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Die mammografisch dichte Brust ist mit einem erhohten Risiko einerseits fur die Entstehung von Brustkrebs und andererseits fur die Maskierung von Karzinomen in der Mammografie korreliert. Dies hat in einer zunehmenden Zahl von Staaten der USA zur gesetzlichen Verpflichtung gefuhrt, die mammografische Brustdichte an die Frau wie auch an den behandelnden Arzt weiterzugeben. Der Arbeitskreis Mammasonografie empfiehlt die Mitteilung der Brustdichte und die Aufklarung der betroffenen Frauen uber die Vorteile individualisiert erganzender Verfahren in Abhangigkeit vom Gesamterkrankungsrisiko der Frau; aufgrund der deutschen Gesundheitsstruktur mit Erfahrung und Qualitatssicherungsprogrammen insbesondere die erganzende Durchfuhrung einer Mammasonografie unter Sicherung von Struktur-, Prozess-, und Ergebnisqualitat. Die Probleme moglicher Uberdiagnostik, zusatzlicher Kosten und erhohten emotionalen Stress sind bei der Aufklarung zu berucksichtigen. Bei familiarer Hochrisikokonstellation sollte eine humangenetische Beratung durchgefuhrt, eine genetische Testung und intensivierte Fruherkennung unter Einbeziehung der MR-Tomografie erwogen werden.

PURPOSE To determine the benefit of ShearWave™ Elastography (SWE™) in the ultrasound characterization of BI-RADS® 3 breast lesions in a diagnostic population. MATERIALS AND METHODS 303 BI-RADS® 3 lesions (mean size: 13.2 mm, SD: 7.5 mm) from the multicenter BE1 prospective study population were analyzed: 201 (66%) had cytology or core biopsy, and the remaining 102 had a minimum follow-up of one year; 8 (2.6%) were malignant. 7 SWE features were evaluated with regard to their ability to downgrade benign BI-RADS® 3 masses. The performance of each SWE feature was assessed by evaluating the number of lesions correctly reclassified and the impact on cancer rates within the new BI-RADS® 3' lesion group. RESULTS No malignancies were found with an E-color "black to dark blue", which allowed the downgrading of 110/303 benign masses (p < 0.0001), with a non-significant increase in BI-RADS® 3' malignancy rate from 2.6% to 4.1%. E-max ≤ 20 kPa (2.6 m/s) was able to downgrade 48/303 (p < 0.0001) lesions with a lower increase in BI-RADS® 3' malignancy rate (3.1%). No other SWE features were useful for reclassifying benign BI-RADS® 3 lesions. CONCLUSION Applying simple reclassification rules, SWE assessment of the maximum stiffness of lesions allowed the downgrading of a sub-group of benign BI-RADS® 3 lesions. This was accompanied by a non-significant increase in the malignancy rate in the new BI-RADS® 3 class.

PURPOSE To define the value of whole breast ultrasound for breast cancer detection in primary women's health care in gynecological routing practice. MATERIALS AND METHODS Among women who were operated at the breast center of the German Diagnostic Clinic (DKD) in the year 2007, we selected different indications for the examinations which were relevant for the detection of breast lesions. RESULTS Twenty-one of 86 breast cancers (24 %) which were treated at the DKD in the year 2007 were detected only because of an individual ultrasound screening examination. None of these women had abnormal clinical findings and only 8 of these women had abnormal mammograms. The majority of these cancers were early stages, pT1a/b. In this group of patients, only 8 benign lesions detected by ultrasound were operated. This corresponds to a ratio of benign vs. malignant operations of 0.4 to 1, which is far superior to the recommendations of international guidelines for quality assurance. CONCLUSION Our results show that ultrasound screening considerably increases the detection of early breast cancers without increasing the rate of unnecessary biopsies. This should encourage gynecologists to learn and perform systematic breast ultrasound examinations and to increase their own performance by continuous training. We can expect that additional studies will prove breast ultrasound to be a powerful method for improving breast cancer detection. Currently available state-of-the-art ultrasound technology allows for early detection, but further education and quality control are important for implementation in nation-wide health care.

