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Article Open Access Published: 10 October 2019 Association of Microcalcification Clusters with Short-term Invasive Breast Cancer Risk and Breast Cancer Risk Factors Maya Alsheh Ali, Kamila Czene, Per Hall & Keith Humphreys Scientific Reports volume 9, Article number: 14604 (2019) Cite this article 799 Accesses Abstract Using for-presentation and for-processing digital mammograms, the presence of microcalcifications has been shown to be associated with short-term risk of breast cancer. In a previous article we developed an algorithm for microcalcification cluster detection from for-presentation digital mammograms. Here, we focus on digitised mammograms and use a three-step algorithm. In total, 253 incident invasive breast cancer cases (with a negative mammogram between three months and two years before diagnosis, from which we measured microcalcifications) and 728 controls (also with prior mammograms) were included in a short-term risk study. After adjusting for potential confounding variables, we found evidence of an association between the number of microcalcification clusters and short-term (within 3–24 months) invasive breast cancer risk (per cluster OR = 1.30, 95% CI = (1.11, 1.53)). Using the 728 postmenopausal healthy controls, we also examined association of microcalcification clusters with reproductive factors and other established breast cancer risk factors. Age was positively associated with the presence of microcalcification clusters (p = 4 × 10−04). Of ten other risk factors that we studied, life time breastfeeding duration had the strongest evidence of association with the presence of microcalcifications (positively associated, unadjusted p = 0.001). Developing algorithms, such as ours, which can be applied on both digitised and digital mammograms (in particular for presentation images), is important because large epidemiological studies, for deriving markers of (clinical) risk prediction of breast cancer and prognosis, can be based on images from these different formats. Introduction Microcalcifications are deposits of calcium oxalate and calcium phosphate within the breast tissue that appear as white specks on a mammogram. The mechanisms by which microcalcifications occur are not clearly understood, although many factors are suspected to play a role, such as age, hormonal unbalance, pregnancy, breastfeeding and diet change. Active cellular processes, or effects of cellular degeneration may be involved1. Calcification deposits are found within the ductal system, the breast acini, stroma and vessels2. Microcalcifications are present in approximately 55% of nonpalpable breast malignancies and are responsible for the detection of 85–95% of cases of ductal carcinoma in situ (DCIS) by screening mammography3, and they can also be present in invasive cancers4. The role of microcalcifications in the detection of breast cancer has been widely studied and some research groups have even investigated the role of microcalcifications in terms of risk and progression of breast cancer. Previous studies have shown that women with false-positive results at screening have, on average, higher risks of breast cancer being detected at subsequent mammographic examinations than women with negative screening results5,6,7, in particular, when the false positive results are due to microcalcifications at mammography8. Detected abnormalities, although noncancerous, may therefore be useful as imaging features for breast cancer risk prediction. Microcalcifications represent a challenge in both perception and interpretation; between 12.7% and 41.2% of women are recalled with calcifications as the main mammographic feature/finding in screening programs.
In-text: (Alsheh Ali et al.)
Your Bibliography: Alsheh Ali, Maya et al. "Association Of Microcalcification Clusters With Short-Term Invasive Breast Cancer Risk And Breast Cancer Risk Factors." Scientific Reports 9.1 (2019): n. pag. Web. 4 Feb. 2020.
Microcalcifications were present in 75% of the cases, and soft-tissue abnormalities in 27% cases with association with calcifications in 14% of cases. Palpable masses were found in 12% of the cases and nipple discharge was present in 12% of the cases. The radiographic–pathologic correlation allowed to suspect the DCIS “aggressiveness” on radiologic signs. Granular, linear, branching and/or galactophoric topography of the microcalcifications were correlated with necrosis, grade 3, comedocarcinoma type. A number of microcalcifications higher than 20 was correlated with necrosis and grade 3. Mammographic size was correlated to histologic size. Masses were correlated with grade 1. A diagnosis strategy can be proposed with a multidisciplinar approach. DCIS increases with breast screening: from 14% in 1992  to 25 % in 2000 . Holland and Hendriks , in this series of 59 cases, point to that fine pleomorphic or fine-linear branching calcifications were more frequent in high nuclear grade (42.4%) than in low nuclear grade (28.8%). There was a correlation between the mammographic size of calcifications and the histologic size of the DCIS and the high nuclear grade 3 types were more extensive. Tan et al.  reported also a significant correlation between mammographic size of calcifications and histologic size of DCIS. But the mammographic size under- Morphology, distribution, cluster, number of calcifications permit to appreciate predictive positive value (PPV). Mammographic sign and the BI-RADS categories can suspect the “agressivity” of DCIS. Even optimal technique and equipments used, sonographic diagnosis of DCIS could be very difficult. Magnetic resonance imaging (MRI) permits to appreciate extension , multifocality, multicentricity or bilaterality of DCIS especially in high nuclear grade. The sensitivity is lower for low nuclear gradeImaging in DCIS can only be optimal with high quality level, quality control and permanent evaluation,
In-text: (Barreau et al. 55-61)
Your Bibliography: Barreau, Béatrice et al. "Mammography Of Ductal Carcinoma In Situ Of The Breast: Review Of 909 Cases With Radiographic–Pathologic Correlations." European Journal of Radiology 54.1 (2005): 55-61. Web. 16 Feb. 2020.
