False-positive results in mammographic screening for breast cancer in Europe: a literature review and survey of service screening programmes.

OBJECTIVE: To estimate the cumulative risk of a false-positive screening result in European mammographic screening programmes, and examine the rates and procedures of further assessment. METHODS: A literature review was conducted to identify studies of the cumulative risk of a false-positive result in European screening programmes (390,000 women). We then examined aggregate data, cross-sectional information about further assessment procedures among women with positive results in 20 mammographic screening programmes from 17 countries (1.7 million initial screens, 5.9 million subsequent screens), collected by the European Network for Information on Cancer project (EUNICE). RESULTS: The estimated cumulative risk of a false-positive screening result in women aged 50-69 undergoing 10 biennial screening tests varied from 8% to 21% in the three studies examined (pooled estimate 19.7%). The cumulative risk of an invasive procedure with benign outcome ranged from 1.8% to 6.3% (pooled estimate 2.9%). The risk of undergoing surgical intervention with benign outcome was 0.9% (one study only). From the EUNICE project, the proportions of all screening examinations in the programmes resulting in needle biopsy were 2.2% and 1.1% for initial and subsequent screens, respectively, though the rates differed between countries; the corresponding rates of surgical interventions among women without breast cancer were 0.19% and 0.07%. CONCLUSION: The specific investigative procedures following a recall should be considered when examining the cumulative risk of a false-positive screening result. Most women with a positive screening test undergo a non-invasive assessment procedure. Only a small proportion of recalled women undergo needle biopsy, and even fewer undergo surgical intervention.

Mammographic screening programmes in Europe: organization, coverage and participation.

OBJECTIVES: To summarize participation and coverage rates in population mammographic screening programmes for breast cancer in Europe. METHODS: We used the European Network for Information on Cancer (EUNICE), a web-based data warehouse (EUNICE Breast Cancer Screening Monitoring, EBCSM) for breast cancer screening, to obtain information on programme characteristics, coverage and participation from its initial application in 10 national and 16 regional programmes in 18 European countries. RESULTS: The total population targeted by the screening programme services covered in the report comprised 26.9 million women predominantly aged 50-69. Most of the collected data relates to 2005, 2006 and/or 2007. The average participation rate across all programmes was 53.4% (range 19.4-88.9% of personally invited); or 66.4% excluding Poland, a large programme that initiated personal invitations in 2007. Thirteen of the 26 programmes achieved the European Union benchmark of acceptable participation (>70%), nine achieved the desirable level (>75%). Despite considerable invitation coverage across all programmes (79.3%, range 50.9-115.2%) only 48.2% (range 28.4-92.1%) of the target population were actually screened. The overall invitation and examination coverage excluding Poland was 70.9% and 50.3%, respectively. CONCLUSIONS: The results demonstrate the feasibility of European-wide screening monitoring using the EBCSM data warehouse, although further efforts to refine the system and to harmonize standards and data collection practices will be required, to fully integrate all European countries. The more than three-fold difference in the examination coverage should be taken into account in the evaluation of service screening programmes.

Difficulties in the diagnosis of intracystic tumors of the female breast.

The objective of the current study was to determine the accuracy of radiological and cytological diagnoses of intracystic and papillary lesions in distinguishing between true papillary benign and malignant lesions. Seventy cytological reports of intracystic proliferations were selected from our cytopathological database at the Breast Health Corporation, Budapest, Hungary, dating back to the last 7 years. Retrospective analysis of the diagnostic approaches--mammography, ultrasonography, clinical examination and cytology--was performed in selected cases. The results of imaging and cytological examination are routinely reported on a categorical scale ranging from 1 to 5. 44 patients underwent surgical excision: histology showed benign lesions in 21 and malignant lesions in 23 cases. Twelve patients, who did not undergo biopsy and presented a stable disease at follow-ups, were also included in the group of benign lesion. Fifteen patients were not available for follow-up. Concerning the total investigated cases the mean categorical values of mammography, ultrasonography and cytology were 2.24, 2.78 and 3.05 respectively. The malignant and benign groups significantly differ from each other concerning the mean age of the patients (p=0.0216), the distribution of the coded mammographical results (p= 0.0171) the cytological results (p=0.0001), and average tumor size measured on mammogram images (p=0.0199). The two group does not significantly differ over the distribution of mammographical density patterns (p=0.1075), radiomorphological appearance (p=0.1101), average tumor size measured on ultrasonography (p=0.2665), and patient complaints (p=0.2634). The evaluation of ultrasonography shows borderline significance (Pearson Chi-square test: p=0.0616, M-L Chi-square test: p=0.0404) between the malignant and benign groups. Differential diagnosis between malignant and benign intracystic and papillary lesions is feasible using common radiological diagnostics. However, more efficient teamwork is needed with the cooperation of a well-trained cytologist and radiologist, who are able to produce precise images of the lesions, and guides the aspiration of the adequate samples for cytology, which is the most valuable examination.