In gynecological practice ultrasound has achieved a high significance for preventive breast diagnosis and in follow-up after breast cancer treatment. This is also represented in the new German S3 guidelines for early detection and for diagnosis and treatment of breast cancer. However, the use of this widespread and highly efficient method continuously gives rise to controversial discussions. Besides different medical political interests these discussions are also largely influenced by different standards and questions of quality control. Within the German mammography screening program ultrasound is only considered for evaluating suspect mammographic lesions. Apart from screening ultrasound is widely used in cases of diffuse benign disease, unclear clinical findings, unclear palpation findings, dense breast tissue and in general when mammography is problematic and for ultrasound-guided interventional diagnosis. Within the framework of gynecological tumor prevention ultrasound is also widely established for early cancer detection in non-symptomatic women.

AIM: In comparison to round breast implants, anatomically formed implants have a broader indi-cation spectrum in augmentation surgery for the formation of a natural breast shape. In order to achieve a long-term result, it is necessary for anatomically formed breast implants to remain secured in the position desired and planned initially. In the case of textured implants of a certain pore size and depth, this can be aided by the development of a stabilising implant-capsule-interaction (interface). The aim of this study was to investigate whether there are sonographic criteria for verifying the -position of anatomically formed breast implants and the development of a stable interface. MATERIAL AND METHODS: 628 patients underwent breast implant surgery and were followed up clinically as well as sonographically at the Frauenklinik und Institut fur Asthetische Chirugie am St. Josefs-Hospital, Wiesbaden. 228 implants (Style 410 Inamed McGhain®) were evaluated after a mean of 27 months postoperatively. Only cosmetic augmentations were included in the -results. Verification of the implant position was conducted by palpation as well as by sonography. Statistical analysis was performed using the McNemar-Test (Chi-squared test). RESULTS: Two marker points on the anterior side of the implant capsule in the lower hemisphere, which are designed for intraoperative position monitoring by palpation, could be reproduced sonographically in all cases and the position of the breast implant could thereby by determined. Two cases of clinically apparent implant rotation of more than 90° around the vertical axis were discovered in this way. The sonographical identification of the development of a stable interface between the implant and the periprosthetic capsule is possible when sonographic criteria of the “parasternal movement layer” are met. The sonographic outcome is significantly superior to palpation. CONCLUSION: Breast sonography used for the clinical follow-up of -patients with anatomically formed breast implants represents an -efficient diagnostic supplement with clinical relevance.

Die technischen Fortschritte der Ultraschallgerate haben den Katalog der Indikationen auf dem Gebiet der Brustdiagnostik erheblich erweitert. Durch zahlreiche Studien wurde dies untermauert. In der Differenzialdiagnostik erreicht der hochauflosende Ultraschall eine Trefferrate von 90–98%. Im praoperativen Staging und in der Erkennung multifokaler Karzinomherde ist der Ultraschall der Mammographie deutlich uberlegen. Bei der Abklarung unklarer Herdbefunde wurde der Ultraschall die wichtigste Methode fur gezielte interventionelle Eingriffe. Lediglich beim Screening von unsymptomatischen menopausalen Frauen ist bislang allein die Mammographie etabliert. Aber aufgrund mangelnder Sensitivitat bei Frauen mit dichtem Parenchym zeigen sich bei pramenopausalen Frauen auch in der Entdeckung okkulter Mammakarzinome grose Vorteile fur den Ultraschall. Insbesondere in der erweiterten Vorsorge fur Risikopatientinnen wird dies in Zukunft einen zunehmenden Stellenwert einnehmen.—Wichtig ist bei der Etablierung des Brustultraschalls jedoch eine gute Standardisierung und Qualitatssicherung.

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.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.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.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.

Aim To evaluate the benefit of echo-contrast-enhanced Doppler sonography in the differentiation of benign vs. malignant breast lesions after surgical removal of a malignant breast mass. Methods Thirty-eight patients referred for biopsy of a palpable, suspicious scar lesion 1–15 years (mean 3.3 years) after surgery for breast cancer were examined. During baseline ultrasound examination a subjective scoring system of the vascularity, the number, the regularity of vessels' course and their Doppler parameters were assessed. After injection of an ultrasound contrast agent (Levovist®) the same scoring system was applied to the parameters together with enhancement kinetics, enhancement intensity and enhancement pattern. Any increase in the scoring level of two or more characteristics (vascularity, number of vessels, intensity of enhancement in the tumor or regularity score of vessels in the lesion) was defined as suspicious for malignancy. A marked increase of enhancement in the immediate tumor periphery was also regarded as suspicious for malignancy. The sonographic results were assessed prospectively and correlated with the histology of the lesion. Results Of the 38 patients with a clinically-suspicious scar lesion, there were 28 true scars and 10 malignant scar lesions. All scar lesions showed no or slight vascularity on baseline sonography. After Echocontrast-enhancement a significant increase in tumor vascularity and the number of tumor vessels could be demonstrated in all 10 malignant lesions but in only one of the 28 benign scars. Conclusion Scars pose inherent technical problems for optimal mammography. Sonographic evaluation of the vascularity of the lesion with contrast enhancing agents showed improved diagnostic accuracy in the hands of an experienced examiner. Copyright © 2000 International Society of Ultrasound in Obstetrics and Gynecology