‘uncertainty … can never be completely eliminated from decision making’, although it can be reduced through raising to awareness typical heuristics that may lead to error or bias in judgement. Here, we suggest that heuristics can work in the opposite direction, to improve quality of discrimination informing judgement. Any heuristic is inherently Janus‐faced, offering potential not only for bias in judgement, but also for refinement. Novices and experts alike must consider this paradox. Hall suggests that doctors need to recognise shifts from certainties in judgement (‘certainly’) to imprecise descriptions mirroring uncertainty (‘probably’, ‘possibly’, ‘maybe’). Constructive ways of reducing uncertainty involve the use of guidelines, seeking consensus and peer review. Katz21 calls for an opposite taxis, where those doctors who characteristically resort to ‘decisiveness, control and certitude’ in the face of uncertainty, should drop the ‘mask of infallibility’. While Hall recognises the need to reduce uncertainty, she also notes that failure to recognise the extent of uncertainty in decision making may be a ‘denial’, an ‘illusion of control and mastery’ that, understandably To the novice, expert judgement appears to be intuitive. Hall5 suggests that ‘intuition is an inescapable part of decision making in medicine’ while ‘intuitive decision making is more likely to occur particularly under conditions of uncertainty’. ‘Intuition’ is, however, a word that raises the hackles of rationalists and positivists, who give it the same status as guesswork, anecdote and personal opinion. Polanyi35 challenges this view in his account of ‘tacit knowing’. Avoiding an invocation of ‘intuition’, Polanyi describes how scientists build up ‘personal knowledge’ that resists verbalisation yet informs action, through what Reber36 describes as ‘attentive immersion in the subject matter under consideration’. Prawat37 describes such ‘immersion’ as the basis to forming a mental organisation or structure necessary for effective action in particular situations. Such structures are positively modified and deepened through meeting ‘impasse’ situations in problem solving that stimulate innovation. We describe this in the visual domain as an arresting aesthetic engagement with sign or symptom offering ‘education of attention’. Immersion over time allows one to induce the underlying structural forms to action, where perception now grasps or appreciates a configuration holistically. Paradoxically, when asked to explain the process of judgement, the expert is unable to do so, as the informing structure to the act remains tacit,16 yet the expert is clear that an informing pattern has been recognised, even under conditions of ambiguity.
In-text: (Bleakley et al. 544-552)
Your Bibliography: Bleakley, Alan et al. "Making Sense Of Clinical Reasoning: Judgement And The Evidence Of The Senses." Medical Education 37.6 (2003): 544-552. Web. 24 Mar. 2018.
The courts occasionally treat false negative errors as if they were errors of negligence. It is frequently alleged after retrospective review that lesions should have been noted prospectively. However, application of theories of perceptual thresholds shows that it makes sense that more lesions will be perceived retrospectively . An appellate court in Wisconsin gave a ruling in 1998 that said: “radiologists simply cannot detect all abnormalities on all x-rays….Errors in perception by radiologists viewing x-rays occur in the absence of negligence”. Hindsight bias is the tendency for people with knowledge of the actual outcome of an event to believe falsely that they would have predicted the outcome. Hindsight bias is an extremely compelling influence; people try to make sense of what they know has happened rather than analyzing the available data independently. The exact mechanism by which hindsight bias influences judgement called “creeping determinism” - a process in which outcome information is immediately and automatically integrated into a person’s knowledge about the events preceding the outcome. Hindsight bias is not supposed to influence the determination of medical negligence, but it ensures that some reasonably-acting defendants will be unfairly subjected to adverse liability judgements when after-injury evaluation has taken place15. Human error can be viewed in either a person-centered or system-centered way, or both. A person-centered approach focuses on the individual who commits the error, and adopts counter-measures aimed at that individual, including disciplinary measures: ‘naming, shaming and blaming’2. The NHS has concluded that the person-centered approach, though attractive from a managerial and legal perspective, is ‘ill-suited to the health care domain’2,22. The system-based approach accepts that humans are fallible and errors inevitable, and seeks to address contributing system causes for these errors. What matters less is who made the error, and more how and why defences failed, and what factors helped create the conditions in which the error occurred2. The concept of Root Cause Analysis has been used as a method to learn from mistakes and reduce hazards in the future. This process is based on the principle of answering three questions: What happened? Why did it happen? What can be done to prevent it happening again?23
In-text: (Brady et al. 3-9)
Your Bibliography: Brady, Adrian et al. "Discrepancy And Error In Radiology: Concepts, Causes And Consequences." Ulster Medical Jouranal 81.1 (2012): 3-9. Web. 20 Jan. 2018.
In-text: (Brook et al. 1401-1410)
Your Bibliography: Brook, Olga R. et al. "Quality Initiatives: Anatomy And Pathophysiology Of Errors Occurring In Clinical Radiology Practice." RadioGraphics 30.5 (2010): 1401-1410. Web. 17 Feb. 2018.
Cognitive or interpretive errors occur when an abnormality is identified on an image but its importance is incorrectly understood, resulting in an incorrect final diagnosis. This type of error may be secondary to a lack of knowledge, a cognitive bias on the part of the radiologist interpreting the study, or misleading clinical information distorting the apparent pretest probability of disease; it could also simply be a result of a radiologist inadvertently propagating an error made by a colleague in a previous radiology report (sometimes termed an alliterative error or satisfaction of report). To make a correct diagnosis from “raw data” of this sort, one must use visual detection, pattern recognition, working memory functions—and ultimately cognitive reasoning—to result in a final interpretation of the meaning of what has been perceived. The perceptual and reasoning steps occur as parts of a process that is filtered through the individual practitioner’s individual knowledge base, past experience, and cognitive biases. The conclusions derived from this process must then be translated into effective language to be communicated to the clinical providers who will act on the information. Further, for each of the approximately 1 billion imaging examinations performed annually, all of these psychophysiologic and cognitive steps must be performed repeatedly. Moreover, it has been shown that radiologists are prone to make the same errors repeatedly, especially when findings are not detected or when their importance is underestimated (9). Does the proverbial cloud of radiologist error contain a silver lining for radiology in the form of an opportunity for true learning and improvement? We believe that it does but only if the lessons of the past several decades of research into radiologist errors are correctly understood and taken to heart. These include, but are not limited to, (a) the need to maintain a state of constant vigilance in interpretation and a healthy degree of skepticism regarding favored diagnoses; (b) struggling to overcome all known cognitive biases and pitfalls; (c) consistent use of a sufficiently broad range of differential diagnoses when formulating conclusions about unknown cases being evaluated; (d) reduction in variation or variability in practice at all levels; (e) a program of continuous lifelong learning to prevent knowledge gaps; (f) a mindful systematic approach to the search of diagnostic images and to the use of checklists and structured and semistructured reporting strategies, when appropriate; (g) cognitive debiasing approaches and metacognition, when appropriate; (h) use of effective technologic aids, as appropriate, if any become available; (i) consistent focus on clear effective communication, especially clear written communication, so that the radiologist’s message is not lost or misunderstood; (j) use of harm mitigation and fail-safe strategies to place redundant layers of protection between the radiologist and the patient, including trigger tools to identify errors so that they can be corrected before harm occurs; (k) reduction, to the extent possible, of interruptions and distractions; (l) attention to individual physician factors, such as illness or advancing age, may be appropriate in some isolated cases to assure that these factors do not significantly affect diagnostic performance; (m) systems-level thinking—understanding the individual radiologist’s role within the context of the larger health care team and process and empathetically understanding the roles and needs of others within that system; and (n) a blame-free and just culture.
