduced in this article. In a pilot study, we have investigated, whether it is possible to excise small carcinomas with the ABBI stereotactic biopsy device (maximum diameter 20 mm) without compromising breast conserving therapy. In a prospective study, 69 patients were diagnosed or treated using the ABBI-system. In all 60 patients with a primary lesion, a cylindrical excision was performed. Of these, 11 invasive and 5 intraductal carcinomas were diagnosed. 7 of the invasive and 2 of the intraductal cancers were treated with breast conserving surgery. In 9 cases, an in-breast recurrence was suspected. In 7 of these a cylindrical excision was performed. One invasive and 3 intraductal carcinomas were found and mastectomy was performed in these four patients. In two patients with the suspicion of an in-breast recurrence, the ABBI-system was used to perform a core-needle biopsy. In one patient, the biopsy finding was positive and mastectomy was performed. Patients with lesions close to the chest wall are not suited for the ABBI-system. The postoperative course was uneventful in all cases, the cosmetic result after breast-conserving therapy was very good. The advantages of this new method consist in the reliable stereotactic localization of suspicious lesions and in the fast intraoperative imaging.

A new technique for breast imaging is presented. This technique combines radiographic mammography directly with automated ultrasound. The combined examination, which is performed without decompression of the breast, yields the conventional mammography films as well as a complete set of B-mode scans and ultrasound projections. These can be geometrically matched with each other in a definitive manner. A prototype of the device was first used in a pilot study of 50 patients followed by a study of an additional 450 patients with a total of 492 breast lesions, of which 269 were confirmed by histology or cytology. The results show that X-ray and ultrasound are complementary in the detection of cancer. The use of an experimental mode of image interpretation for combined mammography and automated ultrasound reduced the number of mammographically suspicious findings that ultimately turned out to be benign. These results were also confirmed in two blind studies including a total of 160 histologically or cytologically confirmed lesions and 40 cases without lesions. With further technical advancement of the technique aimed at rapid and easy application and confirmation of the results obtained so far, the combination of mammography and automated ultrasound might be introduced into a routine clinical setting.

Stereotactic procedures are indicated in nonpalpable breast lesions that are suspicious in mammography. Using the ABBI system all established procedures (stereotactic needle biopsy, fine needle biopsy, core needle biopsy) can be performed. Also the resection of cylindrical tissue specimen with a maximum diameter of 20 mm can be carried out, controlled by digital mammography. For the exact diagnosis of lesions with a diameter up to 15 mm, cylindrical extirpation is recommended. In several cases this can be considered as definitive lumpectomy. Neither lesions localized close to the thoracic wall nor retromamillary lesions can be treated by using the ABBI system. While digital mammography is the method of choice for the detection of microcalcifications, the visualization of opacifications may be difficult. Overall the ABBI system was used in 40.7% of our patients with nonpalpable breast lesions.

The ABBI (Advanced Breast Biopsy Instrumentation) system is a new method of breast surgery of nonpalpable tumors which permits intraoperative mammography. In a pilot study it was shown that a small carcinoma can be removed by a mammographically and stereotactically controlled biopsy (20 mm maximum diameter). An indicated breast-conserving therapy can be carried out when using this method.