Search

Purpose: Accurate measurement of breast tumour size is fundamental for treatment planning. We compared the accuracy of digital mammography (DM), digital breast tomosynthesis (DBT), ultrasound (US) and magnetic resonance imaging (MRI) for the preoperative evaluation of breast cancer size., Materials and Methods: We retrospectively reviewed 149 breast cancers in 110 patients who underwent DM, DBT, US and MRI between January 2010 and December 2011, before definitive surgery. The lesions were measured by two radiologists, without knowledge of the final histological examination, considered the gold standard. For each imaging modality, the maximum tumour size was measured to the nearest millimetre; the measurements were considered concordant if they were within ± 5 mm. Pearson's correlation coefficient was calculated for each imaging modality., Results: The median pathological tumour size was 22.3 mm. MRI and DBT had a level of concordance with pathology of 70% and 66%, respectively, which was higher than that of DM (54%). DBT and MRI measurements had a better correlation with pathological tumour size (R:0.89 and R:0.92, respectively) compared to DM (R:0.83) and US (R:0.77)., Conclusions: DBT and MRI are superior to DM and US in the preoperative assessment of breast tumour size. DBT seems to improve the accuracy of DM, although MRI remains the most accurate imaging modality for breast cancer extension.

Purpose: The purpose of this study was to assess the usefulness of routine ultrasonography in women with negative mammography and dense breasts [Breast Imaging Reporting and Data System (BIRADS D3-4)]., Materials and Methods: We applied a protocol involving routine ultrasonography in a consecutive series of subjects with negative mammography and dense breasts. After evaluation by internal and external reviewers of cancers detected by ultrasonography performed to confirm negative mammography, we determined the additional cancer detection rate of ultrasonography and the cost of the protocol., Results: Out of 17,883 total mammographies, 167 cancers were diagnosed (detection rate: 0.93%). Out of 257 suspicious mammographies, 138 cancers were detected. Out of 17,626 negative mammographies, 6,449 (36.5%) were classified as "dense breast" and underwent ultrasonography: 29 cancers were detected (detection rate: 0.44%, or 17.3% of total cancers). Out of 25 cancer cases reviewed, negative mammography and asymptomatic status was confirmed in 15 (detection rate 0.23%, or 8.9% of total cancers). The cancer detection rate was 0.11%, 0.22%, 0.32% and 0.14% for age groups <40, 40-49, 50-59 and >59, respectively. The cost per additional carcinoma detected by ultrasonography alone was euro 25,847.85 whereas that per examined woman was euro 21.68., Conclusions: The study confirms the possibility that ultrasonography can detect mammographically occult breast carcinoma in dense breasts. The evidence is insufficient to recommend this policy in routine screening practice but suggests that, at least in current clinical practice, adding ultrasonography in dense breasts may be useful despite the substantial costs.

Purpose: To evaluate the sensitivity for breast cancer of different diagnostic tests performed in a consecutive series of women aged under 36 years., Materials and Methods: The study analyses 155 women with breast cancer incident in the Tuscany Cancer Registry from 1985 to 2000. The sensitivity of each method was evaluated in relation to the most recent test performed during the year before diagnosis and to different variables, such as tumour size and calendar period., Results: Sensitivity was 70.3 % for physical examination, 76.0% for mammography, 69.1% for ultrasonography and 80.6% for cytology (86.2% if inadequate samples are excluded). Sensitivity was associated to pT category for physical examination (pT1=60.6%; pT2-4=86.4%; chi squared=10.2, p= 0.001) and for ultrasonography (pT1=61.9%; pT2-4=92.0%; chi squared=5.7, p=0.01) and to breast radiological density for mammography (50-100% density=75.5%; 0-50% density=91.3%; chi squared=1.85, p<0.17). Among 112 cases examined with palpation, mammography and cytology, these methods had a sensitivity of 78.5%, 75.8% and 91.9%, respectively, and an overall sensitivity of 98.2%. Among 65 cases examined with palpation, ultrasonography and cytology, these methods had a sensitivity of 67.6%, 70.7% and 92.3%, respectively, and an overall sensitivity of 95.3%. Among 123 cases examined with palpation, imaging (mammography and/or ultrasonography) and cytology, these methods had a sensitivity of 76.4%, 78.0% and 90.2%, respectively, and an overall sensitivity of 96.7%. Cancer was suspected by one method only in 2.4% of cases with palpation, 1.6% with imaging and 7.3% with cytology. Comparison between mammography and ultrasonography was possible in 58 cases undergoing both tests: sensitivity was 79.3% for ultrasonography and 74.1% for mammography, respectively chi squared=0.1, p=0.66). If sensitivity had been determined according to the test performed immediately before diagnosis it would have been higher, that is 74.4% for palpation, 76.8% for mammography, 73.5% for ultrasonography and 90.9% for cytology (97.7% if inadequate samples were excluded), and overall sensitivity would be 96.1%., Conclusions: Differential diagnosis of breast cancer in women aged under 36 years is difficult, sensitivity being lower as compared to older women, with the only exception of cytology. The association of multiple tests (diagnostic imaging and cytology) is crucial to achieve an acceptable false negative rate. In particular, the extensive use of cytology in the presence of an even minimal doubt at palpation and/or imaging is strongly recommendable. Sensitivity must be calculated on the basis of an independent pathology registry, and false negatives must be defined within a given period after the test. Analysis limited to tests performed immediately before diagnosis leads to a biased overestimation of sensitivity.

Purpose: To evaluate the sensitivity of the mammographic screening programme and the causes of diagnostic fault in cases surfacing as interval cancers., Materials and Methods: Interval cancers (CI) were identified by linkage of the screening database for the years 2000-2002 to the database of hospital discharge records (HDR) for breast cancer during 2000-2002. Linkage between screening attenders during 2000-2001 and HDR (biennial follow-up for year 2000, one year follow-up for year 2001) was used to calculate the proportional rate of observed/expected IC. The observed/ expected rate was compared with international standards and literature data. Screening mammograms followed by IC, randomly admixtured with negative controls, underwent blind review by an independent radiologist, using the recommended classification criteria to evaluate causes of error (occult, minimal signs, screening error)., Results: The analysis of HDR during 2000-2002 allowed us to identify 31 out of 89 expected IC. Proportional observed/expected IC rate in the first or second year of screening interval was 26 or 67%, respectively. Screening mammograms for radiological review were available in 38 of 61 total IC: 20 cases (52.6%) were classified as occult, whereas minimal signs or screening errors were 2 (5.2%) or 16 (42.1%), respectively. Diagnostic suspicion had been reported at screening in 7 of 16 cases classified as screening error, but were not diagnosed at the subsequent diagnostic assessment., Conclusions: Proportional IC rate was higher than reported in the literature or currently recommended (<30% in the 1st, <50% in the 2nd year). The analysis of error causes shows an excess of screening errors with respect to current recommendations (<20% of IC should be classified as screening error at review), but also an excess of IC suspected at screening but misdiagnosed at assessment (7/38=18.4 %). Overall the analysis revealed a reduced sensitivity of the screening programme, as often observed in service screening as compared to excellence centres, and suggests proper action to improve diagnostic accuracy. Analysis and critical review of IC is an early indicator of screening efficacy which is not currently used in Italian screening programmes. Using HDR for this purpose may have limited drawbacks, but gives the advantage of earlier identification of IC as compared to cancer registries and is the most reliable source of information in areas lacking a cancer registry. The present study methodology might be currently applied in screening programmes.