In-text: (Bruno, Walker and Abujudeh 1668-1676)
Your Bibliography: Bruno, Michael A., Eric A. Walker, and Hani H. Abujudeh. "Understanding And Confronting Our Mistakes: The Epidemiology Of Error In Radiology And Strategies For Error Reduction." RadioGraphics 35.6 (2015): 1668-1676. Web. 26 Jan. 2018.
In-text: (Croskerry 775-780)
Your Bibliography: Croskerry, Pat. "The Importance Of Cognitive Errors In Diagnosis And Strategies To Minimize Them." Academic Medicine 78.8 (2003): 775-780. Web. 20 Jan. 2018.
In-text: (Evans et al.)
Your Bibliography: Evans, A. J et al. Breast Calcification: A Diagnostic Manual. London: Greenwich Medical Media Ltd, 2002. Print.
In addition to malignat lesions, many non-malignant processes also produce dystrophic microcalcifications in breast tissue. In order to minimise invasive investigations, radiologists take into account the various characteristics of microcalcifications. The form, size, pleomorphism and distribution of the calcifications provide clues to the underlying pathology. Mammographic grading systems encapsulate the overall level of concern. The grading system used throughout Australia and parts of Europe is a five tier system that differs from the BI-RADs system used in North America (National Breast Cancer Centre, 2002). In this system, grade 3 lesions are regarded as indeterminate/equivocal and lesions graded 3 and above require imaging workup and possible biopsy. The risk stratification by radiological grade is clinically helpful in counselling women. In particular, the high PPV of category 5 radiology, signifies a greater than 90% chance of malignancy, mandating careful exclusion of malignancy. However, even among grade 5 lesions, almost 10% of cases were ultimately shown to be non-malignant histologically. This observation reiterates the necessity to evaluate all suspicious microcalcifications by tissue biopsy before definitive treatment, as imaging alone is not a sufficiently robust determinant of malignancy. Importance of microcalcifications in the diagnosis of early-stage breast cancer The detection of small cancers, defined as those ⩽15 mm in diameter on histology, is an important indicator of screening quality. Our national accreditation standards mandate that at least 25 screen-detected cancers per 100 000 women screened should be ⩽15 mm (BreastScreenAustralia, 2005). Our data demonstrate that in addition to the strong association with high grade DCIS, the assessment of screen-detected microcalcifications is an important method of detecting invasive cancers, including small invasive cancers. and evidence has been presented that when invasive malignancies present as calcifications, the invasive cancers are often HER2 positive, a feature that has been associated with poorer prognosis in prior studies It appears that the assessment of screen-detected microcalcifications permits preferential diagnosis of higher grades of DCIS and of biologically more aggressive subsets of invasive cancer with which they are associated. In this context, the assessment of mammographic microcalcifications represents a valuable opportunity for altering the natural history of these cancers and reducing mortality from breast cancer. One of the criticisms of breast cancer-screening programmes is that a proportion of cancers detected through screening mammography may have been indolent and may never have presented clinically during the woman's lifetime, had they not been detected by screening. To the extent that these women face the morbidity and anxiety associated with the diagnosis and treatment of breast cancer, the diagnosis of these cancers is regarded as one of the negative consequences of screening. As there are presently no reliable means of predicting at the individual level which cancers are destined to progress and which will remain indolent, the estimates of the magnitude of such over-diagnosis are based on statistical inferences, with a rather wide range of estimates spanning zero to over 30% of cancers (National Breast Ovarian Cancer Centre, 2010). Nevertheless, the diagnosis of DCIS is included in these calculations and accounts for much of the allegedly over-diagnosed malignancies. Concerns of over diagnosis One of the criticisms of breast cancer-screening programmes is that a proportion of cancers detected through screening mammography may have been indolent and may never have presented clinically during the woman's lifetime, had they not been detected by screening. To the extent that these women face the morbidity and anxiety associated with the diagnosis and treatment of breast cancer, the diagnosis of these cancers is regarded as one of the negative consequences of screening. women with a diagnosis of DCIS are at 10 times greater risk for the future development of invasive breast cancer that the assessment of microcalcifications leads to the detection of a significant number of biologically significant invasive cancers and preferentially detects higher grades of DCIS ut also, since in subsequent rounds the radiologists have access to the prior images taken at preceding rounds, they are in a better position to detect true interval changes. Consequently stable microcalcifications, likely to be benign, are apt not to be recalled for assessment. Conclusions The assessment of screen-detected microcalcifications represents an important opportunity to diagnose DCIS and biologically significant invasive breast cancer at an early stage
In-text: (Farshid et al. 1669-1675)
Your Bibliography: Farshid, G et al. "Independent Predictors Of Breast Malignancy In Screen-Detected Microcalcifications: Biopsy Results In 2545 Cases." British Journal of Cancer 105.11 (2011): 1669-1675. Web. 15 Mar. 2020.
