Storage phosphor direct magnification mammography in comparison with conventional screen-film mammography--a phantom study

Contact mammography with current photostimulable storage phosphors is hampered by its low spatial resolution. Detail visualization can be improved by geometric magnification radiography which enlarges small details to exceed inherent image noise. This study compares storage phosphor mammography using a dedicated direct magnification system with state-of-the-art conventional screen-film mammography. Storage phosphor direct magnification survey views (1.7x) and spot views (4x) were obtained with a prototype mammography unit providing focal spot sizes of 120-40 microns. Conventional technique screen-film survey views (1.1x) and spot views (1.8x) served as comparison. A contrast detail study and a receiver operating characteristic (ROC) analysis using an anthropomorphic breast phantom with superimposed microcalcifications was performed. Contrast detail resolution in the digital and conventional survey views were equivalent. For the spot views, contrast detail resolution was significantly higher with the digital technique (p < 0.001). ROC analysis of 400 observations demonstrated a significantly higher performance (p < 0.001) with digital images versus conventional screen-film mammograms. The area under the ROC curve (Az) in the digital survey views was 0.76 +/- 0.07 versus 0.59 +/- 0.02 in the conventional technique. In digital spot views, Az was 0.82 +/- 0.07 as compared with 0.66 +/- 0.04 in the conventional spot views. These results suggest that storage phosphor digital mammography in conjunction with direct geometric magnification technique may be superior to conventional screen-film mammography in the detection of microcalcifications.     

Improvement of detectability of microcalcifications by magnification digital mammography

Our aim in this study was to evaluate the potential utility of magnification mammography with a CR system by investigating the basic imaging parameters and detectability of microcalcifications in comparison with those of conventional screen-film systems. The basic imaging parameters were evaluated by measuring scatter fraction, modulation transfer function (MTF), Wiener spectrum, and incident dose for the various magnification factors. The detection of simulated microcalcifications in radiographs of a mammographic phantom and breast specimens were evaluated subjectively and quantitatively for screen-film and CR techniques with various magnification factors. The scatter fraction of digital magnification mammography decreased with increasing magnification factor. MTF of magnification digital mammography improved with increasing magnification factor. The detectability of microcalcifications with the CR system was significantly improved by magnification technique. From the above results, it is expected that the use of magnification mammography with a CR system will improve the detectability of microcalcification.     

Digital optical card. A promising technology for documentation and communication of images

PURPOSE: To assess a patient-oriented digital optical card (OC) for documentation and communication of images using the analysis of breast microcalcifications to illustrate its resolution power. METHODS: Fifty film mammograms with histologically proved clustered microcalcifications were digitized using a 5 lp/mm CCD-scanner. A region of interest containing the cluster was selected for documentation on an OC as an overview OC-image and as a magnified OC-image (5 lp/mm). The shape (spherical/nonspherical) as well as the total number of microcalcifications were quantitatively analyzed by 2 radiologists. RESULTS: The detection rate for total number of overall and spherical microcalcifications using digital media was significantly reduced (p < 0.01) compared to analog mammography. There were no significant differences in the detection rate of nonspherical microcalcifications between film mammograms (100%) and magnified section OC-images (92.7%). The overview OC-image revealed 72% of those calcifications (p < 0.01). CONCLUSION: According to our results, this technology is not appropriate for diagnosis of breast microcalcifications, but may be a promising communication digital medium for transmitting an image/report unit to referring physicians.     

Image compression in digital mammography: effects on computerized detection of subtle microcalcifications

Our previous receiver operating characteristic (ROC) study indicated that the detection accuracy of microcalcifications by radiologists is significantly reduced if mammograms are digitized at 0.1 mm x 0.1 mm. Our recent study also showed that detection accuracy by computer decreases as the pixel size increases from 0.035 mm x 0.035 mm. It is evident that very large matrix sizes have to be used for digitizing mammograms in order to preserve the information in the image. Efficient compression techniques will be needed to facilitate communication and archiving of digital mammograms. In this study, we evaluated two compression techniques: full frame discrete cosine transform (DCT) with entropy coding and Laplacian pyramid hierarchical coding (LPHC). The dependence of their efficiency on the compression parameters was investigated. The techniques were compared in terms of the trade-off between the bit rate and the detection accuracy of subtle microcalcifications by an automated detection algorithm. The mean-square errors in the reconstructed images were determined and the visual quality of the error images was examined. It was found that with the LPHC method, the highest compression ratio achieved without a significant degradation in the detectability was 3.6:1. The full frame DCT method with entropy coding provided a higher compression efficiency of 9.6:1 at comparable detection accuracy. The mean-square errors did not correlate with the detection accuracy of the microcalcifications. This study demonstrated the importance of determining the quality of the decompressed images by the specific requirements of the task for which the decompressed images are to be used. Further investigation is needed for selection of optimal compression technique for digital mammograms.     