Purpose: To evaluate the efficacy of cytology on axillary lymph node ultrasound-guided aspiration biopsy in the reduction of inappropriate surgery, such as the sentinel node (SN) procedure if positive, or axillary dissection if negative., Materials and Methods: Cytology was performed on 159 consecutive cases, on the ultrasonographically most suspicious lymph node. Lymph node histology was used as a reference standard to determine accuracy. Four different scenarios were simulated: routine axillary ultrasonography with cytology of the lymph nodes visible at ultrasonography (A), or of only the lymph nodes suspicious at ultrasonography (B), with ultrasonography limited to clinically negative axillae and cytology of the lymph nodes visible at ultrasonography (C), or only of the lymph nodes suspicious at ultrasonography only (D)., Results: Cytologic sensitivity was 58.6%, specificity 100%. Immediate axillary dissection only in the case of positive cytology would have avoided 6/6 inappropriate axillary dissections and 5/34 (14.7%) inappropriate SN, compared to routine practice (immediate dissection for palpable adenopathy, SN in the remaining cases). Each of the simulated scenarios saved inappropriate surgical procedures (A: 6 dissections, 5 SNs; B: 6 dissections, 3 SNs; C: 13 SNs; D: 11 SNs) at no expense (A and B) or limited expense (C: Euro 348, D: Euro 232 for each inappropriate surgical procedure saved)., Conclusions: Axillary lymph node cytology can save axillary dissections or sentinel node procedures and is recommended as routine practice. Routine axillary ultrasonography, with cytology of sonographically visible lymph nodes, followed by immediate axillary dissection only in case of positive cytology proved to be the best approach in terms of cost-benefit ratio.

Purpose: To compare the diagnostic accuracy of two commercial CAD systems (CADx and R2) and their impact as an aid to conventional reading of screening mammograms., Materials and Methods: The image set considered consisted of 120 mammograms, 89 confirmed negative and 31 with subsequent interval cancers (11 classified as false negatives (FN), 20 as "minimal signs" (MS)). The set was digitised and processed with CAD, and printouts obtained of the mammograms with indications of the areas warranting review. Six expert radiologists read the mammograms three times, once using conventional reading and twice using CAD reading with CADx and R2, respectively. The two CAD systems were compared in terms of diagnostic accuracy of the marks and the impact of CAD reading compared to conventional reading and to the use of independent second reading simulated by combining pairs of single conventional readings., Results: R2 highlighted more calcifications (218 vs 132, +65%) and CADx highlighted more masses (208 vs 105, +98%). CADx and R2 marked 15 and 17 out of 31 cancers, respectively (sensitivity 48.3% vs 54.8%, chi squared=6.4, p=0.79), 10 and 6 out of 11 FN (90.9% vs 54.5%, chi squared=2.0, p=0.15), respectively, and 5 and 11 out of 20 MS (25.0% vs 55.0%, chi squared=2.6, p=0.10), respectively. As for specificity, the false positive markings for masses were on average (per case) 1.60 for CADx and 0.75 for R2, those for calcifications were 1.08 for CADx and 1.77 for R2 and the total false positive markings were 2.68 for CADx and 2.52 for R2. CADx and R2 marked 73 and 63 of 89 negative controls (specificity = 0.18 vs 0.29, chi squared=2.52, p=0.11), respectively. All the radiologists showed greater sensitivity with CAD reading compared to conventional reading. On average, sensitivity with conventional reading was 58.6% (109/186), as against 70.9% (132/186) for CADx or R2 (chi squared=5.71, p=0.016). Sensitivity for FN cases was 71.2% (47/66) with conventional reading, 84.8% (56/66) with CADx (chi squared=2.82, p=0.09) and 80.3% (53/66) for R2 (chi squared=1.03, p=0.30) (CADx vs R2, chi squared=0.21, p=0.64). Sensitivity for MS cases was 51.6% (62/120) for conventional reading, 63.3% (76/120) for CADx (chi squared=2.88, p=0.08) and 65.8% (79/120) for R2 (chi squared=4.40, p=0.03) (CADx vs R2, chi squared=0.07, p=0.78). The recall rates were 18.1% (97/534) for conventional reading, 29.7% (159/534) for CADx (chi squared=5.72, p=0.01) and 24.3% (130/534) for R2 (chi squared=10.11, p=10-5) (CADx vs R2, chi squared=3.71, p=0.05). Double reading was significantly more sensitive than conventional reading (chi squared=29.6, p=10-6), CADx (chi squared=5.33, p=0.02) and R2 (chi squared=5.33, p=0.02). The recall rate for double reading was significantly higher than for conventional reading (chi squared=21.5, p=10-6) whereas no significant difference was detected when compared to CADx (chi squared=0.16, p=0.68) or R2 (chi squared=3.4, p=0.06)., Conclusions: Despite using different algorithms, the two CAD systems exhibit comparable levels of diagnostic accuracy and a similar positive impact on sensitivity when used as an aid to conventional reading. Single reading with either CAD system is as specific but not as sensitive to double independent reading: its use as an alternative to double reading cannot be recommended and should be investigated further by means of controlled prospective studies.