Microcalcifications occur in 30–50% of breast cancer cases and constitute one of the most infortunately the precision of mammography, expressed as its positive predictive value TP/(TP+FP), where TP is the number of true positives and FP is the number of false positives, varies from 15–30% ,  and 10–30% of breast cancers may be missed. Therefore, double reading is recommended , in order to achieve increased sensitivity of mammography mportant diagnostic markers in both benign and malignant lesions of the breast , .A number of researchers have attempted to develop feature extraction and classification techniques for the detection and characterization of microcalcifications , , , , , , , , , , , , , , , , , , , , , . Many investigators have developed computerized methods to distinguish between malignant and benign clusters based on morphological-spatial features of individual calcifications or cluster as a whole , , , , , , ,  while others have introduced texture features in their studies , , , , .he American College of Radiology (ACR) ,  has developed the Breast Imaging Reporting and Data System (BI-RADS) in an attempt to create a unique and common lexicon for use in reporting findings on mammograms and a common language for unambiguously describing the level of suspicion and recommended follow-up for a mammographic lesion. The BIRADS lexicon describes seven categories: Category 0 recommends additional imaging (spot compression, special mammographic views or ultrasound), Category 1 corresponds to a negative mammogram, Category 2 features benign findings, Category 3 characterizes probably benign finding and a 6-month follow-up is suggested, Category 4 suggests biopsy for patients with lesions classified as suspicious, Category 5 refers to lesions highly suggestive of malignancy that must be excised and finally Category 6 represents histologically proven malignancy and the patient must follow appropriate therapy.espite ACR reports that BIRADS category 3 lesions have low probability of malignancy (less than 2%) and suggests short-interval follow-ups , , , , biopsies are performed occasionally for BIRADS 3 lesions, and this topic has been a matter of considerable debate , . Biopsy is usually performed in It is important to note that single reading with CAD has been proven to be less effective than double reading by radiologists, as there is no difference in cancer detection rates but double reading with arbitration shows a significantly better recall rate. Additionally, CAD increases the biopsy rate of healthy women ,
In-text: (Giannakopoulou et al. 853-859)
Your Bibliography: Giannakopoulou, Georgia et al. "Downgrading BIRADS 3 To BIRADS 2 Category Using A Computer-Aided Microcalcification Analysis And Risk Assessment System For Early Breast Cancer." Computers in Biology and Medicine 40.11-12 (2010): 853-859. Web.
One of the keys to early detection and treatment is a mammogram, an x-ray of the breast. A screening mammogram is for women who do not appear to have breast problems. he PeerView feature of the Hologic R2 CAD system outlines the central density of a detected mass or distortion so the radiologist can evaluate the margin, shape and interior characteristics. Detected microcalcifications are highlighted so the radiologist can determine the number, shape and distribution. Screening mammography efficiency is enhanced when sensitivity is high and the: recall rate is w. Double reading, though used by few practices in the United States, is more commonly used in European screening programs for increasing sensitivity. CAD has become increasingly popular as an alternative way to increase sensitivity, since double-reading is time-consuming and because of a shortage of radiologists.
In-text: (Hochfelder 16-18)
Your Bibliography: Hochfelder, Barry. "IMPROVING RESULTS IN SCREENING MAMMOGRAMS." Advanced Imaging 23(4) (2008): 16-18. Web. 4 Feb. 2020.
see print out
In-text: (Kim et al. 471-478)
Your Bibliography: Kim, Kwan Il et al. "Changing Patterns Of Microcalcification On Screening Mammography For Prediction Of Breast Cancer." Breast Cancer 23.3 (2015): 471-478. Web.
Missed abnormailities We advocate the use of checklists for different types of radiologic examinations, depending on the body part imaged, to facilitate active search patterns to decrease the incidence of this type of error [5–11]. Type 2 errors, the third most common type (9%), involved errors due to faulty interpretation, where the finding is seen but attributed to the wrong cause. A contributing factor that we noticed was the lack of expertise in the interpreting radiologist (e.g., fellowship-trained vs non-fellowship-trained radiologists and the number of years of clinical practice). To decrease these errors, the radiologists must be active in maintaining current knowledge through the literature, subspecialty training, and continuing medical education courses. Detailed analysis of diagnostic errors in radiology should be performed according to the classification used in this study. The lessons learned should be shared with colleagues at the departmental monthly difficult case conferences. type 12 errors 6% overreliance on the prior radiology report. the influence that one radiologist can exert on another called alliterative errors. as human being s we have a tendanct y to be aggreablre with our peers. In conclusion, nearly one third of delayed diagnoses in radiology were not recognized on subsequent radiologic examinations. Underreading, satisfaction of search, faulty reasoning, and location were the most common types of errors. Seven percent of missed findings were found in the “corner” of the film, and 13% were serendipitous. It is important to analyze and understand diagnostic errors in radiology so that steps can be implemented to decrease future mistakes. Read More: https://www.ajronline.org/doi/full/10.2214/AJR.13.11493 Read More: https://www.ajronline.org/doi/full/10.2214/AJR.13.11493 Read More: https://www.ajronline.org/doi/full/10.2214/AJR.13.11493
In-text: (Kim and Mansfield 465-470)
Your Bibliography: Kim, Young W., and Liem T. Mansfield. "Fool Me Twice: Delayed Diagnoses In Radiology With Emphasis On Perpetuated Errors." American Journal of Roentgenology 202.3 (2014): 465-470. Web. 20 Jan. 2018.
Renfrew classification This classification was proposed by Renfrew et al. 5 in 1992, and at the time of writing (July 2016) remains the most widely accepted classification. Renfrew et al. have proposed the following classification system 1,2,4: •type 1: complacency◦finding identified but attributed to wrong cause •type 2: faulty reasoning◦finding identified as abnormal but attributed to wrong cause •type 3: lack of knowledge◦finding identified but attributed to wrong cause due to lack of knowledge •type 4: under-reading◦missed abnormality that was appreciable in retrospect •type 5: poor communication◦finding identified as abnormal but poor communication to relevant clinician •type 6: technique◦abnormality was not identifiable (even in retrospect) secondary to poor technique •type 7: prior examination◦failure to review previous imaging results in missed finding •type 8: history◦finding missed due to incomplete clinical information •type 9: location◦finding missed because it was outside of region of interest •type 10: satisfaction of search◦failure to find a subsequent abnormality after the initial abnormality was detected •type 11: complication◦most often of interventional procedures •type 12: satisfaction of report◦over-reliance on the prior report Brook classification Brook et al. proposed the following classification as an alternative to the Renfrew classification which takes more than human error into account 3: •latent errors◦'in-built' system or technical faults that predispose to errors •active failures or human error◦diagnostic errors and misinterpretation ◦complications from procedures ◦can involved more than person or be secondary to latent errors •external causes◦beyond the control of the radiologist (e.g. power failures, quenches, etc.) •customer causes◦related to the patient and non-radiology staff (e.g. complying with instructions, unfamiliarity with procedure) References . Edit article Share article Twitter Facebook Pinterest Google plus Tumblr Email . Article information Support Radiopaedia and see fewer ads
In-text: (Knipe and Babu)
Your Bibliography: Knipe, Henry, and Varun Babu. "Errors In Diagnostic Radiology | Radiology Reference Article | Radiopaedia.Org." Radiopaedia.org. N.p., 2018. Web. 17 Feb. 2018.