Background Postoperative scarring and radiotherapy changes in the conservatively treated breast often mimic breast cancer recurrence, resulting in many unnecessary biopsies. Local breast cancer recurrence may be detected more accurately with contrast-enhanced colour Doppler imaging. Methods Fifty-eight women with suspected local breast cancer recurrence were evaluated prospectively by means of conventional and contrast-enhanced colour Doppler imaging before surgical biopsy. Results Sensitivity for the detection of breast cancer recurrence using contrast enhancement was 94 per cent (specificity 67 per cent). Contrast enhancement significantly increased overall diagnostic accuracy, from 80 to 90 per cent (P < 0·04). Conclusion Contrast-enhanced colour Doppler imaging is a highly accurate method for detecting local breast cancer recurrence. Its adoption may substantially reduce biopsy rates.

The vascularity of a tumour is an indication of its propensity for malignancy, and the capacity for neovascularisation is a prerequisite for tumour growth. Colour flow Doppler imaging can provide flow information about blood vessels in normal breast tissue and benign or malignant tumours. Colour flow imaging of the breast is reviewed with particular reference to the use of echo enhancing agents to increase sensitivity. The technique allows the visualisation of blood flow deep within the breast and enhances the specificity on separating benign from malignant tumours.

To define the value of whole breast ultrasound for breast cancer detection in primary women's health care in gynecological routing practice.Among women who were operated at the breast center of the German Diagnostic Clinic (DKD) in the year 2007, we selected different indications for the examinations which were relevant for the detection of breast lesions.Twenty-one of 86 breast cancers (24 %) which were treated at the DKD in the year 2007 were detected only because of an individual ultrasound screening examination. None of these women had abnormal clinical findings and only 8 of these women had abnormal mammograms. The majority of these cancers were early stages, pT1a/b. In this group of patients, only 8 benign lesions detected by ultrasound were operated. This corresponds to a ratio of benign vs. malignant operations of 0.4 to 1, which is far superior to the recommendations of international guidelines for quality assurance.Our results show that ultrasound screening considerably increases the detection of early breast cancers without increasing the rate of unnecessary biopsies. This should encourage gynecologists to learn and perform systematic breast ultrasound examinations and to increase their own performance by continuous training. We can expect that additional studies will prove breast ultrasound to be a powerful method for improving breast cancer detection. Currently available state-of-the-art ultrasound technology allows for early detection, but further education and quality control are important for implementation in nation-wide health care.

Dieses Kapitel beschreibt die farbcodierte Dopplersonographie in der Mammadiagnostik, die ein relativ weites Feld potenzieller Anwendungen bei der Dignitatsbeurteilung und erweiterten Diagnostik von Mammatumoren bietet. Doppersonographische Beurteilungskriterien sind dabei die qualitative und quantitative Bewertung von Gefasdichte und Gefasmorphologie sowie die Analyse von Flussprofilen bezuglich der Gefaswiderstande und Stromungsgeschwindigkeiten. Neben den pathophysiologischen Hintergrunden werden die apparativen Voraussetzungen, Messtechniken, diagnostische Kriterien und der Einsatz von Kontrastmittel erlautert. Besondere Bedeutung besitzt die sonographische und dopplersonographische Dignitatsbeurteilung.

Technological improvements in image quality have allowed to expand the indications for the use of breast ultrasound. This includes tumor differentiation, peroperative staging, follow-up after cancer treatment and interventional diagnosis. Up to now, only mammography has been useful for population-based screening. However, high-resolution and quality-controlled ultrasound can further improve early cancer detection. This is useful in high-risk patients and women with dense breasts who are mammographically problematic. The population-wide use of this advanced indication for breast ultrasound depends on equipment quality and investigator experience. Up to now, there has been a lack of guidelines and regulations. The implementation of quality control is essential before high-quality and effective breast ultrasound can be generally offered.

