The effect of a combined tube current modulation system on dose delivered to patients undergoing thoracic and abdominal CT with a 128-slice scanner.

Combined tube current modulation techniques (such as Care Dose4D used in this study) during computed tomography (CT) procedures bring together the benefits of the angular and z-axis modulation techniques, measuring X-ray attenuation profile in the z-axis together with the data from the perpendicular x-y direction with a sophisticated algorithm. The purpose of this study was to investigate the radiation dose, in terms of computed tomography dose index (CTDI(vol)), delivered to patients during thoracic and abdominal CT using this technique and compare it with the corresponding CTDI(vol) of the fixed tube current CT technique. The results revealed a 5-32% dose reduction for chest CT and a dose reduction of 7.6-60% for the three-sequence abdominal CT scan of normal and overweight patients. In the case of obese patients a 15.4-18.7% dose increase for chest CT and a (-1.5) - (26.3)% dose increase for the three-stage abdominal examinations for females and males, respectively, was revealed.

Monte Carlo simulation of breast imaging using synchrotron radiation.

PURPOSE: Synchrotron radiation (SR), being the brightest artificial source of x-rays with a very promising geometry, has raised the scientific expectations that it could be used for breast imaging with optimized results. The "in situ" evaluation of this technique is difficult to perform, mostly due to the limited available SR facilities worldwide. In this study, a simulation model for SR breast imaging was developed, based on Monte Carlo simulation techniques, and validated using data acquired in the SYRMEP beamline of the Elettra facility in Trieste, Italy. Furthermore, primary results concerning the performance of SR were derived. METHODS: The developed model includes the exact setup of the SR beamline, considering that the x-ray source is located at almost 23 m from the slit, while the photon energy was considered to originate from a very narrow Gaussian spectrum. Breast phantoms, made of Perspex and filled with air cavities, were irradiated with energies in the range of 16-28 keV. The model included a Gd(2)O(2)S detector with the same characteristics as the one available in the SYRMEP beamline. Following the development and validation of the model, experiments were performed in order to evaluate the contrast resolution of SR. A phantom made of adipose tissue and filled with inhomogeneities of several compositions and sizes was designed and utilized to simulate the irradiation under conventional mammography and SR conditions. RESULTS: The validation results of the model showed an excellent agreement with the experimental data, with the correlation for contrast being 0.996. Significant differences only appeared at the edges of the phantom, where phase effects occur. The initial evaluation experiments revealed that SR shows very good performance in terms of the image quality indices utilized, namely subject contrast and contrast to noise ratio. The response of subject contrast to energy is monotonic; however, this does not stand for contrast to noise ratio, since there is a range of optimal performance for SR (18-21 keV). In comparison to conventional mammography, SR shows improved subject contrast for energies lower than the mean energy of each spectrum. CONCLUSIONS: The comparison of the results of the two models, conventional and SR, proved that SR exhibits better performance in the majority of cases. The proposed simulation model offers the possibility to perform exhaustive search to evaluate the performance of SR in clinical applications such as breast imaging.

First application of total skin electron beam irradiation in Greece: setup, measurements and dosimetry.

Total Skin Electron Beam (TSEB) irradiation is considered as the treatment of choice for cutaneous T-cell lymphoma internationally, for either curative purposes or palliative care. An attempt for the first application of this external radiation therapy technique in Greece took place at the Radiation Therapy Unit of 2(nd) Department of Radiology of University of Athens at University General Hospital "Attikon". TSEB modality was developed on a linear accelerator VARIAN Clinac 2100C. To create a uniform and sufficiently large field (≈200 cm × 80 cm) at SSD=380 cm, two symmetrical 6 MeV electron beams are combined with 17.5° tilts concerning the horizontal direction. An immobilization system was constructed to support patient during treatment and to modulate the composite electron field. Irradiation procedure demands a standing patient that takes, in total, six treatment positions. For the confirmation of treatment suitability and the determination of physical features of the clinical electron field, specific measurements were carried out using a parallel-plate ionization chamber and TLDs at water equivalent plastic and anthropomorphic phantoms. Measurements at the referred conditions showed a homogeneous total field with intensity variation of ±2% in the longitudinal axis and ±4% at horizontal axis. The mean energy of the composite field (E¯(o)) is 3.4 MeV, the most probable energy (E(p,0)) is 4.4 MeV and the half-value depth in water (R(50)) is 1.5 g/cm(2). The maximum X-ray background of the TSEB field is 2.1% at head and feet. The above results lead us to conclude that TSEB treatment using "Six-dual-field" technique can be applied in our department safely.