0.29), final assessment categories (κ: 0.27), and moderate in evaluation of associated findings (κ: 0.48) by using BI-RADS lexicon. It was higher for the assessment of milk of calcium and round microcalcifications than other typically benign microcalcifications, and for fine linear or fine linear branching microcalifications than other probably malignant calcifications. There was a fair interobserver agreement (κ: 0.30) in the description of the morphologic type of microcalcifications according to Le Gal's classification. Discussions and conclusion: In our study, both BI-RADS lexicon and Le Gal's classification did not succeed expectedly in reducing the ambiguity in assessment of breast microcalcifications. Further studies and perhaps development of new methods are required to improve accuracy and standardization in mammographic interpretation. Between 30% and 50% of nonpalpable breast cancers present themselves as microcalcifications alone , Since there is a considerable overlap in mammographic appearances of benign changes and malignant disease, a careful analysis of microcalcifications should be performed. Many radiologic criteria have been introduced to differentiate malignant from benign calcifications. Nevertheless, none of them could be applied successfully. In 1984, Le Gal et al. evaluated microcalcifications discovered by mammography with histological verification according to their morphology . A classification of five types was made. This classification has not been used widely. And in 1993, American College of Radiology (ACR) developed Breast Imaging Reporting and Data System (BI-RADS) to standardize mammographic reporting . Our study was performed t In conclusion, both BI-RADS lexicon and Le Gal's classification did not succeed expectedly in reducing the ambiguity in assessment of breast calcifications, but they are useful in standardization of the mammography reports. Further studies and augmentation of existing methods or even development of new ones are required to evaluate microcalcifications in order to avoid unnecessary biopsies and detect the breast cancer earlier. Currently, mammography is the most effective screening method in the detection of early breast cancer. Microcalcifications constitute one of the earliest presenting features of carcinoma, and can be detected mainly with mammography. Since microcalcifications can also be observed in benign diseases of the breast such as fibrocystic changes, correlation is less specific in detection of breast cancer. Many radiologic criteria have been proposed to differentiate benign and malignant microcalcifications.
In-text: (M, FB and Ariyūrek 153-154)
Your Bibliography: M, Gülsün, Demirkazik FB, and Ariyūrek. "Evaluation Of Breast Microcalcifications According To Breast Imaging Reporting And Data System Criteria And Le Gal's Classification." Clinical Imaging 28.2 (2004): 153-154. Web.
The introduction of population-based breast cancer screening and implementation of digital mammography has led to an increased incidence of ductal carcinoma in situ (DCIS) without a decrease in incidence of advanced breast cancer. This suggests DCIS overdiagnosis exists. Currently, most women with low-grade DCIS are being treated with surgery aiming for radical margins, and, if breast-conserving therapy is given, radiotherapy forms part of this treatment. We hypothesize that asymptomatic, low-grade DCIS can safely be managed by watchful waiting, because these lesions harbor a low risk of progression to invasive breast cancer, and if this progression occurs, this will be low-grade and hormone
In-text: ("Management Of Screen Detected Cancer" S165-S167)
Your Bibliography: "Management Of Screen Detected Cancer." European Journal of Cancer 50 (2014): S165-S167. Web. 16 Feb. 2020.
Standardisation of the classification of breast imaging reports will improve communication between the referrer and the radiologist and avoid ambiguity, which may otherwise lead to mismanagement of patients. Following wide consultation, the Royal College of Radiologists Breast Group has produced a scoring system for the classification of breast imaging. This will facilitate audit and the development of nationally agreed standards for the investigation of women with breast disease. This five-point system is as follows: 1, normal; 2, benign findings; 3, indeterminate/probably benign findings; 4, findings suspicious of malignancy; 5, findings highly suspicious of malignancy. It is recommended that this be used in the reporting of all breast imaging examinations in the UK. Classification The level of suspicion for malignancy on imaging should be categorised from 1–5 as follows: 1. normal; there is no significant imaging abnormality. 2. Benign findings; the imaging findings are benign, and further investigation purely on the basis of the imaging findings is not indicated. 3. Indeterminate/probably benign findings; there is a small risk of malignancy, and further investigation is indicated. 4. Findings suspicious of malignancy; there is a moderate risk of malignancy and further investigation is indicated. 5. Findings highly suspicious of malignancy; there is a high risk of malignancy and further investigation is indicated. Category 1 mammographic findings include incidental involutional and other benign breast changes that are commonly seen on normal screening mammograms and are not related to symptoms in women attending diagnostic clinics. These changes include bilateral benign powdery microcalcification, benign secretory microcalcification, “popcorn” calcification in fibroadenomas, and small, well-defined, soft-tissue nodules less than 5 mm in size. Category 2 findings include clearly benign lesions (for example, simple cysts) that are, or may be, responsible for the patient's symptoms or signs or are larger or more widely distributed than are commonly seen. The presence of any atypical or suspicious features should result in a category 3 or higher score. The age of the patient may be taken into account when classifying solid masses with benign imaging features. Primary breast malignancy is rare below the age of 25 years and there is evidence that a solid mass with the typical imaging and clinical features of a fibroadenoma in a woman under 25 years does not require needle biopsy or follow up.10 Units following this practice should classify such lesions as imaging category 2 (other units should classify them as category 3). Solid masses with benign features found in women aged 25 years and over should be classified as