This study was performed to examine whether an improvement in the transvaginal sonographic evaluation of the endometrium is possible by the addition of sonomorphological criteria to the measurement of endometrial thickness in women with postmenopausal bleeding.Various sonomorphological criteria were analyzed prospectively in 321 patients with postmenopausal bleeding. In a logistic regression model relevant criteria were selected and a diagnostic formula for differentiation of endometrial sonographic findings was derived.The criteria of endometrial structure, endometrial-myometrial border and endometrial thickness were significant for the differentiation of malignancy. These results allowed an estimation of the probability of malignancy for each sonographic endometrial finding. Using the cut-off point of 0.1 for the probability of malignancy, the sensitivity and specificity were 96.8% and 61.9%, respectively, with an accuracy of 72.3%. In contrast, the differentiation by endometrial thickness as the sole criterion (cut-off pointor = 5 mm) achieved a sensitivity of 97.9% and a specificity of 33.2%, with an accuracy of 52.3%.A useful diagnostic formula based on sonomorphological and metric criteria for endometrial differentiation was obtained. The specificity and accuracy increased with a minimal loss of sensitivity. However, estimates for sensitivity, specificity, and accuracy may be overoptimistic because they were derived from the same data used for development of the model.

Objective: To determine the diagnostic performance of SonoVue (Bracco) in the enhancement of Doppler signals in breast lesions and in the improvement of diagnostic accuracy. Methods: This multicenter study included 220 patients undergoing investigations of parenchymal lesions, 40 of which had breast tumors. After a baseline Doppler examination, intravenous doses of 0.3, 0.6, 1.2 and 2.4 ml SonoVue were injected. Doppler signal quality before and after injection was compared. Off-site assessment of the global quality of Doppler signal and duration of clinical useful enhancement, as well as off-site and on-site evaluation of quality of color and spectral Doppler, were performed. On-site evaluation of diagnostic accuracy was also carried out. Safety assessments included monitoring of adverse events up to 24 h following the last injection of SonoVue. Results: On-site evaluations: baseline Doppler was conclusive in only 4/21 carcinomas and in 2/17 benign lesions. Enhanced Doppler improved differential diagnosis in 20/21 carcinomas and in 9/12 benign lesions. Time to color enhancement was 0.55 min for the lowest and 0.35 min for the highest dose. The total duration of enhancement was 3.47 min for the lowest and 5.62 min for the highest dose, respectively. Off-site assessment: SonoVue improved the quality of Doppler blood flow information both in parenchymal and focal lesions. Statistically significant changes from baseline in global quality of Doppler investigations were observed at all four SonoVue doses (P

Antiangiogenic therapy is a promising new strategy to inhibit tumor growth and formation of metastases. Vascular endothelial growth factor (VEGF) and its receptors, VEGF-receptor 1 (VEGF-R1; FLT-1) and VEGF-R2 (KDR), have been shown to play a major role in tumor angiogenesis. PTK787/ZK 222584, a specific inhibitor of both VEGF-receptor tyrosine kinases, was investigated for its antitumoral and antiangiogenic activity in a murine renal cell carcinoma model. After intrarenal application of the renal carcinoma cells, mice develop a primary tumor and metastases to the lung and to the abdominal lymph nodes. Daily oral therapy with PTK787/ZK 222584 at a dose of 50 mg/kg resulted in a significant decrease of 61 and 67% in primary tumors after 14 and 21 days, respectively. The occurrence of lung metastases was significantly inhibited at both time points (98% reduction and 78% reduction, respectively). After 14 days, no lymph node metastases developed in the PTK787/ZK 222584-treated group, whereas after 21 days of treatment, the lymph node metastases were reduced by 87%. Vessel density in tumor tissues, detected by immunohistochemistry with an anti-CD31 antibody, was significantly decreased by PTK787/ZK 222584. Using color Doppler imaging ultrasound, significant changes in blood flow in the tumor feeding renal artery were found under treatment with PTK787/ZK 222584. Blood flow changes correlated with changes in vessel density but not with tumor volume. The compound was well tolerated in all in vivo experiments and had no significant effects on body weight or general well-being of the animals. This was in contrast to the animals treated with the antiangiogenic agent TNP-470. s.c. therapy with 30 mg/kg TNP-470 every other day had to be discontinued after 13 days because of animal weight loss (20%) and ataxia. These results demonstrate that PTK787/ZK 222584 is a potent inhibitor of tumor growth, metastases formation, and tumor vascularization in murine renal cell carcinoma. Furthermore, we have been able to demonstrate that color Doppler imaging ultrasound can be used to measure blood flow to a tumor and that flow correlates with vessel density. Thus, this may be a valuable noninvasive method for monitoring the effects of antiangiogenic agents such as PTK787/ZK 222584 on tumor vasculature.