Patient radiation doses in cardiac computed tomography: comparison of published results with prospective and retrospective acquisition.

Prospective ECG triggering has the potential of reducing radiation exposure while maintaining diagnostic accuracy of cardiac computed tomography (CT). The aim of this study is to review patient radiation doses associated with coronary artery calcium scoring (CACS) and CT coronary angiography (CTCA) and to compare results between prospective and retrospective acquisition schemes. Patient radiation doses from CACS and CTCA were extracted from 67 relevant studies. Mean effective dose for CACS and CTCA with prospective ECG triggering is significantly lower than retrospective acquisition, 0.9±0.4 vs. 3.1±1.4 mSv, p < 0.001, and 3.4±1.4 vs. 11.1±5.4 mSv, p < 0.001, respectively. In both cardiac CT examinations, application of dose modulation techniques result in significantly lower doses in retrospective schemes, however, even with dose modulation, retrospective acquisition is associated with significantly higher doses than prospective acquisition. The number of slices acquired per rotation and the number of X-ray sources of the CT scanner (single or dual source) do not have a significant effect on patient dose.

A review of patient dose and optimisation methods in adult and paediatric CT scanning.

An increasing number of publications and international reports on computed tomography (CT) have addressed important issues on optimised imaging practice and patient dose. This is partially due to recent technological developments as well as to the striking rise in the number of CT scans being requested. CT imaging has extended its role to newer applications, such as cardiac CT, CT colonography, angiography and urology. The proportion of paediatric patients undergoing CT scans has also increased. The published scientific literature was reviewed to collect information regarding effective dose levels during the most common CT examinations in adults and paediatrics. Large dose variations were observed (up to 32-fold) with some individual sites exceeding the recommended dose reference levels, indicating a large potential to reduce dose. Current estimates on radiation-related cancer risks are alarming. CT doses account for about 70% of collective dose in the UK and are amongst the highest in diagnostic radiology, however the majority of physicians underestimate the risk, demonstrating a decreased level of awareness. Exposure parameters are not always adjusted appropriately to the clinical question or to patient size, especially for children. Dose reduction techniques, such as tube-current modulation, low-tube voltage protocols, prospective echocardiography-triggered coronary angiography and iterative reconstruction algorithms can substantially decrease doses. An overview of optimisation studies is provided. The justification principle is discussed along with tools that assist clinicians in the decision-making process. There is the potential to eliminate clinically non-indicated CT scans by replacing them with alternative examinations especially for children or patients receiving multiple CT scans.

Assessment of effective dose in paediatric CT examinations.

Current concerns focus on the high doses encountered in computed tomography (CT) examinations as they are extending towards younger and more radiosensitive patients. Previous work produced conversion coefficients for effective dose (E) from dose-length product (DLP) for four anatomical body regions applicable to any patient size. This work aims to update the earlier work, incorporating the new ICRP 2007 tissue-weighting factors and testing the methodology on modern scanners. For each age and body region, E was determined relative to DLP. Measurements were carried out on a 64-slice scanner to test this methodology. The conversion coefficients show exponential decrease with patient size. Conversion factors for the pelvis region are lower than before (30-40 %), those for the chest increased (by up to 25 %) whereas those for the head and abdomen remained fairly similar. Application of the coefficients to modern scanners verified the results, so that this methodology can be applied for a wide range of paediatric CT examinations.