Estimating risk associated with care in alternative settings: deterioration among children hospitalized

The incidence of ductal carcinoma in situ (DCIS) has increased with the widespread use of screening mammography. DCIS is often suspected when clustered microcalcifications are evidenced on routinely performed mammography. High quality mammographies are required and should be completed with magnification views. Mammographic--pathologic correlations are described according to the new classifications as well as unusual forms of presentation on mammography. Early contrast enhancement in DCIS on dynamic MRI is reported and seems to be related with angiogenesis. A wire localization procedure of non-palpable lesions has to be performed and per-operative specimen radiography is mandatory. Stereotaxic large core needle biopsy is a valuable alternative to surgical biopsy but a multidisciplinary team approach is necessary and follow-up is recommended if no excisional biopsy is done. Quality in the management of DCIS depends on the coherence of the "multidisciplinary team".     

Assessment of image quality and total performance in Norwegian mammography laboratories. Findings in a national survey based on different phantoms and ROC methodology

PURPOSE: To assess the image quality at different mammography laboratories. MATERIAL AND METHODS: Two commercial mammographic test phantoms and one phantom based on excised mammary tissue were used in an assessment of the imaging chain and total performance at 45 Norwegian mammography laboratories. The breast-tissue phantom was used for a receiver operating characteristics (ROC) analysis. This was carried out by putting overlays with identifiable regions (some of which contained a cluster of simulated calcifications) on top of the mammary tissue, and then having a radiologist report the confidence of a finding for each region. RESULTS AND CONCLUSION: The areas under the ROC curves were in general high. In nearly all the laboratories, performance was improved when a magnification technique was applied. There were wide variations among the laboratories in total performance as measured by the area under the ROC curve, and also in the physical parameters derived by means of the commercial phantoms. In general, a good ROC performance was associated with a good physical performance in the imaging chain.     

Computerized analysis of mammographic microcalcifications in morphological and texture feature spaces

We are developing computerized feature extraction and classification methods to analyze malignant and benign microcalcifications on digitized mammograms. Morphological features that described the size, contrast, and shape of microcalcifications and their variations within a cluster were designed to characterize microcalcifications segmented from the mammographic background. Texture features were derived from the spatial gray-level dependence (SGLD) matrices constructed at multiple distances and directions from tissue regions containing microcalcifications. A genetic algorithm (GA) based feature selection technique was used to select the best feature subset from the multi-dimensional feature spaces. The GA-based method was compared to the commonly used feature selection method based on the stepwise linear discriminant analysis (LDA) procedure. Linear discriminant classifiers using the selected features as input predictor variables were formulated for the classification task. The discriminant scores output from the classifiers were analyzed by receiver operating characteristic (ROC) methodology and the classification accuracy was quantified by the area, Az, under the ROC curve. We analyzed a data set of 145 mammographic microcalcification clusters in this study. It was found that the feature subsets selected by the GA-based method are comparable to or slightly better than those selected by the stepwise LDA method. The texture features (Az = 0.84) were more effective than morphological features (Az = 0.79) in distinguishing malignant and benign microcalcifications. The highest classification accuracy (Az = 0.89) was obtained in the combined texture and morphological feature space. The improvement was statistically significant in comparison to classification in either the morphological (p = 0.002) or the texture (p = 0.04) feature space alone. The classifier using the best feature subset from the combined feature space and an appropriate decision threshold could correctly identify 35% of the benign clusters without missing a malignant cluster. When the average discriminant score from all views of the same cluster was used for classification, the Az value increased to 0.93 and the classifier could identify 50% of the benign clusters at 100% sensitivity for malignancy. Alternatively, if the minimum discriminant score from all views of the same cluster was used, the Az value would be 0.90 and a specificity of 32% would be obtained at 100% sensitivity. The results of this study indicate the potential of using combined morphological and texture features for computer-aided classification of microcalcifications.     