To evaluate the benefit of echo-contrast-enhanced Doppler sonography in the differentiation of benign vs. malignant breast lesions after surgical removal of a malignant breast mass.Thirty-eight patients referred for biopsy of a palpable, suspicious scar lesion 1-15 years (mean 3.3 years) after surgery for breast cancer were examined. During baseline ultrasound examination a subjective scoring system of the vascularity, the number, the regularity of vessels' course and their Doppler parameters were assessed. After injection of an ultrasound contrast agent (Levovist) the same scoring system was applied to the parameters together with enhancement kinetics, enhancement intensity and enhancement pattern. Any increase in the scoring level of two or more characteristics (vascularity, number of vessels, intensity of enhancement in the tumor or regularity score of vessels in the lesion) was defined as suspicious for malignancy. A marked increase of enhancement in the immediate tumor periphery was also regarded as suspicious for malignancy. The sonographic results were assessed prospectively and correlated with the histology of the lesion.Of the 38 patients with a clinically-suspicious scar lesion, there were 28 true scars and 10 malignant scar lesions. All scar lesions showed no or slight vascularity on baseline sonography. After Echocontrast-enhancement a significant increase in tumor vascularity and the number of tumor vessels could be demonstrated in all 10 malignant lesions but in only one of the 28 benign scars.Scars pose inherent technical problems for optimal mammography. Sonographic evaluation of the vascularity of the lesion with contrast enhancing agents showed improved diagnostic accuracy in the hands of an experienced examiner.

Because of the increasing use of sonography to rule out cancer in women with palpable breast abnormalities, this study was performed to determine the rate of sonographically occult malignancy in this clinical setting.Women who were recommended for biopsy based on mammographic and/or clinical findings underwent breast sonography. This study retrospectively analyzed the subset of patients with palpable malignant lesions. Lesions were classified as visible or occult on mammography and sonography. Patients without a tissue diagnosis of tumor were excluded.Of 1,346 masses that underwent biopsy or aspiration, 616 lesions were palpable, and of these, 293 were malignant. Sonography detected all 293 palpable malignant lesions (95% confidence interval for sensitivity, 99-100%). Eighteen lesions were mammographically occult. The median lesion size as determined by sonography was 1.8 cm; for the lesions that were mammographically occult, the median size was 1.6 cm. The most common histopathologic diagnosis for both groups of lesions was infiltrating ductal carcinoma.All palpable malignant breast lesions were visible by sonography in patients in whom a biopsy was recommended. However, we caution that until the false-negative rate of sonography for equivocal palpable abnormalities is determined prospectively, sonography cannot be accurately applied to rule out malignancy in this setting.

Mammographie und Ultraschall haben eine hohe Sensitivitat zur Erkennung von Mammatumoren [1, 2]. Allerdings resultieren aus beiden Untersuchungsmethoden haufig unklare Befunde, die eine operative Abklarung erfordern, obwohl eine benigne Veranderung vorliegt [5–8]. Daher mus die Spezifitat bei der Brustdiagnostik weiter verbessert werden.

Wie durch verschiedene Studien gezeigt wurde, erlaubt die Dopplersonographie eine Verbesserung der Tumordifferenzierung gegenuber der alleinigen Sonographie und Mammographie. Allerdings geben geratetechnische Unterschiede derzeit noch grose Probleme in der Standardisierung. Seit einigen Jahren werden daher verschiedene Ultraschallkontrastmittel entwickelt, die den Signal-Rausch-Abstand erhohen. Durch die hohere Reflektivitat des Blutes konnen dadurch Gefase dargestellt werden, die ohne Signalverstarker nicht sichtbar sind. Seit etwa 2 Jahren ist das intravenos anwendbare Ultraschallkontrastmittel Levovist (Fa. Schering) verfugbar. Die darin gelosten Mikropartikel fuhren dosisabhangig zu einer starken Erhohung der Echogenitat des Blutes.