Adult patient radiation doses from non-cardiac CT examinations: a review of published results.

OBJECTIVES: CT is a valuable tool in diagnostic radiology but it is also associated with higher patient radiation doses compared with planar radiography. The aim of this article is to review patient dose for the most common types of CT examinations reported during the past 19 years. METHODS: Reported dosimetric quantities were compared with the European diagnostic reference levels (DRLs). Effective doses were assessed with respect to the publication year and scanner technology (i.e. single-slice vs multislice). RESULTS: Considerable variation of reported values among studies was attributed to variations in both examination protocol and scanner design. Median weighted CT dose index (CTDI(w)) and dose length product (DLP) are below the proposed DRLs; however, for individual studies the DRLs are exceeded. Median reported effective doses for the most frequent CT examinations were: head, 1.9 mSv (0.3-8.2 mSv); chest, 7.5 mSv (0.3-26.0 mSv); abdomen, 7.9 mSv (1.4-31.2 mSv); and pelvis, 7.6 mSv (2.5-36.5 mSv). CONCLUSION: The introduction of mechanisms for dose reduction resulted in significantly lower patient effective doses for CT examinations of the head, chest and abdomen reported by studies published after 1995. Owing to the limited number of studies reporting patient doses for multislice CT examinations the statistical power to detect differences with single-slice scanners is not yet adequate.

Clinical implementation of total skin electron beam (TSEB) therapy: a review of the relevant literature.

Total skin electron beam therapy has been in medical service since the middle of the last century in order to confront rare skin malignancies. Since then various techniques have been developed, all aiming at better clinical results in conjunction with less post-irradiation complications. In this article every available technique is presented in addition to physical parameters of technique establishment and common dose fractionation. This study also revealed the preference of the majority of institutes the last 20 years in "six dual field technique" at a high dose rate, which is a safe and effective treatment.

Light emission efficiency and imaging performance of Gd2O2S: Eu powder scintillator under x-ray radiography conditions.

PURPOSE: To evaluate Gd2O2S:Eu powder phosphor as a radiographic image receptor and to compare it to phosphors often used in radiography. Gd2O2S:Eu is nonhygroscopic, emitting red light with decay time close to that of Gd2O2S:Tb. METHODS: The light intensity emitted per unit of x-ray exposure rate (absolute luminescence efficiency) was measured for laboratory prepared screens with coating thicknesses of 33.1, 46.4, 63.1, 78.3, and 139.8 mg/cm2 and tube voltages ranging from 50 to 140 kVp. Parameters related to image quality such as the modulation transfer function (MTF) and the detective quantum efficiency (DQE) were also experimentally examined. In addition, a previously validated Monte Carlo code was used to estimate intrinsic x-ray absorption and optical properties, as well as the MTF and the Swank factor (I) of the Gd2O2S:Eu scintillators. RESULTS: Gd2O2S:Eu light intensity was found higher than that of single CsI:T1 crystal for tube voltages up to 100 kVp. The MTF and the DQE were found to be comparable with those of Gd2O2S:Tb and CsI:T1 screens. MTF estimated by the Monte Carlo code was found very close to the experimental MTF values. Gd2O2S:Eu showed peak emission in the wavelength range 620-630 nm. Its emission spectrum was excellently matched to various optical detectors (photodiodes, photocathodes, CCDs, and CMOS) employed in flat panel detectors. CONCLUSIONS: Gd2O2S:Eu is an efficient phosphor potentially well suited to radiography and especially to some digital detectors sensitive to red light.

Can electronic zoom replace magnification in mammography? A comparative Monte Carlo study.