category 3. Such lesions require needle biopsy to establish a diagnosis and exclude malignancy. Prefixes to be used: Mammography –M; Ultrasound – U; MRI – MRI. These were arrived at following consideration of the feedback from group members. There were a number of objections to the commonly used “R” prefix in view of possible confusion with “right”. Both “I” and “O” for overall imaging opinion (see below) were not popular as it was felt they could be confused with one and zero, respectively. Each breast should be classified according to its most suspicious lesion and this classification should be stated in the report summary, e.g., “Left breast M2” or “Right breast U3”. In addition, an individual classification may be applied to separate significant lesions within the same breast in the body of the report. The findings should be correlated with the clinical symptoms or signs, if present, and this should be stated in the report. Further investigation Further investigation may include imaging [such as mammography, ultrasound, or magnetic resonance imaging (MRI)] and needle sampling. In exceptional cases open biopsy may be required to establish a definitive diagnosis or a follow-up examination may be appropriate, e.g., to re-examine a small, enhancing lesion found on MRI at a different stage of the menstrual cycle. Overall imaging opinion An overall imaging opinion may be given, summarizing the results of imaging investigations performed up to the date of reporting, and should be based on the most suspicious finding in each breast. The overall imaging opinion may be changed subsequently by the results of further investigations. The overall imaging opinion should also use the five-point scale. Management Patient management should be based on the principle of the “triple test,” i.e., clinical examination, imaging, and needle sampling (core biopsy or fine-needle aspiration for cytology). If both clinical examination and imaging are normal or unequivocally benign then needle sampling is not required. If the clinical findings are uncertain or suspicious and/or the overall imaging findings are 3, 4 or 5, percutaneous needle sampling is indicated. Comparison with other current systems It should be noted that the descriptions of the categories broadly mirror those of the BI-RADS and Australian NBCC systems. The main differences are in the use of category 3, where the RCRBG classification lies between the BI-RADS “probably benign” definition of lesions with a less than 2% risk of malignancy and the NBCC “indeterminate/equivocal” definition, which implies a higher risk of malignancy. The three systems are summarised in Table 1.
In-text: (Maxwell et al. 624-627)
Your Bibliography: Maxwell, A.J. et al. "The Royal College Of Radiologists Breast Group Breast Imaging Classification." Clinical Radiology 64.6 (2009): 624-627. Web. 11 Feb. 2018.
Early detection of breast cancer through mammography reduces mortality and its success is said to be dependent upon the production of consistently high quality images.2, 3 It has been estimated that 10%–30% of cancers are missed through poor quality mammograms,4 with one explanation being inadequate compression force. Literature therefore speculates that visual image quality (IQ) and compression force levels may be directly related.5, 6, 7
In-text: (Mercer et al. 363-365)
Your Bibliography: Mercer, C.E. et al. "Does An Increase In Compression Force Really Improve Visual Image Quality In Mammography? – An Initial Investigation." Radiography 19.4 (2013): 363-365. Web. 15 Mar. 2020.
In-text: (Mercer et al. 200-206)
Your Bibliography: Mercer, Claire E. et al. "Practitioner Compression Force Variation In Mammography: A 6-Year Study." Radiography 19.3 (2013): 200-206. Web.
As NHSBSP requires serial imaging to occur at regular intervals, with images reviewed to assess for subtle changes,10 if compression force variability between practitioners exists then comparison between images over time may become more challenging. Our study establishes that the amount of breast compression force seems highly dependent upon practitioner rather than client. This has implications for radiation dose and image quality consistency for sequential screening within the National Health Service Breast Screening Programme together within the symptomatic setting. have established that compression force and breast thicknesses can fluctuate for the same client when they are imaged by different practitioners. Implications from this can result in variations in mean breast glandular dose between 3 yearly screening events. The possibility exists for variations to occur in image quality
In-text: (Mercer et al. 200-206)
Your Bibliography: Mercer, Claire E. et al. "Practitioner Compression Force Variation In Mammography: A 6-Year Study." Radiography 19.3 (2013): 200-206. Web. 16 Mar. 2020.
Digital spot mammography using an add-on upright unit: diagnostic application in daily practice
In-text: (Mesurolle et al. 61-65)
Your Bibliography: Mesurolle, Benoı̂t et al. "Digital Spot Mammography Using An Add-On Upright Unit: Diagnostic Application In Daily Practice." European Journal of Radiology 51.1 (2004): 61-65. Web.
s a breast malignancy that is characterized by the proliferation of malignant ductal epithelial cells without evidence of invasion through the basement membrane. The incidence of DCIS has risen dramatically as the use of screening mammography has increased; between 1981 and 2001, the age-adjusted incidence rate of DCIS increased from 2.4 to 27.7 per 100,000 women.17 Mammography is the primary tool for detecting DCIS, but it has limitations especially in women with dense breast tissue. The most common mammographic finding in DCIS is the presence of microcalcifications, but a low-grade lesion without necrosis is less likely to manifest as calcifications than either an intermediate- or a high-grade lesion. Other mammographic findings might include a mass or architectural distortion. In the present study, the overall sensitivity of mammography for detection of DCIS in asymptomatic women was 84% (182/217), and was similar to previous studies.7, 18, 19 The sensitivity of mammography for detection of the non-calcified DCIS was 50% (36/71), whereas that of the calcified DCIS was 100% (146/146).
In-text: (Mun et al. e27-e35)
Your Bibliography: Mun, H.S. et al. "Screening-Detected Calcified And Non-Calcified Ductal Carcinoma In Situ: Differences In The Imaging And Histopathological Features." Clinical Radiology 68.1 (2013): e27-e35. Web. 16 Feb. 2020.