Purpose: To evaluate the diagnostic accuracy of 11-G vacuum-assisted stereotactic core biopsy (VAB) of isolated clusters of microcalcifications identified by mammography., Materials and Methods: Retrospective analysis of 364 consecutive procedures from February 1999 to June 2002. Final outcome was histological diagnosis at surgery or mammographic follow-up. Linkage with local cancer registry was available. Diagnostic accuracy and upgrading of atypical ductal hyperplasia (ADH) to carcinoma or of ductal carcinoma in situ (DCIS) to invasive carcinoma (INV) was evaluated. The positive predictive value (PPV) of radiological judgement (score 1 to 5) and of the cluster volume (only for unifocal lesions) for ADH or more severe lesions was also considered., Results: A total of 364 consecutive VAB procedures were evaluated (average age 54.9, range 33-81). VAB report was negative, ADH, DCIS or INV in 192, 22, 126 or 24 cases, respectively. Of 188 cases with ADH or more severe reports at VAB or surgical biopsy 16 had an originally negative VAB report, yielding a sensitivity of 91.4%. Upgrading at surgical biopsy for cases with follow-up was 29.4% (5/17) for ADH (DCIS=2, INV=3) and 17.3% (20/115) for DCIS. Of 221 cases with known outcome and mammograms available for review PPV was 37.1%, 65.9%, 90.9%, and 89.4% for radiological suspicion degrees 2,3,4 and 5, respectively (chi squared for trend = 32.44, p<10(-6)) and was 70.0%, 72.4% and 89.4% for cluster volumes of 0-60, 61-500 and >500 mmc, respectively (chi squared for trend= 2.36, p=0.12) among 195 unifocal clusters. No microcalcifications were found at core radiography in 20 cases (VAB negative=18, ADH=1, INV=1) with DCIS or INV occurring in 4 or 1 case, respectively, at further surgery., Conclusions: Core biopsy avoids unnecessary surgery in many subjects with suspicious microcalcifications, although it implies a non negligible risk of false negative report. Surgical biopsy in VAB negative cases could be indicated according to other variables (e.g. the degree of radiological suspicion). VAB has relevant limits in grading breast lesions, as ADH or DCIS are associated to a considerable risk of upgrading at surgical biopsy. VAB reports other than INV need to be confirmed at surgery before an individual treatment strategy may be defined.

Purpose: To evaluate the role of computer aided diagnosis (CAD) to improve screening mammograms interpretation., Materials and Methods: Six radiologists underwent a screening mammography proficiency test first by conventional, then by CAD assisted reading. Sensitivity and recall rate at conventional and CAD reading were compared. Independent conventional double reading was simulated (15 pair combinations) and compared to single CAD reading., Results: CAD marked 31 of 32 cancers (case-based sensitivity=96.8%). On a film and lesion basis, CAD identified 31 of 32 (96.8%) malignant calcifications and 29 of 42 (69.0%) malignant opacities, the only cancer not identified by CAD being depicted as an isolated opacity. CAD marked 348 areas (153 microcalcifications and 195 opacities) in 88 of 108 non cancer cases, with a case-based specificity of 18.5% (20/108). Considering all six readings, cancer was identified in 164 or 174 of 192 readings (85.4 vs 90.6%, c2 2.03, df=1, p=0.15) and recalls of non-cancer cases were 108 or 159 of 648 readings (16.6 vs 24.5%, c2 11.7, df=1, p<0.001) at conventional or CAD reading, respectively. CAD reading (average of 6 readings, 192 cancer, 648 non-cancer readings) was slightly, non significantly less sensitive (sensitivity 90.6 vs 92.9%, c2 0.73, df=1, p=0.39) and slightly, but not significantly more specific (recall rate 24.5 vs 26.1%, c2 0.56, df=1, p=0.45) as compared to simulated independent double reading (average of 15 combinations, 480 cancer, 1620 non-cancer readings)., Conclusion: CAD seems to allow for a limited absolute increase (+5.2%) in sensitivity and for a limited absolute increase (+7.9%) in recall rate, the latter difference only reaching statistical significance. CAD reading showed no significant difference in diagnostic accuracy as compared to conventional (simulated) double reading, although further studies are needed to confirm it as possible alternative to double reading in the current screening practice.

Purpose: To define the normal cut off of endometrial thickness as measured at transvaginal ultrasonography (TVUS) in order to define postmenopausal women without symptoms or with abnormal uterine bleeding (AUB) at risk of endometrial carcinoma (EC)., Materials and Methods: 3460 postmenopausal women (2240 asymptomatic, 1220 with AUB) undergoing TVUS. These series was linked with the Tuscany Cancer Registry archives in order to identify subjects who developed EC subsequent (within two years) to TVUS., Results: Thickness (half layer) was significantly reduced in 2234 subjects not developing EC (1.68 mm; range = 0-20, SD 3.14) as compared to 6 subjects developing EC (4.67 mm, range = 0-10, SD 3.67) (p=0.02). A 4 mm cut off was associated with a sensitivity of 66.7%, a specificity of 92.1%, a positive predictive value of 2.2% and a negative predictive value of 99.9%. Similarly, in subjects with AUB, thickness (half layer) was significantly smaller in the 1175 subjects not developing EC (2.46 mm, range 0-20, SD 3.59) as compared to 45 subjects developing EC (8.0 mm, range 0-44, SD 6.76) (p<0.001). The best cut off for clinical purposes was 4 mm, with a sensitivity of 91.1%, a specificity of 79.8%, a positive predictive value of 14.8% and a negative predictive value of 99.6%., Conclusions: The study confirms the usefulness of measuring endometrial thickness (half layer cut off = 4 mm) with TVUS in asymptomatic postmenopausal women, both in asymptomatic subjects to indicate further special surveillance and in subjects with AUB to indicate immediate invasive assessment.

Purpose: To assess the predictive value for a positive biopsy of different indicators (rectal examination, transrectal ultrasonography, total PSA, PSA density)., Material and Methods: Positive predictive value was assessed on 1107 consecutive US-guided transperineal biopsies performed from 1991 to 2001 (cancer=344, dysplasia (PIN)=64, atypical hyperplasia=4, benign hyperplasia=686, inadequate=9) with univariate and multivariate analysis., Results: Increasing age (chi square for trend 52.2, p <0.001), positive rectal examination (chi square 233, df=1, p<0.001) or ultrasonography (chi square 191, df=1, p<0.001), total PSA (chi square for trend 68.9, p<0.001) and PSA density (cutoff 0.15, chi square 104, df=1, p<0.001; cutoff 0.20, chi square 104, df=1, p<0,001) were all significantly associated to the likelihood of a positive biopsy outcome. Multivariate analysis stresses the independent role of Psa density over total PSA. If the parameters studied had determined the biopsy, spared benign biopsies [positive rectal examination=505 (66%), positive ultrasonography=467 (61%), PSA>4=124 (16%), PSA>10=159 (74%), PSA density >0,15=426 (62%), PSA density >0.20=517 (75%)] would not have justified the amount of delayed cancer biopsies [positive rectal examination=103 (29%), positive ultrasonography=55 (15%), PSA>4=42 (12%), PSA>10=569 (46%), PSA density >0,15=73 (25%), PSA density >0,20=107 (37%)]., Conclusions: The parameters currently available prior to biopsy, if used alone, allow no reliable prediction of biopsy outcome. Positive predictive value, particularly for PSA density, allows a better evaluation of biopsy indication, particularly for random sextant biopsies in the 4-10 ng/ml PSA range, which are frequently negative.