Magnification, which is considered to be a relatively high "dose cost" mammographic technique, is a complementary examination performed on women exhibiting breast complaints or abnormalities. Particular attention is given to the imaging procedure as the primary aim is to confirm the existence of suspected abnormalities, despite the additional dose. The introduction of post-processing capabilities and the widespread use of digital mammography promoted some controversy in the last decades on whether electronic zoom performed on the derived initial screening mammogram can effectively replace this technique. This study used Monte Carlo simulation methods to derive simulated screening mammograms produced under several exposure conditions, aiming to electronically magnify and compare them to the corresponding magnification mammograms. Comparison was based on quantitative measurements of image quality, namely contrast to noise ratio (CNR) and spatial resolution. Results demonstrated that CNR was higher for geometric magnification compared to the case of electronic zooming. The percentage difference was higher for lesions of smaller radius and achieved 29% for 0.10 mm details. Although spatial resolution is maintained high in the zoomed images, when investigating microcalcifications of 0.05 mm radius or less, only with geometric magnification can they be visualised.

Mid-trimester maternal serum hCG levels in predicting adverse pregnancy outcome.

OBJECTIVE: In this prospective study, we investigated the association between mid-trimester maternal serum human chorionic gonadotropin (ms-hCG) levels and adverse pregnancy outcome in a South-Western Greek population. MATERIALS AND METHODS: 130 healthy Greek women with spontaneous pregnancies were investigated for ms-hCG levels between the 13th and 24th weeks of gestation and followed for adverse pregnancy outcome, hCG levels > 2.0 multiples of the median value for gestation were considered abnormal. Statistical analysis was performed by Pearson's chi-square test. RESULTS: Gestational complications developed in a total of 12 of the 130 women studied (9.23%). Elevated ms-hCG levels were detected in a total of 14 of the 130 women studied (10.77%). CONCLUSION: Multiparameter testing of placental function in the mid-trimester (uterine artery Doppler, placental morphology and ms-hCG screening) may allow us to identify women with increased risk of developing severe placental insufficiency and pregnancy complications.

Mid-trimester maternal serum markers in predicting adverse pregnancy outcome.

OBJECTIVE: In a prospective study, we investigated the association between mid-trimester maternal serum AFP (ms-AFP), maternal serum hCG (ms-hCG) levels and adverse pregnancy outcome in a South-Western Greek population. MATERIALS AND METHODS: 126 healthy Greek women with spontaneous pregnancies were investigated for ms-AFP and ms-hCG levels between the 13th and 24th weeks of gestation and followed for adverse pregnancy outcome. Abnormal outcomes were considered as ms-AFP levels or ms-hCG levels > 2.0 multiples of the median value for gestation (MoM). Statistical analysis was performed by Pearson's chi-square test. RESULTS: Elevated ms-AFP levels were detected in a total of 25 out of the 126 women studied (19.84%). Elevated ms-hCG levels were detected in a total of ten of the 126 women studied (7.93%). Elevated ms-AFP and ms-hCG levels were detected in a total of four of the 126 women studied (3.17%). CONCLUSION: Multiparameter testing of placental function in the mid-trimester (uterine artery Doppler, placental morphology, ms-AFP and ms-hCG screening) may allow us to identify women with increased risk of developing severe placental insufficiency and pregnancy complications.

Mid-trimester maternal serum AFP levels in predicting adverse pregnancy outcome.

OBJECTIVE: In this prospective study, we investigated the association between mid-trimester maternal serum alpha-fetoprotein AFP (MSAFP) levels and adverse pregnancy outcome in a South-Western Greek population. MATERIALS AND METHODS: 110 healthy Greek women with spontaneous pregnancies, investigated for MSAFP levels between the 13th and 24th week of gestation and followed for adverse pregnancy outcome. AFP levels > 2.0 multiples of the median value for gestation were considered abnormal. Statistical analysis was performed by Pearson's chi-square test. RESULTS: Elevated MSAFP levels were detected in a total of 27 of the 110 women studied (24.5%). Among them, only four women (14.8%) developed pregnancy complications. CONCLUSION: Multiparameter testing of placental function in the mid-trimester (uterine artery Doppler, placental morphology and MSAFP screening) may allow us to identify women with increased risk of developing severe placental insufficiency and pregnancy complications.