It is difficult to distinguish between benign and malignant microcalcifications from their mammographic appearance alone (figure 6). Cranio-caudal and lateral magnification/spot compression views aid further characterisation and help in the assessment of the probability of malignancy. There is conflicting evidence on the value of tomosynthesis for both detection and characterisation of calcification, so this should not be routinely used until further evidence is available. 44,45 Magnification views are also useful in defining the extent of ductal carcinoma in situ (DCIS) if conservation surgery is being considered. Ultrasound assessment of micro-calcification may identify focal areas of altered echotexture, indicating possible invasive foci within DCIS. 46,47,48 Microcalcifications with definitively benign features do not require needle biopsy. If there is thought to be any risk of malignancy, image guided core biopsy with specimen radiography should be performed. 6 Representative microcalcification must be demonstrated in the core specimens on specimen radiography. 6,7 If it is not, the procedure should be repeated. Ideally, this repeat biopsy should be by means of VACB. Otherwise a diagnostic surgical biopsy should be performed, unless malignancy has been diagnosed within cores that contain no calcification. Pathology request forms should document the presence or absence of representative calcification and the pathologist should be able to access the specimen x-rays. The identification of microcalcification on histology is not in itself a reliable indicator of adequate sampling. Histological microcalcification is a common incidental finding and may be present when there is no calcification visible on mammography. Surgical biopsy is unnecessary when histology shows a definitively benign cause for calcifications in core specimens and when specimen radiography confirms the presence of calcifications clearly representative of those considered suspicious on mammography. A marker with a metal component may be useful to mark the site after needle biopsy. This is especially the case for: Clinical guidance for breast cancer screening assessment 17 small lesions which might be removed by biopsy lesions which could be difficult to identify if subsequent excision biopsy is required when multiple areas have been biopsied to mark the relevant sites Multiple foci and extensive microcalcification Careful consideration needs to be given to cases with multiple foci of abnormality or extensive microcalcification. It is important to ensure that adequate sampling is undertaken to guide both the MDT and the patient in their decisions about surgery. It is important that there is enough evidence to justify rec
In-text: (NHS Cancer Screening Programmes)
Your Bibliography: NHS Cancer Screening Programmes. Clinical Guidance For Breast Cancer Screening Assessment. NHSBSP Publication 49. London: NHSBSP, 2016. Print.
Your Bibliography: NHSBSP. Quality Assurance Guidelines For Breast Cancer Screening Radiology. Sheffield: NHS Cancer Screening Programmes, 2011. Print.
Your Bibliography: NHSBSP. Quality Assurance Guidelines For Breast Cancer Screening Radiology. Sheffield: NHS Cancer Screening Programmes, 2011. Print.
see print out
In-text: (Peters, Jones and Daniels 32-37)
Your Bibliography: Peters, Gudrun, Catherine M Jones, and Katie Daniels. "Why Is Microcalcification Missed On Mammography?." Journal of Medical Imaging and Radiation Oncology 57.1 (2012): 32-37. Web. 4 Feb. 2020.
Ductal carcinoma in situ (objective 1b) The number of in situ carcinomas expected includes ductal carcinoma in situ (DCIS), lobular carcinoma in situ and microinvasive disease. Detection of DCIS at screening, particularly high-grade 2.3.1 Screen reading specificity (objective 3) As shown in Table 2, the minimum standard for the recall of women for further assessment is less than 10% of women screened (achievable standard less than 7%) for their prevalent screen. For subsequent screens it is less than 7% (achievable standard less than 5%). Where particularly high cancer detection rates are found it may not be possible to reduce referral for assessment rates greatly. These standards relate to women from 50 up to their 71st birthday called or recalled for screening as part of the NHSBSP. This is a measure of radiological screen reading specificity and it excludes technical recalls. All readers are expected to attain the minimum standard of <10% recall. types, is assumed to be a factor contributing to long-term reduction in mortality although no firm scientific evidence currently exists to confirm this. The majority of DCIS detected at screening is of the high-risk type. It is believed to be good practice to detect and treat DCIS and for this reason the minimum standard is set at ≥0.5 per 1000 for prevalent screens and ≥0.6 per 1000 for incident screens. DCIS numbers include in situ carcinoma and in situ carcinoma with possible or definite microinvasion. This is based on 10% of the total target cancer detection rate. No achievable standard or upper limit has been set because there is evidence that hig
In-text: (Public Health England)
Your Bibliography: Public Health England. NHS Breast Screening Programme Clinical Guidance For Breast Cancer Screening Assessment. London: N.p., 2016. Print.
Your Bibliography: Schoen, Marc. "Boosting Decision Making And Performance Under Pressure." Psychology Today. N.p., 2018. Web. 25 Mar. 2018.
see print out
In-text: (Spangler et al. 320-324)
Your Bibliography: Spangler, M. Lee et al. "Detection And Classification Of Calcifications On Digital Breast Tomosynthesis And 2D Digital Mammography: A Comparison." American Journal of Roentgenology 196.2 (2011): 320-324. Web.
The introduction of mammographic screening has been associated with a large rise in the apparent incidence of ductal carcinoma in situ (DCIS). Approximately 20% of screen-detected cancers in the National Health Service Breast Screening Programme (NHSBSP) are in the form of DCIS.1 The proportion of screen-detected cancers that are detected as DCIS is also associated with age; the younger the screening population, the higher the proportion of DCIS detected. Since the beginning of the NHSBSP there has been a great deal of debate concerning the value for the patient of detection of DCIS;2,3 some have argued that detection of this stage of breast carcinoma often represents overdiagnosis (detecting disease which would never become clinically apparent or threaten life) and causes anxiety and physical harm (unnecessary surgery). Others suggest that detection of DCIS is important because they believe that it is an obligate precursor of invasive carcinoma. Importantly The NHS Breast Screening Programme (NHSBSP) diagnosed 3159 non-invasive breast cancers in women of all ages during the period 2005–2006.50 Prior to the introduction of the screening programme, only 295 cases of ductal carcinoma in situ (DCIS) were recorded in England and Wales in the age band 50–64.51 The major reason for this marked increase is that the trademark characteristic of microcalcification in the majority of DCIS cases is easily visualised radiologically on a mammogram. Consequently, with the introduction of breast screening, the incidence of this type of cancer has been increasing rapidly, and DCIS now accounts for about 20% of all cancers detected by the NHSBSP the sloane project The audit aims to collect data from patients in the UK who have noninvasive cancer or atypical hyperplasia detected by screening in the NHSBSP.