The organisation and results of first screening round of the Hungarian nationwide organised breast cancer screening programme.

BACKGROUND: The aim of this paper is to give an overview of organisational issues of the Hungarian nationwide organised breast cancer screening programme and to provide the results of the first screening round of the programme for the years 2002-2003. PATIENTS AND METHODS: Data were derived from the financial database of the National Health Insurance Fund Administration covering the period 2000-2003. Women who underwent mammography screening were included into the study. RESULTS: Uptake of the organised screening programme in 2002-2003 was 45.09%, while the recall rate was 7.23%. Malignant cases represented 65.38% of total surgeries and 0.36% of total number of screened women yielding a cancer detection rate 3.6 per 1000 screened women. Malignant cases of 10.78% were identified as ductal carcinoma in situ, while 89.22% was invasive cancer. Benign to malignant ratio was 0.54 : 1. CONCLUSION: There is therefore an urgent need to closely monitor performance and to review programme policies and procedures with the aim of increasing both the participation rate and the proportion of women eligible to attend screening.

Diagnostic accuracy of mammography and contrast-enhanced MR imaging in 238 histologically verified breast lesions.

PURPOSE: To determine the sensitivity and specificity of X-ray mammography and of MR imaging in 238 consecutively operated breasts, and to correlate the findings to histopathological diagnosis. MATERIAL AND METHODS: Over 15 months, 220 patients scheduled for breast surgery were examined consecutively, before surgery, by means of both mammography and MR imaging. Of the 220 patients, 18 underwent bilateral breast surgery. The entire breast was examined by means of T1-weighted transversal images using a 3D fast low-angle shot (FLASH) sequence. One pre- and 2 post-contrast scans were performed. Each breast was examined by means of mammography and 3 views were applied as routine. All palpable and mammographically suspect lesions were examined on additional images as microfocus magnification or spot compression. The two methods were evaluated independently of each other. RESULTS: In total, 145 malignant and 93 benign lesions were found at histopathological examination. The sensitivity of mammography was 89% and MR imaging 92%. The specificity was 72% in both methods. When the results of the 2 methods were combined, a sensitivity of 99% and a specificity of 55% was achieved. CONCLUSION: Mammography and MR imaging seemed to complement each other to produce a high sensitivity. Unfortunately it is impossible at present to supplement mammography with MR imaging in each patient as a routine owing to the current technical and financial limitations.

Galactography: the diagnostic procedure of choice for nipple discharge.

Galactography was performed in 204 women with a nipple discharge and the secretion confirmed histopathologically. All 116 intraductal tumors (papilloma, papillomatosis, carcinoma), which were associated with a serous or bloody discharge, were detected preoperatively. A palpable mass had little diagnostic significance, and exfoliative cytology was positive in only 11% (2/18) of the patients with carcinoma. The authors recommend that all patients with a spontaneous bloody or serous discharge from a single lactiferous orifice undergo galactography in addition to physical, cytological, and mammographic examination. Intraductal injection of methylene blue dye will demonstrate the affected duct system to the surgeon and can often make surgery less radical or even unnecessary.

[Use of xeroradiography in cervical pneumomyelography]. / Anwendung der Xeroradiographie bei zervikaler Pneumomyelographie.

For diagnosing lesions of cervical intervertebral disks, pneumomyelography is carried out in addition to diskography in cases with an indication for surgery. The application of xeroradiography in pneumomyelography is discussed for the first time. In contrast to the conventional X-ray film technique, xeroradiograms yield shraper contours at the gas/tissue interface.

The diagnostic and therapeutic value of breast cyst puncture and pneumocystography.

Out of 53,459 women undergoing mammography, 434 pneumocystographic examinations were performed in 338 patients. Thirteen benign and 13 malignant intracystic tumors were detected, for a frequency of 6.0%. Intracystic cancers comprised 1.3% of all malignant tumors. Neither visual nor cytological examination of cyst fluid was sufficient to detect or rule out cancer, and the authors feel that pneumocystography is the only reliable method. Excision is the preferred therapy, and histological examination is the definitive method of differentiating benign from malignant tumors. In more than 97% of cases, pneumocystography of simple cysts is therapeutic. Without evidence of intracystic tumor on pneumocystography, cyst removal is unnecessary. The patient can be followed up with mammography, and any recurrent or new cysts can be diagnosed and treated by pneumocystography alone.