Purpose: To analyse the association of hormone replacement therapy (HRT) and radiological density, defined as the fraction of breast volume occupied by fibroglandular opacity., Material and Methods: We considered 678 postmenopausal women, consecutively undergoing mammography within an organized screening program, 188 (27.7%) of whom were receiving HRT. Attribution of radiological density was performed prospectively and blind as to HRT status., Results: Both radiological density (p = 0.12) and exposure to HRT (p < 0.001) were found to correlate with age (younger women are more likely to use HRT and to have denser breasts, even without HRT) so the analysis of the correlation between HRT and radiological density was adjusted for the possible confounding effect of age. After stratification by age group, univariate analysis showed a significant correlation between HRT and radiological density (density = > 50%: HRT+ = 34.0%, HRT- = 17.6%: F-value 18.86, df = 1, p < 0.001). Also the duration of HRT was significantly associated to radiological density (Pearson coeff. = 0.12: p = 0.0011). Multivariate analysis adjusting for the confounding effect of age showed an increased risk of dense breast (17% or 7% for a radiological density > 25% or > 50%, respectively) in HRT users with respect to non users., Discussion: The study design, the adoption of a classification of breast density less exposed to intraobserver variability and multivariate analysis of a large series, allows a reliable evaluation of the association of HRT to breast density. As no threshold value is known for the masking effect of density on breast cancer, the negative effect of HRT on screening sensitivity cannot be accurately quantified., Conclusions: This study confirms the effect of HRT on radiological density in postmenopausal women, suggesting a possible reduction of screening sensitivity and efficacy. Such a hypothesis still needs validation by means of a prospective analysis of the correlation between HRT and the frequency of interval cancer occurrence (the best indicator of sensitivity).

Purpose: To report the results of a test performed by 75 volunteer radiologists involved in screening program in Italy., Material and Methods: The test includes 12 screening detected cancers and 6 cancers (4 screening detected and 2 interval lesions) with minimal signs at review of a previous negative mammogram. Data on previous experience in mammography (years of activity, years of screening activity, total number of mammograms read and number of mammograms read per year) were also collected., Results: Standards for passing the test were at least 83.3% for sensitivity for screening detected cancers and at most 30% for recall rate among negative cases. Mean sensitivity was 83.9% (median 83.3%, range 50-100%) and mean recall rate was 16.3 (median 14.4%, range 3.8-42.4%). In all, 44 radiologists (58.7%) passed the test. On average 1.4 of 6 cancers with minimal signs were correctly identified. According to readers' experience (at least 5 years in mammographic activity, at least 3 years in screening mammography, at least 10,000 total mammograms read, at least 5,000 per year) radiologists were classified as expert (13) or not (62): no difference in test performance was observed between the two groups. The only significant association occurred for years of mammographic activity and sensitivity., Discussion and Conclusions: Test results suggest the need for proper training of radiologists prior to involvement in a screening program. Seeding proficiency tests with cancers with minimal signs was of no benefit as far as evaluation is concerned.

Purpose: The aim of the present study was to provide data on interval cancer incidence after the first round of the screening program in the city of Florence, and to provide and discuss the results of the review of previous screening mammograms., Material and Methods: The screening program "Progetto Firenze Donna" involves all women age 50 to 69 years resident in the city of Florence. In the interval from the end of the first and the start of the second screening round 51 interval cancers were identified, of which 41 were available for radiological review. Films were reviewed by expert screening radiologists, not involved in the program and blinded to the final diagnosis, according to the review criteria recommended by the UK Guidelines for radiologists (blind and informed review)., Results: Sensitivity (screening errors/total) was different among blind reviewers (reader A = 7.3%, reader B = 14.6%), as well as specificity which shows an inverse pattern (reader A = 98.4%, reader B = 97.6%). Informed review classified 5 cases as "screening error" (12.2%), 11 as "minimal sign" (26.8%) and 25 as "occult" (61%). Informed review classified a higher proportion of cases as "minimal sign" (minimal abnormalities are better perceived with the knowledge of the site and the pattern of subsequent cancer)., Discussion and Conclusions: Analysis of interval cancers is fundamental for the quality control of a screening program. According to this experience, informed review tends to overestimate "minimal signs" in the cancer site and should not be used (or "minimal signs" should be anyhow assumed as negative). Identification of interval cases as "minimal signs" may be influenced by individual variability. Standard criteria should be adopted to identify and review/classify interval cancers to allow comparisons between different programs.

Purpose: To evaluate the role of double reading of screening mammograms by expert radiologists., Material and Methods: We analyzed the results of independent readings of a proficiency test of screening mammography (140 cases, 32 cancers) performed by four expert radiologists. Double reading was simulated by matching the four original readings in 6 possible combinations. The impact of double reading over single reading was evaluated in terms of increased sensitivity and increased recall rate., Results: Of 32 carcinomas 22, 6, or 4 were identified by 4, 3, or 2 readers, respectively. Of 108 cases negative for cancer a recall for further investigations was suggested by 4, 3, 2, 1 or no reader(s) in 3, 3, 9, 14, or 79 cases, respectively. Inter-reader diagnostic repeatability was good (k = 0.65). Single readers achieved an average sensitivity of 89% (range 87.5-90.6%) and an average recall rate of 12.2% (range 7.4-16.6%). Simulated double reading achieved an average increase in sensitivity of 8.8% (range 6.2-10.95%) and an average increase of recall rate of 6.2% (range 3.8-8.3%)., Conclusions: Even though the relative increase of recall rate is relevant (+53.2%), the corresponding gain in sensitivity justifies the use of double reading, which was confirmed to be worthwhile also when expert radiologists are involved. This study confirms the opportunity of adopting double reading as a routine procedure in mammographic screening.

Purpose: We evaluated the results obtained by 130 Italian radiologists undergoing a proficiency test of clinical mammography., Material and Methods: Radiologists were invited to report a series of 100 mammograms (two views), including 32 cancers and 78 non-cancers, with limited information regarding age, subjective symptoms, and findings at palpation. Sensitivity and specificity were then calculated. The test was validated by a panel of experts, and standards for test sufficiency were established on that basis (sensitivity > 80%, specificity > 85%). The tested radiologists differed by mammographic practice (average = 5.7 years, range 0.5-18), total number of mammograms read (average = 8,784, range 300-50,000) and per year (average = 1,535 range 300-5,000)., Results: Sensitivity (standard > 80%, average 81.1%, range 39-100%) and specificity (standard > 85%, average 84.0%, range 38-98%) standards were reached by 79 (60.8%) and 81 (62.3%) radiologists, respectively. Overall, only 37 (28.5%) radiologists passed the test (reached both standards). Mammographic practice (years of experience) (chi 2 for trend 5.26, p = 0.02), total mammograms read (chi 2 5.86, p = 0.05), and mammograms read per year (chi 2 8.07, p = 0.01) significantly correlated with a sufficient test., Discussion: The evaluated sample is rather large but not necessarily representative of Italian radiologists. Had the sample been selected, there is no way to know if the results would have been biased towards a better or worse figure with respect to the national average. A significant correlation was found with reading experience (the best results were obtained by operators with > 10,000 films read and with > 2,000 films read/year), as which is important because most Italian radiologists reporting mammography usually read a limited number of cases., Conclusions: These results on such a wide sample of radiologists, possibly representative of the national average, are disappointing, and suggest that the average quality of mammography reporting in Italy may not be up to standards. Thus, we suggest that quality control program for clinical mammography not only test the equipment but include training and accreditation of radiologists.