Analysis of the spatial-frequency-dependent DQE of optically coupled digital mammography detectors

The effect of optical coupling efficiency on the spatial-frequency-dependent propagation of signal and noise is considered for x-ray image detectors for digital mammography in which a phosphor screen is optically coupled to a charge-coupled device (CCD) image array. For experimental purposes, optical coupling between a Gd2O2S:Tb phosphor screen and a CCD image array was provided by relay lenses. Neutral density filters were inserted between the lenses to vary the optical coupling efficiency without altering the inherent spatial resolution. The total coupling efficiency, defined as the number of electrons (e-) recorded in the CCD per x-ray interaction in the phosphor, was calculated in each case. The modulation transfer function, and the contributions to the total noise power spectrum (NPS) of x-ray quantum noise, secondary quantum noise, and inherent detector noise were measured as a function of coupling efficiency. These data were used to calculate the spatial-frequency-dependent detective quantum efficiency [DQE(f)]. The NPS due to x-ray quantum noise had a significant spatial-frequency dependence for coupling efficiencies of more than 9 e- per x-ray interaction, but little spatial-frequency dependence for coupling efficiencies of less than 2 e- per x-ray interaction. These results indicate that to preserve high spatial-frequency values of DQE(f), and to ensure that images are x-ray quantum-noise limited at high spatial frequencies, a coupling efficiency on the order of 10 e- per x-ray interaction is required.(ABSTRACT TRUNCATED AT 250 WORDS)     

Visibility of microcalcifications in computed and screen-film mammography

Due to the clinically and technically demanding nature of breast x-ray imaging, mammography still remains one of the few essentially film-based radiological imaging techniques in modern medical imaging. There are a range of possible benefits available if a practical and economical direct digital imaging technique can be introduced to routine clinical practice. There has been much debate regarding the minimum specification required for direct digital acquisition. One such direct digital system available is computed radiography (CR), which has a modest specification when compared with modern screen-film mammography (SFM) systems. This paper details two psychophysical studies in which the detection of simulated microcalcifications with CR has been directly compared to that with SFM. The first study found that under scatter-free conditions the minimum detectable size of microcalcification was approximately 130 microns for both SFM and CR. The second study found that SFM had a 4.6% higher probability of observers being able to correctly identify the shape of 350 microns diameter test details; there was no significant difference for-either larger or smaller test details. From the results of these studies it has been demonstrated that the modest specification of CR, in terms of limiting resolution, does not translate into a dramatic difference in the perception of details at the limit of detectability. When judging the imaging performance of a system it is more important to compare the signal-to-noise ratio transfer spectrum characteristics, rather than simply the modulation transfer function.     

Evaluation of a high-density scintillating glass for portal imaging

One of the main factors that limits the performance of T.V. camera-based portal imaging systems is the poor light-collection efficiency of the lens and T.V. camera. An x-ray detector that produces more light per incident x ray would help overcome this limitation. We have been evaluating a high-density (3.8 g/cm3), thick (12 mm) glass scintillator for its suitability as an x-ray detector for T.V. camera-based portal imaging systems. The light output and spatial resolution of the glass scintillator has been compared to that of a copper plate/phosphor screen detector using radiographic film and the T.V. camera of our portal imaging system. The film measurements show that the light output of the glass scintillator is 82% of that of the copper plate/phosphor screen, while the T.V. camera measurements show that this value is 48%. A theoretical model of light transport described in this paper suggests that this discrepancy is due to refraction at the glass-air interface. Our measurements of the modulation transfer function (MTF) show that the spatial resolution obtained with the glass scintillator is similar to that obtained with the copper plate phosphor screen. However, the spatial resolution obtained with the glass scintillator decreases as the angle of x-ray incidence increase; this decrease, which is not observed for the copper plate/phosphor screen detector, is due to the large thickness of the glass scintillator. Due to the limited light output and the variable spatial resolution, the transparent glass scintillator, in its current form, is not suitable for portal imaging.     

