The ROC method is being used increasingly in radiology for the purpose of checking image quality. A phantom has been developed for use in mammography, which takes account of the tissues of the breast and of abnormal changes. In order to compare image quality, various films and film-screen systems were employed. The effect of slice-thickness, focal spot size and radiation scatter on image quality has been examined. The suitability of the method for quality control has been tested on a small sample. In addition, certain important parameters of the radiographic technique have been determined by physical measurements. Certain methodological difficulties must be considered, eg. the problem of statistical significance. It has been shown, however, that film-screen systems can approach the image quality of screenless films and require a lower dose of x-rays. For larger slice thickness, the use of a grid produces significantly better results than film without screens alone. The findings of the quality control show that it is important to check image quality by means of physical measurements. The ROC method has proved less valuable in this respect.
Measurements of radiation exposure of the breast during various mammographic procedures were carried out with LiF dosimeters. Using non-screen film (Kodak Definix Medical) at 30 kv., average skin dose in 105 patients was 10.1 R per exposure. During xeroradiography (45 kv.) skin dose was about 25% of this and for a film-screen system (Mammoray RP 3/MR 50 at 30 kv.) only 7% of this value. Skin dose (at constant potential) rises almost exponentially with increasing tissue thickness. The age of the patient and the type of tissue in the breast has a significant effect on the radiation dose. From the measurements, an average dose per exposure was calculated for the entire breast and for the glandular tissue. This gave a result of 1.6 rd (16 mGy) and 1.0 rd (10 mGy).
Pathologic discharge from the nipple may be the only symptom of an early stage of carcinoma. Galactography is then the diagnostic method of choice to locate intraductal, nonpalpable lesions. The technique of galactography, the adequate surgical approach of pathologic galactographs (milk-duct segment resection), and the appropriate histological work-up of the surgical specimen are demonstrated. We report on 1918 galactographies in 1363 women with pathological discharge. In only 427 cases was a milk duct segment resection necessary (31.4%). In 8.5%, we found invasive intraductal cancer and in 2.9% ductal carcinomata in situ. Only 1 patient with breast cancer had axillary metastases. Extensive intraductal solid, papillary or adenomatous proliferations were found in 11.9% of the patients with excision. In 46.7% of the patients, papillomas were excised, a definitive treatment for this process. The supposition for success in the early diagnosis of cancer is close teamwork among the radiology, surgery and pathology services: the diagnostic result depends upon this. We attribute our yield of exact diagnosis to a very sophisticated histological work-up. We believe that this is necessary to avoid diagnostic failures.
From 1976 to 1978 11, 197 women were examined clinically and mammographically. Biopsy material from 1,673 breasts were examined microscopically. In 536 cases, or almost every third case (32%), a carcinoma of the breast was detected. The cancer was bilateral in 19 cases and the total number of women was therefore 517. A clinically occult tumour was only found in 7.7% (40 of 517) of the cases. 5% of these patients were high risk patients and 2.7% preventive examinations. 5 women with occult carcinoma of the breast were under age 40 and 14 under age 50. Benign changes of the glandular tissue were found in 59.5% of the cases. Marked proliferative changes were found in 4.6% of the cases and carcinoma in situ was found in 3.8% of the patients. In the age group 45--54 benign and proliferative changes of the parenchyma occured almost twice as often as cancers. The ratio between benign and malignant findings was 1:1 in the age group 55--59 and was less than 1:2 in the age group over 70. A sophistication of the mammograhic technique must be obtained. A thorough microscopic examination of tissue from subcutaneous mastectomies and tissue obtained at the time of reduction mammoplasties showed occasionally unexpected malignant tissue in an unexpected location. Especially these cases are suitable for later comparison to the mammographies.
In 614 breasts tumours assumed to be harmless cysts on palpation were aspirated. In 430 cases aspiration was the definitive treatment. In the other 184 cases excision was necessary in order to obtain histology. 11 cysts were radiologically suspect after air filling. In one case excision demonstrated an undifferentiated milk duct carcinoma. 12 cysts had radiologically suspicious areas outside their margins. In 4 cases lobular carcinoma in situ was present. 161 excisions were necessary because no fluid was aspirated at puncture of the tumour. In 10 cases histology showed malignancy: half of these were metastases from a known primary tumour and half were primary breast carcinomas. Out of 17 precancerous states neoplasia could be demonstrated in two cases in addition to papillary and proliferative duct changes. We have classified this neoplasia as lobular carcinoma in situ.
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