This study reports the results of some voluntary Italian radiologists performing 103 proficiency tests in clinical (100 patients, 32 cancers) and screening mammography (150 patients, 17 cancers). Relative to the average accuracy of a panel of expert radiologists, 12 of 49 readers (27%) and 32 of 54 readers (56%) passed the clinical and screening mammography test, respectively. The results were significantly correlated with the readers' previous experience (years of mammographic practice [< 2, 2-4, > 4] and number of mammograms read [< 5,000, 5-10,000, > 10,000]). The rate of passed test was: < 2 years = 0%, 2-4 years = 40%, > 4 years = 66.6% (P = 0.002); < 5,000 mammograms read = 15.3%, 5-10,000 = 28.5%, > 10,000 = 69.2% (P = 0.02). The best results were achieved by the readers with a previous reading experience of at least 10,000 mammograms, a figure which might be used as the reference for a future criterion of accreditation on a national basis. Proper training before reporting mammography is fundamental to ensure a good diagnostic performance. The low number of tests performed in most Italian mammographic practice facilities makes local training highly questionable and requires quite a long time. Reference centers, adequately equipped for training, should be identified for this purpose. Proficiency tests such as those described in the present study are useful to assess individual performance and should be a part of a training program.

The authors reviewed a series of 748 consecutive male patients referred for breast screening; their average age was 50.5 years. A malignant lesion was detected in 20 patients (18 infiltrating ductal carcinomas, 1 intraductal carcinoma and 1 myxosarcoma). Of 18 infiltrating carcinomas, 17 were found in patients over 60 years of age; pT classes were pT1c in 13 patients, pT2 in 2, pT4b in 1, pT4d in 1 and pTx in one patient. Biopsy demonstrated 92 benign lesions (74 gynecomastia cases and 18 other lesions), whereas 636 lesions were considered benign at direct or cancer registry follow-up. Sensitivity was 85% for palpation, 88.8% for mammography, 93.7% for cytology and 100% for US. Specificity was 95.3%, 94%, 95.6% and 97.9%, respectively. Combined palpation and mammography had 100% sensitivity. Sixty-five of 92 benign lesions were submitted to biopsy, even in the absence of suspicion, for psychological/cosmetic reasons. Negative cytology spared unnecessary biopsy in 9 cases, which were fairly suspicious at other exams. To conclude, we confirm the role of this multimodality clinical-instrumental diagnostic approach, with a special emphasis on the role of US. Cytology was as useful to avoid unnecessary open biopsy in men as it is in women. Male breast cancer has the same semiology as female breast cancer, though with a prevalence of opacities with blurred outline and in the absence of scirrhous-stellate patterns. The diagnostic protocol we used to diagnose breast cancer in women seems to be fully indicated also in men.

The authors report on a series of 1009 consecutive patients submitted to clinical examination, mammography, cytology and galactography for the presence of nipple discharge. Galactography was performed mainly in the presence of hematic nipple discharge. Surgical biopsy was performed in 392 cases, and 52 cancers (31 invasive and 21 intraductal lesions) were diagnosed, which were suspected at palpation, mammography, cytology and galactography in 17, 17, 18 and 31 cases, respectively. Forty of 52 cancers were suspected on the basis of combined exam findings, while 8 cancers (7 intraductal and 1 invasive lesions) were submitted to biopsy on the basis of a galactographic diagnosis of multiple benign papilloma, an (invasive) lesion with a diagnosis of single papilloma, and 3 (invasive) lesions because of persistent hematic discharge. Cancer was suspected with only one exam in 14 cases: 3 at cytology, 2 at mammography, 1 at clinical examination and 8 at galactography. Hematic discharge alone is not a sufficient reason to indicate surgery, because its positive predictive value for cancer is low (< or = 10%), while cytology is of limited help because of its poor sensitivity (34.6%). In contrast, galactography (59.6% sensitivity) gives a greater contribution to differential diagnosis and is always indicated in the presence of hematic discharge. Galactographic evidence suspicious for cancer (67.3% positive predictive value) or for multiple papilloma (9.7% positive predictive value) is sufficient to advise open biopsy. The surgical removal of single papillomas is of questionable benefit, since single papillomas are benign lesions, with no clear evidence of progression to cancer. In our series, only one cancer was misdiagnosed as a single papilloma at galactography (0.5% positive predictive value).

The diagnostic features are reported of 143 consecutive patients with breast cancer intramammary recurrences observed after conservative treatment, 1984 to 1994. Disease-free interval after surgery was 3.7 years on the average, being longer for the patients receiving postoperative breast irradiation (3.9 vs 3.1 years). The conserved breast was followed-up on a regular basis with palpation and mammography, whereas US and cytology were used only in selected suspicious cases. Palpation, mammography, cytology or US suspected the recurrence in 75, 64, 81 and 77% of cases, respectively. Mammographic false negatives were not explained by breast parenchymal density (Wolfe's pattern) or by breast irradiation, but were likely to be ascribed to the masking effect of surgical scars and distortion. Most failures at cytology were caused by inadequate sampling: when sampling was adequate, cytology exhibited the highest sensitivity (97%). In all, combined palpation + mammography, palpation + cytology and palpation + mammography + cytology diagnosed correctly 97, 98 and 100% of cases, respectively. Palpation should be always combined with mammography in the follow-up of the conserved breast, but US and aspiration cytology should be performed in case of any clinico-radiologic abnormality carrying even a minimal risk of recurrence.

We report the results of two pilot studies for the early detection of prostatic carcinoma in resident men aged 60-75 years, using combined digital rectal examination (DRE) and transrectal ultrasonography (TRUS) versus prostate-specific antigen (PSA; cutoff: 4 ng/ml) as screening tests. Both screening protocols exhibited high cancer detection rates (DRE + TRUS = 1.82%, PSA = 1.67%), with a high prevalence/incidence ratio (observed/expected ratio: DRE-TRUS = 13.8:1, PSA = 11.3:1) and a diagnostic anticipation of about 6-7 years. Stage (DRE + TRUS: A = 0%, B = 69%, C-D = 31%; PSA:A = 14%, B = 77%, C-D = 9%) and grading distribution (no case with Gleason score < 5) suggests that most screen-detected cancers were clinically assessable but the extent of overdiagnosis of latent carcinomas cannot be estimated. Both screening protocols proved to be cost-effective (biopsy rate: DRE + TRUS = 2.7%, PSA = 2.8%; cost per screened subject: DRE + TRUS = L. 33,750, PSA = L. 30,400; cost per cancer detected: DRE + TRUS = L. 1,854,000, PSA = L. 1,817,500) but screening by PSA was much better accepted (attendance rate: DRE + TRUS = 33.7%, PSA = 66.9%), which makes it the screening test of choice for controlled studies on screening efficacy. This study allows no definitive conclusions to be drawn on screening efficacy but confirms only that screening is feasible at a reasonable cost and yields high diagnostic anticipation. Whether this benefits the screened population is currently debated and needs to be confirmed by controlled studies. Screening may have upsetting negative outcomes such as overdiagnosis, overtreatment, increased treatment-related mortality rates and worsened quality of life, and there is no evidence supporting the recommendation of screening as a routine practice.