X-ray quantum limited portal imaging using amorphous silicon flat-panel arrays

We have measured the linearity, spatial resolution (MTF), noise (NPS), and signal-to-noise characteristics (DQE) of an electronic portal imaging device (EPID) based on an amorphous silicon flat-panel array. The array has a 128 x 128-pixel matrix and each pixel is 0.75 x 0.75 mm2 in dimension so the array covers an area of 96 x 96 mm2. The array acts like a large area light sensor and records the optical signals generated in a metal plate/phosphor screen x-ray detector when the detector is irradiated by a megavoltage x-ray beam. In addition, approximately 0.5% of the total signal is generated by nonoptical processes. The noise measurements show that the device is quantum noise limited with the noise power generated by the x-ray quanta being up to 100 times greater than the noise added by the external readout electronics and flat-panel light sensor itself. However, the flat-panel light sensor does reduce the spatial resolution (compared to a perfect optical sensor with infinitesimal pixel size) because of its moderate pixel size and because optical spread can occur in the transparent glues used to attach the phosphor screen to the flat-panel light sensor. The response of the sensor is very linear and does not suffer from the glare phenomenon associated with TV camera-based EPIDs--characteristics which suggest that the amorphous silicon EPID will be well suited to transit dosimetry. Nevertheless, some limitations need to be overcome before these devices can be used clinically. These include developing larger flat-panel light sensors, the elimination of "noisy" pixels with high dark signal, and improvements in the uniform sensitivity of the sensors. This last requirement is only needed for transit dosimetry applications where it would greatly simplify calibration of the device. In addition, an image acquisition scheme must be developed to eliminate artifacts created by the pulsed x-ray beam generated by linear accelerators. Despite these limitations, our studies suggest that the amorphous silicon EPIDs are very well suited to portal imaging.     

Distribution of radiolabeled monoclonal antibody MX35 F(ab')2 in tissue samples by storage phosphor screen image analysis: evaluation of antibody localization to micrometastatic disease in epithelial ovarian cancer

Our objective was to quantify the targeting of the monoclonal antibody (mAb) MX35 F(ab')2 to micrometastatic epithelial ovarian cancer. This mAb detects a Mr 95,000 glycoprotein with homogeneous distribution on 80% of ovarian tumor specimens. Six patients with minimal residual disease from an imaging trial were injected with 2 or 10 mg of 131I- and 125I-labeled mAb MX35 F(ab')2. Biopsied samples were removed at second-look laparotomy 1-5 days post-i.v. or -i.p. infusion of antibody. Serial cryostat sections were stained by indirect immunoperoxidase method for antigen distribution and exposed to storage phosphor screens for quantitative autoradiography. Coregistration of tumor histology, antigen expression, and radionuclide distribution demonstrated specific localization in micrometastatic tumor foci (50 micrometer to 1 mm) found within tissue stroma. The radiolabeled antibody uptake determined by well scintillation counts ranged between 5.2 and 223.5 x 10(-4) percentage of injected dose/g of tumor tissue for 131I. Specific localization of mAb in tumor was determined by tumor:normal tissue (fat) ratios ranging from 0.9:1 to 35.9:1 for 131I. The high resolution and linear response of the storage phosphor screen imager was used to estimate the radionuclide activity localized in each micrometastatic site. Quantitation of phosphor screen response revealed microCi/g values of 0.026-0.341 for normal tissue and 0.184-6.092 for tumor biopsies, evaluated 4 or 5 days post-antibody injection. The tumor:normal tissue (adjacent to tumor) ratios were between 1 and 4 times greater using the phosphor screen method than well counter measurements, but even larger variations of ratios up to 20:1 were observed between tumor cell foci and stromal cells within the same tissue section. This study has demonstrated that mAb MX35 F(ab')2 localizes to the micrometastatic ovarian carcinoma deposits within the peritoneal cavity. The dosimetry results suggest a therapeutic potential for this antibody in patients with minimal residual disease (<5 mm).     

Performance evaluation of a whole-body PET scanner using the NEMA protocol. National Electrical Manufacturers Association

This study evaluates the performance of the newly developed high-resolution whole-body PET scanner ECAT EXACT HR+. METHODS: The scanner consists of four rings of 72 bismuth germanate block detectors each, covering an axial field of view of 15.5 cm with a patient port of 56.2 cm. A single block detector is divided into an 8 x 8 matrix, giving a total of 32 rings with 576 detectors each. The dimensions of a single detector element are 4.39 x 4.05 x 30 mm3. The scanner is equipped with extendable tungsten septa for two-dimensional two-dimensional measurements, as well as with three 68Ge line sources for transmission scans and daily quality control. The spatial resolution, scatter fraction, count rate, sensitivity, uniformity and accuracy of the implemented correction algorithms were evaluated after the National Electrical Manufacturers Association protocol using the standard acquisition parameters. RESULTS: The transaxial resolution in the two-dimensional mode is 4.3 mm (4.4 mm) in the center and increases to 4.7 mm (4.8 mm) tangential and to 8.3 mm (8.0 mm) radial at a distance of r = 20 cm from the center. The axial slice width measured in the two-dimensional mode varies between 4.2 and 6.6 mm FWHM over the transaxial field of view. In the three-dimensional mode the average axial resolution varies between 4.1 mm FWHM in the center and 7.8 mm at r = 20 cm. The scatter fraction is 17.1% (32.5%) for a lower energy discriminator level of 350 keV. The maximum true event count rate of 263 (345) kcps was measured at an activity concentration of 142 (26.9) kBq/ml. The total system sensitivity for true events is 5.7 (27.7) cps/Bq/ml. From the uniformity measurements, we obtained a volume variance of 3.9% (5.0%) and a system variance of 1.6% (1.7%). The implemented three-dimensional scatter correction algorithm reveals very favorable properties, whereas the three-dimensional attenuation correction yields slightly inaccurate results in low- and high-density regions. CONCLUSION: The ECAT EXACT HR+ has an excellent, nearly isotropic spatial resolution, which is advantageous for brain and small animal studies. While the relatively low slice sensitivity may hamper the capability for performing fast dynamic two-dimensional studies, the scanner offers a sufficient sensitivity and count rate capacity for fully three-dimensional whole-body imaging.     