A comparative study of the luminescence properties of LYSO:Ce, LSO:Ce, GSO:Ce and BGO single crystal scintillators for use in medical X-ray imaging.

The present study is a comparative investigation of the luminescence properties of (Lu,Y)(2)SiO(5):Ce (LYSO:Ce), Lu(2)SiO(5):Ce (LSO:Ce), Gd(2)SiO(5):Ce (GSO:Ce) and (Bi(4)Ge(3)O(12)) BGO single crystal scintillators under medical X-ray excitation. All scintillating crystals have dimensions of 10 x 10 x 10 mm(3) are non-hygroscopic exhibiting high radiation absorption efficiency in the energy range used in medical imaging applications. The comparative investigation was performed by determining the absolute luminescence efficiency (emitted light flux over incident X-ray exposure) in X-ray energies employed in general X-ray imaging (40-140 kV) and in mammographic X-ray imaging (22-49 kV). Additionally, light emission spectra of crystals at various X-ray energies were measured, in order to determine the spectral compatibility to optical photon detectors incorporated in medical imaging systems and the overall efficiency (effective efficiency) of a scintillator-optical detector combination. The light emission performance of LYSO:Ce and LSO:Ce scintillators studied was found very high for X-ray imaging.

Monte Carlo studies on the influence of focal spot size and intensity distribution on spatial resolution in magnification mammography.

Magnification is a special technique applied in mammography in cases where breast complaints have already been noticed, aiming to examine a specific area of the breast. Small-sized focal spots are essential in such techniques in order to reduce the resultant geometrical unsharpness. The x-ray intensity distribution of the focal spot is another crucial parameter for such a technique as it affects the mammographic resolution. In this study a Monte Carlo simulation model is utilized, in order to examine the effect of a wide range of focal spot sizes and three representative intensity distributions on spatial resolution under magnification. A thick sharp edge consisting of lead, non-transparent to x-rays was imaged under various conditions for this purpose, and the corresponding spatial resolution was calculated through the modulation transfer function (MTF). Results demonstrate that focal spots larger than 0.10 mm can mainly be used for low degrees of magnification, especially when combined with double peak Gaussian intensity distribution of the focal spot (sum of two single peak Gaussian distributions with different centers), as the resultant spatial resolution is not as high as the corresponding from smaller foci or uniform and single peak Gaussian distributions. Moreover, for the degrees of magnification usually utilized in clinical practice they do not reach the acceptable limit of 12 lp mm(-1). The replacement of the x-ray tube when the focal spot starts being destroyed is very crucial as the possible alteration of single peak Gaussian distribution to double peak Gaussian results in the degradation of spatial resolution. A focal spot of 0.10 mm or smaller, combined with single peak Gaussian intensity distribution, can be considered appropriate even for higher degrees of magnification and its use can contribute in the effort to optimize the magnification views in mammography.

A morphological index for assessing hip osteoarthritis severity from radiographic images.