The authors reviewed a consecutive series of 4,160 breast lesions (511 carcinomas and 3,649 benign lesions) studied with 10-MHz US in 1990-1991. US sensitivity was 72.6%, specificity was 97.3% and positive predictive value was 78.9%. Sensitivity was independent of age whereas it strongly depended on tumor size (pT1a = 54.2%, pT1b = 70.6%, pT1c = 80.6%, pT2-4 = 90.2%) (81.1% palpable masses and 41.3% nonpalpable masses) and histologic type (11.4% intraductal carcinomas and 69.4% special types). The association was confirmed of the classic US signs with carcinoma (irregular margins and posterior shadowing) and benign lesions (lateral shadowing, no echogenicity and posterior acoustic enhancement) patterns, even though the former are not accurate enough for diagnostic purposes. US demonstrated 376 of 402 palpable carcinomas (50 diagnosed as benign and 326 as suspicious) and 58 of 109 nonpalpable carcinomas (13 diagnosed as benign and 45 as suspicious). US was the only imaging method to yield findings suggestive of cancer in 13 of 511 total cases and contributed to final diagnosis in 6 more clinically and radiologically negative cases in which US findings suggested a benign lesion but indicated the need for aspiration cytology. If on the one hand US was the only method responsible for unnecessary biopsy in 21 of 141 surgical benign lesions, on the other hand negative or benign US findings helped avoid unnecessary biopsy in 277 cases diagnosed as suspicious at palpation or mammography. US should be used as the routine examination in the assessment of clinical and mammographic abnormalities. Its contribution to cancer detection is limited but it allows the number of unnecessary biopsies to be markedly reduced as well as a more accurate guide for fine needle aspiration in most palpable cancers and in approximately half of nonpalpable ones.

The authors report on 354 consecutive cases of invasive breast carcinoma followed up 3 to 13 years. The prognostic value of the mammographic appearance of cancer, determined according to Broberg, was studied, as well as that of other indicators, such as pT, pN and estrogen receptor content. An association was found between the mammographic appearance and the other prognostic indicators, but such an association was at the limits of statistical significance (pT p = 0.033, pN p = 0.039, ER p = 0.033) and the mammographic patterns associated with more favorable indicators were not consistent across the three variables. Ten-year actuarial overall survival was significantly associated with pT (p < 0.0001), pN (p < 0.0001) or estrogen receptor content (p < 0.001), but not with mammographic appearance. Multivariate analysis confirmed such results. We found no evidence, as suggested in some literature reports, of any association of the mammographic appearance of breast cancer with survival, and we believe that this indicator has no practical use in predicting prognosis in breast cancer patients.

The authors evaluated 30 interval cancers consecutively observed from 1989 to 1991 and compared them to 98 screening-detected cancers observed in the same period. Interval cancers have a more advanced stage (stage I = 13 lesions, stage II + = 17 lesions) with respect to screening-detected cancers (stage 0 = 10 lesions, stage I = 61 lesions, stage II + = 27 lesions). This finding seems unrelated to an intrinsically higher aggressivity of interval cancers (length biased sampling) which do not differ significantly from screening-detected cancers as far as histopathologic characteristics of prognostic value are concerned. Diagnostic delay due to technical or reading error (9 cases), to radiologically occult cancer in clear (10 cases) or dense parenchymal areas (11 cases) is most likely. This seems to be confirmed by the low frequency observed among interval cancers of easily visible lesions such as isolated microcalcifications (3% vs. 35%) or stellate opacities (13% vs. 31%), and by the higher frequency of opacities with irregular margins (57% vs. 26%) which are more likely masked by dense parenchyma. The chances of reducing interval cancer rate by attempting to increase sensitivity or by increasing screening frequency are discussed, as well as the possible negative consequences of such protocols in terms of cost-effectiveness.

The authors report the results of the Florence District program for the year 1992. 11,033 subjects were examined. Attendance rate (64.4%) was significantly related to age (42-49 = 71.0%; 50-59 = 66.7%; 60-70 = 58.5%). Recall rate to diagnostic assessment was 2.09% (mammographic abnormalities = 199, subjective symptoms other than pain = 32) and was related to age (42-49 = 3.12%; 50-59 = 1.65%; 60-70 = 1.77%). According to the results of diagnostic assessment 53 surgical biopsies (0.48%) were recommended and performed. The biopsy rate was also related to age (42-49 = 0.2%; 50-59 = 0.4%; 60-70 = 0.7%). Forty-seven carcinomas were detected in 46 subjects (benign/malignant biopsy ratio = 0.13). Cancer detection rate was 0.42% and changed significantly with age (42-49 = 0.13; 50-59 = 0.36; 60-70 = 0.68%), as well as the observed/expected cancer ratio (42-49 = 0.89; 50-59 = 2.03; 60-70 = 2.98). Detected cancers were nonpalpable in 57% of cases. Pathologic staging was pTIS in 2 cases, pT1a in 5, pT1b in 17, pT1c in 17, pT2 in 5, and pT4b in one case. Six of 47 (12.8%) cancers involved axillary nodes. A preliminary estimate of screening cost yielded a total cost of Lit. 397,671,000 for the year 1992--i.e., Lit. 36,000 per examined subject and Lit. 8,461,000 per detected cancer. The results are compared with reference standards for the evaluation of screening performance provided by the national breast screening program in the United Kingdom.

The preliminary results of a feasibility study of a randomized trial for the early detection of prostate carcinoma are reported. 4,229 healthy men aged 60-75 years were invited to undergo digital rectal examination (DRE) and transrectal ultrasonography (TRUS); 1,284 of them responded and were thus examined. Subjects with suspicious findings at DRE and/or TRUS underwent transperineal US-guided biopsy and prostate-specific antigen (PSA) determination. Subjects with equivocal findings were controlled after 6 months with DRE, TRUS and PSA. The screening program was rather simple (examination time < 10') and cost was limited (cost x subject = US $25). So far, 27 biopsies (2.1%) have been performed. Eighteen cancers have been detected (1.41%), the prevalence/expected incidence ratio being 10.6:1. Stage at diagnosis was B1 in 12, B2 in 3, C in 2 and D in one case, respectively. Cancer had been suspected at DRE in 12, at TRUS in 17 and at PSA (cutoff = 4 micrograms/ml) in 15 of 18 cases, respectively. This study provides evidence that screening for prostate cancer is feasible at a moderate cost and diagnostic anticipation is relevant. A prospective randomized trial is needed to assess whether early detection has any impact at all on mortality. When designing such a study, the effect of compliance, which was low in our experience, on the statistical power should be carefully evaluated. The possibility of pre-screening with PSA, which is much more accepted and might improve attendance rates, should also be evaluated by specific studies.