Optimally weighted wavelet transform based on supervised training for detection of microcalcifications in digital mammograms

We are developing a computer-aided diagnosis (CAD) scheme for detection of clustered microcalcifications in digital mammograms. The use of an empirically chosen wavelet and scale combination for detection of microcalcifications as an initial step of the CAD scheme has been reported by us previously. In this study, we developed a technique for optimizing the weights at individual scales in the wavelet transform to improve the performance of our CAD scheme based on the supervised learning method. In the learning process, an error function was formulated to represent the difference between a desired output and the reconstructed image obtained from weighted wavelet coefficients for a given mammogram. The error function was then minimized by modifying the weights for wavelet coefficients by means of a conjugate gradient algorithm. The Least Asymmetric Daubechies' wavelets were optimized with 297 regions of interest (ROIs) as a training set by a jackknife method. The performance of the optimally weighted wavelets was evaluated by means of receiver-operating characteristic (ROC) analysis by use of the above set of ROIs. The analysis yielded an average area under the ROC curve of 0.92, which outperforms the difference-image technique used in our existing CAD scheme, as well as the partial reconstruction method used in our previous study.     

Use of computed radiography in the study of an historic painting

The authors demonstrate the use of radiography in the investigation of an historic painting and describe the potential benefits of computed radiography compared with conventional screen-film radiography. The subject for the comparison was a 16 x 19-foot oil-on-canvas painting, Scipio Africanus Freeing Massiva, by Giovanni Battista Tiepolo. Radiographs of the painting were obtained by using a portable, industrial radiographic unit and both conventional screen-film and photostimulable phosphor plate cassettes. For this investigation, computed radiography had a number of advantages over screen-film radiography, largely due to its wider dynamic range and its capabilities for enhancing the digital images with image processing tools such as magnification, edge enhancement, colorization, and airbrushing. The ability to electronically combine images from the large painting into a single composite image file was extremely valuable, as this technique was much less cumbersome and resulted in much higher quality composite images than could be achieved with conventional radiography. An additional advantage of computed radiography includes the capability to easily archive and transmit these images in a digital format for subsequent review.     

Comparison of the diagnostic performance of high-frequency ultrasound as a first- or second-line diagnostic tool in non-palpable lesions of the breast

To compare the diagnostic performance of high-frequency ultrasound (HFU) as a first- or second-line diagnostic tool in non-palpable lesions (NPL) of the breast and to define the place of HFU in the diagnostic process, 89 women with this kind of lesion, previously detected by mammography, underwent HFU with 7.5-13 MHz transducers. The examinations were performed by two equally experienced operators of which only one (operator I) was aware of the mammographic findings. The mammographic examinations revealed the following non-palpable lesions: asymmetry-hyperdensity (17 cases), nodule (44 cases), stellate lesion (5 cases), microcalcifications (23 cases). Total sensitivity of HFU in the examinations performed by operator I was 83 %, while in the examinations performed by operator II (unaware of the mammographic findings) it was only 35 %. In all cases HFU allowed the operators to determine the basic features of the lesions. Our experience confirms that ultrasonography, even if performed with high frequency, cannot be proposed as a screening examination but may profitably be employed as a second-step technique to characterize NPL previously identified by mammography. This 'second-step' role can do the following: rule out true pathology (cases of false-positive mammography findings); furnish some basic features in the case of focal lesions; show other findings in the case of microcalcifications, such as microcysts, 'filled duct' appearance, parenchymal inhomogeneities and nodules; guide interventional procedures; and localize lesions preoperatively.     