A new method is proposed for assessing the severity of hip osteoarthritis (OA) based on radiographic hip joint space (HJS) morphology. 64 hips of patients with verified unilateral OA or bilateral OA were studied by digitizing the corresponding pelvic radiographs. Radiographic OA severity was assessed employing the Kellgren and Lawrence (KL) scale. Using custom-developed software, radiographs were enhanced, the margins of both HJSs were outlined, and 64 regions of interest (ROIs), corresponding to the delineated HJSs, were obtained. Employing custom-developed algorithms, an index ("joint space morphological index" - JSMI) evaluating alterations in the shape and size of HJS was introduced, calculated and normalized with respect to each patient's individual anatomy. The JSMI values were used to introduce classification rules concerning the characterization of a hip in accordance with the KL scale. For each patient in the unilateral OA group, the OA severity was expressed as the percentage of the HJS area difference between the patient's osteoarthritic and contralateral normal hip. The per cent HJS area difference and the JSMI values were used in the design of a regression model for providing a quantitative estimation of OA severity. The per cent HJS area difference correlated highly with the pathological JSMI values (r = -0.83, p<0.001). The implementation of the JSMI-based classification rules resulted in high classification accuracies for characterizing hips as normal or osteoarthritic, 90.6% (95% exact confidence interval (CI): 80.7-96.5%), as well as for discriminating among OA severity categories, 91.7% (95% CI: 77.5-98.2%). Additionally, a simplified approach of JSMI calculation is suggested for daily clinical use. These JSMI values (JSMI simplified) were found not to differ significantly from (p>0.05), and to be strongly correlated with (r = 0.96, p<0.001), the corresponding ones obtained by the computerized approach. Additionally, the implementation of classification rules based on JSMI simplified resulted in classification accuracies identical to the corresponding ones obtained for the JSMI-based rules. The proposed method may be utilized for evaluating OA and monitoring OA progression.

Energy, angular and spatial distributions of primary electrons inside photoconducting materials for digital mammography: Monte Carlo simulation studies.

Materials such as a-Se, a-As(2)Se(3), GaSe, GaAs, Ge, CdTe, CdZnTe, Cd(0.8)Zn(0.2)Te, ZnTe, PbO, TlBr, PbI(2) and HgI(2) are potential candidates as photoconductors in direct detectors for digital mammography. The x-ray induced primary electrons inside a photoconductor's bulk comprise the initial signal that propagates and forms the final signal (image) on the detector's electrodes. An already developed model for a-Se has been properly extended to simulate the primary electron production in the materials mentioned. Primary electron characteristics, such as their energy, angular and spatial distributions that strongly influence the characteristics of the final image, were studied for both monoenergetic and polyenergetic x-ray spectra in the mammographic energy range. The characteristic feature in the electron energy distributions for PbI(2) and HgI(2) is the atomic deexcitation peaks, whereas for the rest of the materials their shape can also be influenced by the electrons produced from primary photons. The electrons have a small tendency to be forward ejected whereas they prefer to be ejected perpendicular (theta = pi/2) to the incident beam's axis and at two lobes around phi = 0 and phi = pi. At practical mammographic energies (15-40 keV) a-Se, a-As(2)Se(3) and Ge have the minimum azimuthal uniformity whereas CdZnTe, Cd(0.8)Zn(0.2)Te and CdTe the maximum one. The spatial distributions for a-Se, a-As(2)Se(3), GaSe, GaAs, Ge, PbO and TlBr are almost independent of the polyenergetic spectrum, while those for CdTe, CdZnTe, Cd(0.8)Zn(0.2)Te, ZnTe, PbI(2) and HgI(2) have a spectrum dependence. In the practical mammographic energy range and at this primitive stage of primary electron production, a-Se has the best inherent spatial resolution as compared to the rest of the photoconductors. PbO has the minimum bulk space in which electrons can be produced whereas CdTe has the maximum one.

Dose and image quality optimization in neonatal radiography.