The authors evaluated 127 cases (31 infiltrating carcinomas, 22 intraductal carcinomas, 74 benign lesions) of breast microcalcifications with no palpable lesions. The patients had undergone mammography, stereotaxic cytology and direct magnification (87 cases). Blind interpretation of standard films and of direct magnification was performed by two independent readers (A, B), who classified the cases according to radiologic pattern (annular, punctate, granular, linear, branching), degree of suspicion and need for surgical biopsy. The study confirmed the association of different types of microcalcifications with breast cancer (predictivity: annular, punctate, granular, linear, branching; A = 25%, 15%, 40%, 92%, 86%; B = 14%, 26%, 39%, 90%, 100%). However, diagnosis was not very accurate (sensitivity: A = 83%, B = 71.1%; specificity: A = 83%, B = 78.4%); it was also observed that most cancers can be diagnosed only at a relatively high cost in terms of unnecessary biopsies. Interobservers' agreement was high relative to diagnosis (negative/dubious vs. suspicious/positive = -88.9%; K = 58.5) and low for pattern attribution (52%). Direct magnification allowed better detail definition but if sensitivity improved (A = 87% vs. 80.6%; B = 64.5% vs. 51.6%), specificity was negatively affected (A = 73.2% vs. 80.4%; B = 69.6% vs. 80.3%), due to an excess of false positives. Stereotaxic cytology [inadequacy rate = 26%, sensitivity and specificity (ex inadequates) = 80% and 100%, respectively] was more accurate than mammography as far as the decision for surgical biopsy was concerned, and was correct in identifying most (A = 6/7, B = 7/11) of the cancers which had been misdiagnosed as benign at conventional and magnification mammography. Stereotaxic cytology should be routinely performed in cases of microcalcifications with no associated palpable lesions.

The authors evaluate 261 consecutive mammographic false positives observed from 1985 to 1987. Histological evidence of benign lesion followed in all cases. The comparison with the actual number of cancers and of the whole of mammographic examinations performed in the study period allowed specificity and positive predictive value of mammography to be assessed as 99.5% and 83%, respectively. Specificity and predictivity are lower in younger women, but this is more likely to depend on a different age-related incidence of cancer and benign lesions than on an intrinsic limitation of the method. The reader's diagnostic aggressivity, more than his experience, seems to affect both specificity and predictivity. At review, false positives were mostly due to asymmetric densities (49) or to circumscribed opacities with clear-cut (44) or blurred (62) outlines, whereas irregular star-like opacities or distortions (19) were infrequent. Microcalcifications were, in most cases, apparently benign (39) or dubious (76); strong suspicion was rare (4). Overall, one-fourth to one-third (27.9%) of the cases were reported as strongly suspicious at review. Palpation and cytology were also falsely suspicious--that is, co-responsible for unnecessary biopsies in over 50% of cases. Our results suggest that further improvement in the specificity or positive predictive value of mammography seems unlikely. Moreover, the benign/malignant biopsy ratio (0.2:1) presently achieved in suspicious mammographic cases appears quite satisfactory.

The authors compare the accuracy and other indicators of efficiency of ten centers (1,784 total cases) performing stereotaxic cytology and adhering to a multicentric study aimed at validating a quality control system for this diagnostic procedure. The results from single centers were compared with average results. No significant differences were observed for most centers from the average sensitivity (86%), specificity (91%), positive predictive value of a dubious (57%) or positive (96%) cytologic report, inadequacy rate on malignant (6%) or benign (11%) lesions, and benign/malignant biopsy ratio (0.63). Some significant differences from the average values indicated the need for some centers to review different phases of the diagnostic process, namely to verify the accuracy of sampling sites (low sensitivity with good specificity and predictivity), to review the criteria for cytologic diagnosis (specificity less than 90%, low predictive value or higher predictive value for dubious compared with positive reports), to optimize the impact of cytology on the final decision (lack of reduction of benign/malignant biopsy ratio). Periodic check of the above parameters is proposed as a routine quality control of this diagnostic procedure.

The authors evaluate 1455 consecutive breast cancers detected 1985-1987, undergoing mammography 6 months before diagnosis at the most. One hundred and seventy-eight cases reported as negative/benign were assumed as false negatives. Overall sensitivity was 88%, and was influenced by tumor stage (TIS = 80%, T1 = 83%, T2 = 91%, T3-4 = 95%) and patients' age (less than 40 = 76%, 40-49 = 78%, 50-59 = 91%, greater than 59 = 94%). Sensitivity varied also with readers' experience full- or part-time involved in reading mammograms (total cases = 92% vs 88%, T1 cases = 86% vs 74%). No correlations were evidenced between mammographic sensitivity and histologic type of cancer. Palpation and cytology allowed the correct identification of 98% of mammographic false negatives. One hundred and seventy-eight false negatives and 142 more cases showing evidence of a mammographic error more than 6 months before diagnosis were reviewed to assess the most common types of radiologic fault. A benign-like lesion was the most frequent finding (49.4%), whereas suspicious signs were infrequent at review (16.6%). Failure to encompass the lesion in the mammographic field or poor technique accounted for 3.8 or 1.3% of cases, respectively. 29% of false-negative subjects (mostly young or with a dense breast) showed no lesion even at review. This study confirms the good sensitivity of mammography but suggests a less confident diagnostic approach in younger women, stresses the need for other tests whenever a minimal doubt is present, and encourages the radiologist's full-time involvement in mammography and breast diagnosis to achieve greater experience and improve his diagnostic sensitivity.

The authors evaluate the recall and biopsy rates during three years of mammographic screening. Recalls (373/25970 = 1.4%) were more frequent at the first (2.3%) than at subsequent screening rounds (1.2%) whereas the predictive value for cancer increased at further screening (11.7 vs 21.7%). Recalls are less frequent in older women, particularly at further screening (40-49 vs 50-59 vs 60-70: 1.7 vs 1.1 vs 0.9%) whereas predictive value is higher (14.8 vs 16.5 vs 36.5%). The presence of mammographic abnormalities accounts for the majority of recalls (1.3%) whereas subjective symptoms other than pain are a less frequent cause of recall (0.2%) although as predictive (22.7 vs 20.4%). Calls for biopsy were limited to cases with suspicion for cancer and this allowed a low biopsy rate (75 = 0.3%) and a high predictive value (92%). The observed results have greatly improved with respect to the past years, due to a higher specificity of recall criteria and to the systematic use of all modern tests (high frequency US, fine-needle aspiration cytology, either manual or US-guided or stereotaxic) at the time of diagnostic assessment. All screening programs, particularly the new ones, should monitor recall and biopsy rates and predictive values as they are indicators of efficiency.