On the dynamic range of different X-ray photon detectors in intra-oral radiography. A comparison of image quality in film, charge-coupled device and storage phosphor systems

OBJECTIVE: To compare film for intra-oral radiography with two charge-coupled device (CCD) and one storage phosphor system for digital imaging in respect of subjective image quality, detectability of small mass differences and appearance of burn-out effects and blooming phenomena at various exposure times. METHODS: Dried mandibles with teeth from different areas were radiographed at exposures covering a relative range from 1 to 100. Image quality was subjectively evaluated after image processing, when applicable, using a visual grading scale from 0 to 10. The number of visible holes in an aluminium block was used to measure the detectability of small mass differences. Burn-out effects and blooming were evaluated by measuring widths of roots and of aluminium and plastic cylinders. RESULTS: Radiographs with the storage phosphor system achieved image quality scores similar to those of film but over a larger exposure range, while CCD images were rated lower and over a smaller range. All holes in the aluminium block were only detected with the storage phosphor system. While the widths of roots were strongly affected by sensor saturation in CCD images and by burn-out in film images, smaller effects were seen with the storage phosphor system. Similar results were obtained with aluminium and plastic cylinders. CONCLUSIONS: Higher image quality was achieved over a much wider exposure range with the storage phosphor system than with either film or the CCD systems.     

Application of longitudinal magnification effect to magnification stereoscopic angiography: a new method of cerebral angiography

A new method of stereoscopic cerebral angiography has been developed which employs 2X radiographic magnification. In order to obtain the same depth perception in the object as with conventional contact stereoscopic angiography, one can made the x-ray exposures at two focal spot positions which are separated by only 1 inch (2.5 cm), whereas the contact technique requires a separation of 4 inches (10 cm). The smaller distance is possible because, with 2X magnification, the transverse detail in the object is magnified by a factor of two, but the longitudinal detail, which is related to the stereo effect, is magnified by a factor of four, due to the longitudinal magnification effect. The small focal spot separation results in advantages such as improved stereoscopic image detail, better image quality, and low radiation exposure to the patient.     

Nocturnal variation in human sympathetic baroreflex sensitivity

INTRODUCTION: The differential diagnosis of malignancy in small foci of microcalcifications or in extremely small nodes can be difficult. We carried out a retrospective analysis of integrated mammographic and US results, correlated with histologic data, to assess the limitations of each method and to optimize and benign/malignant ratio. MATERIALS AND METHODS: Our series consisted of 485 nonpalpable breast lesions submitted to histologic examination after vegetable charcoal marking. We gave each lesion an 0-5 score according to the degree of diagnostic doubt/suspicion after mammography and US, which results were correlated with histologic data to assess the carcinoma frequency in the various groups identified. RESULTS: The analysis of mammographic and US images showed that the most frequent mammographic alteration in the lesions submitted to biopsy was an isolated cluster of microcalcifications (40.99%): of these, 36.86% were neoplastic. The nodules submitted to biopsy, which were 29.81% of the total, showed a cancer rate (36.80%) very similar to that of the microcalcifications. The carcinoma rate rose to 37.93% when the microcalcifications were associated with nodes. The highest carcinoma rates, i.e., 52.94% and 66.66%, respectively, were found in parenchymal distortions, either isolated or associated with microcalcifications, which however were only 7.03% and 3.10%, respectively, of the total number of cases. DISCUSSION AND CONCLUSIONS: Our study showed that: 1) a highly suspicious US result must be seriously considered when a negative mammography has poor intrinsic contrast; 2) a highly suspicious US image with a little suspicious good contrast mammography requires further confirmation before surgery is planned; 3) when the mammographic finding is mid-to-highly suspicious, further investigations are needed even if US is negative. To conclude, even though the histologic examination of nonpalpable breast lesions involves performing a biopsy, we believe this is acceptable when performed on an outpatient basis, under local anesthesia and removing a limited amount of tissue only. The benign/malignant ratio ranges 2 to 1.5: if it is further reduced (below 1.5), there will be the risk of missing some early neoplastic lesions.     

Current status of digital mammography

Some inherent limitations to further technical improvement in film-screen mammography exist. Many of these limitations can be overcome effectively with digital mammography, in which image acquisition, display, and storage are performed independently, thus allowing the optimization of each. Presented is a brief background of digital and analog imaging with emphasis on the features and drawbacks of digital mammography systems. Image storage, processing, and display, computer-aided detection and diagnosis, as well as telemammography are also discussed.