In a special care baby unit, neonates, mainly premature, encounter serious to life-threatening diseases, the timely diagnosis and treatment of which may require a large number of radiographs. Increased neonatal radiosensitivity and longer life expectancy increase the risk of radiation-induced cancer, which emphasizes the importance of minimizing dose while maintaining clinically satisfactory image quality. An optimization study on radiation dose and image quality in neonatal radiography is presented. Neonates were categorized into four groups depending on birthweight. For a total of 378 chest and chest-abdomen radiographs, exposure parameters were recorded. Entrance surface dose (ESD) was estimated and dose-area product (DAP) was measured. Image quality evaluation was performed by two observers and was based on the visibility of certain anatomical features and catheters placed during treatment using a five-grade scale. ESD values increased with neonatal weight and demonstrated wide variation (16.4-76.9 microGy, mean 38.2 microGy). A wide variation was also observed in DAP values (1.2-15.0 mGycm2, mean 7.2 mGycm2). Image quality evaluation revealed the feasibility of achieving a diagnostically satisfactory image (score >70%) using both low and high tube voltage techniques, with the latter resulting in reduced ESDs. The majority of estimated ESDs are in accordance with the reference level of 50 microGy recommended by the National Radiological Protection Board for neonatal radiography. The results suggest that the use of high tube voltage techniques could result in further reductions in neonatal dose, without image quality degradation, underlying the requirement for establishing standard examination protocols for neonatal radiography with respect to neonatal weight.

Texture analysis of perimenopausal and post-menopausal endometrial tissue in grayscale transvaginal ultrasonography.

The aim of this study was to investigate the feasibility of texture analysis in characterizing endometrial tissue as depicted in two-dimensional (2D) grayscale transvaginal ultrasonography. Digital transvaginal ultrasound endometrial images were acquired from 65 perimenopausal and post-menopausal women prior to gynaecological operations; histology revealed 15 malignant and 50 benign cases. Images were processed with a wavelet-based contrast enhancement technique. Three regions of interest (ROIs) were identified (endometrium, endometrium plus adjacent myometrium, layer containing endometrial-myometrial interface) on each original and processed image. 32 textural features were extracted from each ROI employing first and second order statistics texture analysis algorithms. Textural features-based models were generated for differentiating benign from malignant endometrial tissue using stepwise logistic regression analysis. Models' performance was evaluated by means of receiver operating characteristic (ROC) analysis. The best logistic regression model comprised seven textural features extracted from the ROIs determined on the processed images; three features were extracted from the endometrium, while four features were extracted from the layer containing the endometrial-myometrial interface. The area under the ROC curve (A(z)) was 0.956+/-0.038, providing 86.0% specificity at 93.3% sensitivity using the cut-off level of 0.5 for probability of malignancy. Texture analysis of 2D grayscale transvaginal ultrasound images can effectively differentiate malignant from benign endometrial tissue and may contribute to computer-aided diagnosis of endometrial cancer.

Texture analysis of tissue surrounding microcalcifications on mammograms for breast cancer diagnosis.

Diagnosis of microcalcifications (MCs) is challenged by the presence of dense breast parenchyma, resulting in low specificity values and thus in unnecessary biopsies. The current study investigates whether texture properties of the tissue surrounding MCs can contribute to breast cancer diagnosis. A case sample of 100 biopsy-proved MC clusters (46 benign, 54 malignant) from 85 dense mammographic images, included in the Digital Database for Screening Mammography, was analysed. Regions of interest (ROIs) containing the MCs were pre-processed using a wavelet-based contrast enhancement method, followed by local thresholding to segment MCs; the segmented MCs were excluded from original image ROIs, and the remaining area (surrounding tissue) was subjected to texture analysis. Four categories of textural features (first order statistics, co-occurrence matrices features, run length matrices features and Laws' texture energy measures) were extracted from the surrounding tissue. The ability of each feature category in discriminating malignant from benign tissue was investigated using a k-nearest neighbour (kNN) classifier. An additional classification scheme was performed by combining classification outputs of three textural feature categories (the most discriminating ones) with a majority voting rule. Receiver operating characteristic (ROC) analysis was conducted for classifier performance evaluation of the individual textural feature categories and of the combined classification scheme. The best performance was achieved by the combined classification scheme yielding an area under the ROC curve (A(z)) of 0.96 (sensitivity 94.4%, specificity 80.0%). Texture analysis of tissue surrounding MCs shows promising results in computer-aided diagnosis of breast cancer and may contribute to the reduction of unnecessary biopsies.