The authors report on 117 consecutive hemorrhagic breast cysts cases. All patients underwent cytologic examination of cystic fluid content and US or pneumocystography. Ten cancers (9 infiltrating, and 1 lobular in situ) and 22 papillomas had histologic confirmation--out of 45 cases undergoing surgical biopsy. Seventy-two cases exhibiting no intracystic growth have been followed for 5.4 years on the average and no cancer has developed so far. Pneumocystography or US had 100% predictive value for intracystic lesions; we observed that surgical biopsy could be safely avoided when both examinations were negative, that is in about 3/4 cases. No differential diagnosis of cancer and papilloma was possible on pneumocystography or US. Even though positive cytology was highly predictive for cancer, cytology exhibited poor sensitivity and surgical biopsy was necessary in all cases presenting with intracystic growth.

The authors report on 791 consecutive cases undergoing stereotaxic cytology for nonpalpable lesions detected at mammography. Histologic diagnosis (malignant = 179, benign = 107) or mammographic follow-up after at least one year (benign = 275) was available in 561 cases. The overall inadequacy rate of stereotaxic cytology was 0.21, and dependent on lesion type (benign = 0.25, malignant = 0.13 p less than 0.001) and on sampling operator experience (range 0.17-0.31, p less than 0.001). Sensitivity (dubious + positive, after exclusion of inadequates) was 0.83 and dependent on histologic type (infiltrating = 0.87, intraductal = 0.68). Specificity (negative/benign, after exclusion of inadequates) was 0.96. Stereotaxic cytology helped in reducing the number of unnecessary benign biopsies and the biopsy ratio was 0.6 benign to 1 malignant biopsy. In cases with moderate suspicion at mammography the radiologist felt reassured by negative cytology and advised mammographic control rather than surgical biopsy. Cytology was determinant in advising surgical biopsy in 9 cancer cases whereas the absence of cytologic positivity contributed to diagnostic delay in 2 cancer cases. Overall, stereotaxic cytology allowed a relevant reduction of unnecessary benign biopsies and should be routinely employed in the diagnostic work-up of nonpalpable lesions detected at mammography.

The authors report on a consecutive series of 305 women under age 30 undergoing mammography because of a solid palpable mass. The presence of diffuse parenchymal density impairing radiologic interpretation was observed in 71% of cases. Cancer was not demonstrated at mammography in 5 of 18 cases. Radiologic suspicion did not improve the cumulative sensitivity for cancer and did not influence clinical management in cancer cases. Mammographic contribution in reducing unnecessary biopsies of benign lesions was also poor and parallelled that of aspiration cytology. Mammography is not recommended in the differential diagnosis of palpable masses in women under 30 and should be limited to the preoperative assessment of cases with a strong suspicion of cancer.

The authors investigated the association between mammographic parenchymal patterns and breast cancer risk by a case control study. Three-hundred and thirty-four cancers, either screen or interval detected in the course of a screening program, were assumed as cases and compared to 668 non-cancer controls matched by age, residence and date of screening examination. Parenchymal patterns were classified by retrospective blind review of randomly mixed films by two independent readers. A high agreement was achieved on a two-group scale (N1-P1 vs P2-DY) inter and intraobserver consistency being 0.94 and 0.95, respectively. The relative risk of breast cancer exposure (RR) with respect to N1 pattern was 1.99 for P1, 3.59 for P2 and 4.18 for DY patterns. The RR of P2-DY with respect to N1-P1 patterns was 2.62. The results did not change after stratification by age group. Parenchymal patterns do not seem to be a reliable criterion for selecting high risk women for screening as in this series only 57% of all cancers occurred in high risk (P2-DY) subjects.

3,126 medical reports on women sent to mammary biopsy following breast examination at the Florence Center for the Study and Prevention of Cancer in November 1978-July 1982 were reviewed in order to assess the diagnostic significance of mammographic microcalcifications. All mammographies were examined in order to assess the presence and morphological aspects of the microcalcifications on the bioptic site. Microcalcifications were classified on the basis of the following morphological criteria: spatial disposition (isolated, clustered, diffuse); total number; number per cm; morphological aspect (dot-like, stick-like or ramified); shape (regular or irregular); radiological density; association with mammographic opacity; maximum and average diameter. Microcalcifications were encountered in 19.7% of 157 breast cancer diagnosed in a mammographic screening programme conducted on the asymptomatic population in 19.5% of 953 breast cancers diagnosed in self-referring women (most with symptoms). Among cases where subsequent histological examination revealed a benign pathology, microcalcifications were more frequent in the cases deriving from the screening programme (14.5% of 198 cases) than among self-referred cases (4.5% of 1818 cases). The presence of microcalcifications is in itself a predictive sign of the presence of a carcinoma (positive predictive value = 66.2%) but this radiological sign is only present in 20% of breast cancers. Among the various parameters considered in assessing the diagnostic significance of microcalcifications, irregular shape was the most indicative of carcinoma with a predictive value of 80% and presence in 88% of carcinoma with microcalcifications. Other microcalcification parameters with a particular predictive significance are diffuse spatial disposition, total number (over 10) and number per cm (over 50), site contiguous with a mammographic opacity and a mean diameter of 0.6-0.9 mm. Unfortunately these latter parameters are only 24% of tumour cases with microcalcifications. The incidence of microcalcifications in cancer does not vary according to age, but is strongly correlated with the tumour stage. In particular microcalcifications are found in about 1/3 of in situ carcinomas. In invasive cancers, the presence of microcalcifications tends to increase with the diameter of the lesion. No correlation was found in breast cancers between the presence of microcalcifications, lymph node condition and histological type.(ABSTRACT TRUNCATED AT 400 WORDS)

A series of 469 breast cancer studied by physical examination (PE), mammography (M) and infrared thermography (TH) is discussed. Follow-up was performed up to 5 years later. The poor diagnostic role of TH is proven for the low sensitivity in the total series (0.47) and, particularly, in T1 cancers (0.26). TH does not increase significantly the cumulative sensitivity (0.98 vs. 0.97 in the total series). Its limited advantage is offset by the great number of useless biopsies due to TH false positive. A correlation between TH pattern and prognosis is evident only when TH is considered independently from other reliable prognostic indicators such as the T or N categories. If survival curves are stratified by T or N or if a multivariate analysis based on TH, T and N variables is performed, all correlations between TH pattern and prognosis disappear; for this reason the use of TH as a prognostic indicator in the clinical practice is disregarded.