Dose reduction in the low-energy X-ray diagnostics of extremities.

The authors determined the surface absorbed dose (Ds = 67-68 mGy) and the average absorbed dose (Dav = 13-15 mGy) by means of non-screen film radiography of the extremities. The authors recommend the use of xeroradiography (with a tungsten anode tube) or, first of all, a rare-earth screen - film combination (e.g. Kodak min-R + Nuklearmedizin NMB film). The two methods permit the dose values to be decreased by a factor of about 4 and 15, respectively. The dose values are smaller, at least for the 8 cm thick tissue equivalent phantom, when a tungsten anode is used instead of a Mo anode.

Selective conventional and xero-arteriography of the external carotid artery for control of intra-arterial chemotherapy.

The control of intra-arterial chemotherapy by selective conventional and xero-angiographic exploration of the external carotid artery is reported. With the aid of a catheter inserted into the superior thyroid, facial or super-facial temporal artery, all the main branches of the external carotid artery can be depicted. Xeroangiography in the area of the external carotid artery is a new method on which no data could be found in the literature. Anatomical variations of the vascular system and vascular lesions caused by surgery, a tumour, or intra-arterial chemotherapy are better demonstrated by xeroradiography. The bones and the soft parts are well depicted at the same time in the xeroradiographic pictures; thus the bony masses of the facial and petrous regions, together with the vessels on the bones, in the bones and in the soft parts are visible on one and the same picture.

Absorbed dose in xeromammography.

The authors have compared the average absorbed dose and the skin exposure per picture from conventional (30 kV, Mo anode, 0.03 mm Mo filter) mammography with that from xeroradiography (38--42 kV, W anode, 1--2 mm Al total filtration). The average absorbed dose per xeromammogram is 4--5 mGy (0.4--0.5 rad), about four times less than in film-mammography. This value is equal to that obtained by others using the DuPont "Lo Dose I" system but is an order of magnitude higher than that published in the literature for Kodak "Mini-R" and "Trimax-rare earth" 3M system. The consumables per picture are about nine times cheaper in xeromammography than in film-mammography.

[Xerosialography (author's transl)]. / Xerosialographie.

The authors performed xerosialography on 41 patients with various diseases of the salivary glands. In 38 patients this provided positive information. Each of eight submandibular sialograms was abnormal; of the 33 parotid examinations, three benign salivary tumours could not be demonstrated radiologically. Xeroradiography is a useful method for the examination of the major salivary glands. It is superior to the traditional film method.

[Mammographic mass examinations for breast cancer among rural population selected via physical examination and epidemiologic questionnaire (author's transl)]. / Mammographische Brustkrebs-Reihenuntersuchungen bei mit physikalischer Untersuchung und epidemiologischem Fragebogen selektierter Bevölkerung vom Lande.

The authors report on their four years' experience in oncologic mass examinations focused on the age group above 30. After 43980 serial examinations, they performed mammography in 3082 women with mammary cancer risk. 156 operations were performed, and 33 histologically established cases of mammary carcinoma were recorded, with 21 early-stage cases. Of 21 occult tumors, 18 did not manifest any metastases. Thanks to the epidemiologic questionnaire, 10 mammary cancer patients were registered. The score of confirmed findings exceeded quantitatively, and, especially, qualitatively, the mammary carcinoma morbidity of the region. The results prove the feasibility of the combined method. The major part of the population did not appear for mass examination. The advanced stage of the 55 cases of breast cancer belonging to this group, as well as that of the 10 cases of which became manifest during the examination interval, would indicate that much is to be said for a more effective health promotion campaign among the population.

[Soft tissue changes in pseudo-pseudo-hypoparathyroidism (author's transl)]. / Weichteilveränderungen bei Pseudopseudohypoparathyreoidismus.

The authors have demonstrated subcutaneous calcification which is characteristic for pseudo-pseudo-hypoparathyroidism (pph) and which is best shown by xero-radiography. If the presence of pph is suspected, or if it needs to be distinguished from some other condition, it is valuable to obtain xerograms of the soft tissues of the extremities. In pph the subcutaneous calcification is in all probability derived from the skeleton.