Auf die physikalischen Grundlagen des Dopplerprinzips wurde bereits fruher eingegangen. Auch fur die Mammadiagnostik gilt wie fur verschiedene andere Organregionen, das der CW-(Continuous-wave-) Doppler, der gepulste Doppler mit dem Duplex-Mode oder der zweidimensionale Farbdoppler, der Angio-oder Power-Mode verwendet werden konnen.

Das Mammakarzinom ist die haufigste Krebserkrankung bei Frauen. Eine Senkung der Mortalitat ist derzeit nur durch eine Verbesserung der Fruhdiagnostik zu erzielen. Bislang galt die Mammographie als einzige Methode, die eine Fruherfassung des Mammakarzinoms erlaubt. Die hierdurch zu erzielende Senkung der Mortalitat wurde in den letzten dreisig Jahren weltweit durch zahlreiche Mammographie-Screeningstudien belegt [1]. Insgesamt erlaubt die Mammographie eine Mortalitatssenkung um etwa 30 % im Screening-Kollektiv. In einigen Studien wurde nach pra- und postmenopausalen Patientinnen gesondert untersucht. Bei Frauen ab dem 50. Lebensjahr zeigt sich ein noch deutlicherer Screeningerfolg. Dagegen erzielt die Mammographievorsorge bei Frauen vor dem 50. Lebensjahr keine Effektivitat. Dies liegt daran, das bei jungen Frauen das Drusengewebe meistens dichter ist und eine hohere Strahlenabsorption aufweist. Dadurch verbergen sich haufig tumorose Verdichtungen und sogar MikroVerkalkungen. Dies reduziert die Sensitivitat der Mammographie bei pramenopausalen Frauen [10].

Transvaginal sonomorphologie and colour Doppler measurements were obtained preoperatively in 212 adnexal tumours: 81 premenopausal tumours (13 malignant and 68 benign) and 131 postmenopausal tumours (55 vs 76). Tumours were divided into five different scores according to their sonomorphology [16]. Scores I and II are related to benign tumours. Score V represents typically malignant tumours. Scores III and IV are associated with benign and malignant tumours. If score I and II are considered as benign and score III to V as malignant the sensitivity in pre- and postmenopausal tumours is 90%. However, the specificity is only 56% vs 70% respectively. In order to improve the accuracy, colour Doppler was additionally performed in tumours with sonomorphological score III and IV. The following criteria were tested: minimum resistance index (Rlmin), number of tumour arteries (ART), maximum (Smax) and sum (Ssum) of peak systolic velocities. All criteria showed significant differences between benign and malignant tumours. Tumours of score III and IV were differentiated by colour Doppler with an accuracy between 66% and 81% for premenopausal and 69% to 86% for postmenopausal women. The combination of sonomorphology and colour Doppler increased the accuracy between 84% and 90% with a sensitivity of up to 92% in pre- and 89% in postmenopausal patients. Sequential colour Doppler sonography as a supplement to transvaginal sonography improves tumour differentiation. The limitation of colour Doppler measurements to score III and IV lesions reduced the length of examination time to a reasonable extent.

According to the German guidelines for quality control of ultrasonic equipment, the following conditions are required for breast ultrasound: A transducer frequency between 5-7.5 MHz and a minimum field of view of 5 cm. Satisfactory images must be obtained in a depth between 0.5 and 4 cm with a wide tolerance of the focal zones. This allows the use of poor quality equipment which does not produce satisfactory image quality and it excludes a number of high frequency and high resolution transducers with a field of view below 5 cm. This study with a test phantom was performed to define image quality objectively.Sixteen ultrasound instruments in different price categories were used to perform standardized examinations on a breast phantom model 550 (ATS Laboratories, Bridgeport, USA). Contrast and spatial resolution in different penetration depths were investigated on cyst phantoms from 1-4 mm diameter and wire targets with defined distances between 0.5-3 mm 4 investigations reported the images.A positive correlation was seen between price category and image quality.This study demonstrates that transducer frequency and image geometry do not allow sufficient quality control. An improvement of ultrasound diagnosis is only possible if equipment guidelines are based on standard examinations with test phantoms.