In-text: (Uncertainties In The Management Of Screen-Detected Ductal Carcinoma In Situ)
Your Bibliography: Uncertainties In The Management Of Screen-Detected Ductal Carcinoma In Situ. Sheffield, UK: NHS Cancer Screening Programmes, 2008. Print.
Ductal carcinoma in situ (DCIS) now represents 20–25% of all ‘breast cancers’ consequent upon detection by population-based breast cancer screening programmes. Difficulty in discerning harmless lesions from potentially invasive ones can lead to overtreatment of this condition in many patients. To counter overtreatment and to transform clinical practice, a global, comprehensive and multidisciplinary collaboration is required. Review Article Open Access Published: 09 July 2019 Ductal carcinoma in situ: to treat or not to treat, that is the question Maartje van Seijen, Esther H. Lips, Alastair M. Thompson, Serena Nik-Zainal, Andrew Futreal, E. Shelley Hwang, Ellen Verschuur, Joanna Lane, Jos Jonkers, Daniel W. Rea, Jelle Wesseling & on behalf of the PRECISION team British Journal of Cancer volume 121, pages285–292(2019)Cite this article 8395 Accesses 1 Citations 13 Altmetric Metricsdetails Abstract Ductal carcinoma in situ (DCIS) now represents 20–25% of all ‘breast cancers’ consequent upon detection by population-based breast cancer screening programmes. Currently, all DCIS lesions are treated, and treatment comprises either mastectomy or breast-conserving surgery supplemented with radiotherapy. However, most DCIS lesions remain indolent. Difficulty in discerning harmless lesions from potentially invasive ones can lead to overtreatment of this condition in many patients. To counter overtreatment and to transform clinical practice, a global, comprehensive and multidisciplinary collaboration is required. Here we review the incidence of DCIS, the perception of risk for developing invasive breast cancer, the current treatment options and the known molecular aspects of progression. Further research is needed to gain new insights for improved diagnosis and management of DCIS, and this is integrated in the PRECISION (PREvent ductal Carcinoma In Situ Invasive Overtreatment Now) initiative. This international effort will seek to determine which DCISs require treatment and prevent the consequences of overtreatment on the lives of many women affected by DCIS. Background Ductal carcinoma in situ (DCIS) was rarely diagnosed before the advent of breast screening, yet it now accounts for 25% of detected ‘breast cancers’. Over 60,000 women are diagnosed with DCIS each year in the USA,1,2 >7000 in the DCIS is often regarded as an early form of (Stage 0) breast cancer However, as only 75% of all DCIS lesions contain calcifications,15 a substantial percentage of DCIS lesions will not be detected by mammography, implying that some lesions might be mammographically occult or that the diameter of the area containing calcifications underestimates the extent of DCIS.16,17 This suggests that DCIS might be left behind following breast-conserving treatment in a proportion of cases.Because both diagnosis and treatment of the condition can have a profound psychosocial impact on a woman’s life, adequate perception of risk by both health professionals and patients is important in determining the appropriate modalities of treatment. Despite an excellent prognosis and normal life-expectancy, women diagnosed with DCIS experience stress and anxiety.29
In-text: (van Seijen et al. 285-292)
Your Bibliography: van Seijen, Maartje et al. "Ductal Carcinoma In Situ: To Treat Or Not To Treat, That Is The Question." British Journal of Cancer 121.4 (2019): 285-292. Web. 16 Feb. 2020.
In-text: (Wilkinson, Thomas and Sharma 20160594)
Your Bibliography: Wilkinson, Louise, Val Thomas, and Nisha Sharma. "Microcalcification On Mammography: Approaches To Interpretation And Biopsy." The British Journal of Radiology 90.1069 (2017): 20160594. Web. 1 Mar. 2020.
see print copy
In-text: (Wilkinson, Thomas and Sharma 20160594)
Your Bibliography: Wilkinson, Louise, Val Thomas, and Nisha Sharma. "Microcalcification On Mammography: Approaches To Interpretation And Biopsy." The British Journal of Radiology 90.1069 (2017): 20160594. Web. 4 Feb. 2020.
several studies, researchers have attempted to correlate the mammographic appearance of microcalcifications with the pathologic classification of DCIS. 2-7 However, the lack of consensus on the histologic classification of DCIS makes it difficult to evaluate and compare these studies. The best mammographic-histologic correlation appears to be between the pattern of microcalcification and cytonuclear differentiation. 4 In poorly differentiated DCIS, the microcalcifications are frequently linear and branching (casting), or coarse granular, and often occur in areas of necrosis, whereas in well-differentiated DCIS, the presence of multiple clusters of fine granular (cotton ball) microcalcifications are characteristic. 2,5 Moderately differentiated DCIS is most commonly associated with a cluster of heterogeneous granular (crushed stone) calcifications, although this appearance can be associated with any histologic type. 2 The presence of comedo necrosis, another potential prognostic marker The presence of comedo necrosis, another potential prognostic marker of DCIS, 1 has also been correlated with mammographic findings. 6 DCIS with necrosis is more likely to contain calcifications that are linear and branching with a ductal distribution. Mammographic images of DCIS without comedo necrosis are less likely to contain microcalcifications and are more likely either to be normal or to contain noncalcified mammographic abnormalities. When calcifications are present, they tend to be fine granular in appearance and are often visualized in association with benign disease. Although these studies have helped improve our understanding of the mammographic appearance of DCIS, the pathology often cannot be accurately predicted by imaging because of considerable heterogeneity of mammographic findings of DCIS. 6'7 Although it is now less commonly seen, patients with DCIS may still
In-text: (Wright and Shumak 113-125)
Your Bibliography: Wright, Barbara, and Rene Shumak. "Part II. Medical Imaging Of Ductal Carcinoma In Situ." Current Problems in Cancer 24.3 (2000): 113-125. Web.
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