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Title: Mammographic compression after breast conserving therapy: Controlling pressure instead of force

Abstract

Purpose: X-ray mammography is the primary tool for early detection of breast cancer and for follow-up after breast conserving therapy (BCT). BCT-treated breasts are smaller, less elastic, and more sensitive to pain. Instead of the current force-controlled approach of applying the same force to each breast, pressure-controlled protocols aim to improve standardization in terms of physiology by taking breast contact area and inelasticity into account. The purpose of this study is to estimate the potential for pressure protocols to reduce discomfort and pain, particularly the number of severe pain complaints for BCT-treated breasts. Methods: A prospective observational study including 58 women having one BCT-treated breast and one untreated nonsymptomatic breast, following our hospital's 18 decanewton (daN) compression protocol was performed. Breast thickness, applied force, contact area, mean pressure, breast volume, and inelasticity (mean E-modulus) were statistically compared between the within-women breast pairs, and data were used as predictors for severe pain, i.e., scores 7 and higher on an 11-point Numerical Rating Scale. Curve-fitting models were used to estimate how pressure-controlled protocols affect breast thickness, compression force, and pain experience. Results: BCT-treated breasts had on average 27% smaller contact areas, 30% lower elasticity, and 30% higher pain scores than untreated breastsmore » (allp < 0.001). Contact area was the strongest predictor for severe pain (p < 0.01). Since BCT-treatment is associated with an average 0.36 dm{sup 2} decrease in contact area, as well as increased pain sensitivity, BCT-breasts had on average 5.3 times higher odds for severe pain than untreated breasts. Model estimations for a pressure-controlled protocol with a 10 kPa target pressure, which is below normal arterial pressure, suggest an average 26% (range 10%–36%) reduction in pain score, and an average 77% (range 46%–95%) reduction of the odds for severe pain. The estimated increase in thickness is +6.4% for BCT breasts. Conclusions: After BCT, women have hardly any choice in avoiding an annual follow-up mammogram. Model estimations show that a 10 kPa pressure-controlled protocol has the potential to reduce pain and severe pain particularly for these women. The results highly motivate conducting further research in larger subject groups.« less

Authors:
; ;  [1];  [2];  [3];  [4]
  1. Department of Biomedical Engineering and Physics, Academic Medical Center, P.O. Box 22660, 1100 DD Amsterdam (Netherlands)
  2. National Expert and Training Centre for Breast Cancer Screening, P.O. Box 6873, 6503 GJ, Nijmegen, The Netherlands and Department for Health Evidence, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen (Netherlands)
  3. National Expert and Training Centre for Breast Cancer Screening, P.O. Box 6873, 6503 GJ, Nijmegen (Netherlands)
  4. (Netherlands)
Publication Date:
OSTI Identifier:
22251641
Resource Type:
Journal Article
Resource Relation:
Journal Name: Medical Physics; Journal Volume: 41; Journal Issue: 2; Other Information: (c) 2014 Author(s); Country of input: International Atomic Energy Agency (IAEA)
Country of Publication:
United States
Language:
English
Subject:
62 RADIOLOGY AND NUCLEAR MEDICINE; BIOMEDICAL RADIOGRAPHY; COMPARATIVE EVALUATIONS; COMPRESSION; ELASTICITY; HOSPITALS; MAMMARY GLANDS; NEOPLASMS; PAIN; PHYSIOLOGY; SENSITIVITY; STANDARDIZATION; TETRAGONAL LATTICES; THERAPY; THICKNESS; X RADIATION

Citation Formats

Groot, J. E. de, E-mail: jerry.degroot@sigmascreening.com, Branderhorst, W., Grimbergen, C. A., Broeders, M. J. M., Heeten, G. J. den, and Department of Radiology, Academic Medical Center, P.O. Box 22660, 1100 DD Amsterdam. Mammographic compression after breast conserving therapy: Controlling pressure instead of force. United States: N. p., 2014. Web. doi:10.1118/1.4862512.
Groot, J. E. de, E-mail: jerry.degroot@sigmascreening.com, Branderhorst, W., Grimbergen, C. A., Broeders, M. J. M., Heeten, G. J. den, & Department of Radiology, Academic Medical Center, P.O. Box 22660, 1100 DD Amsterdam. Mammographic compression after breast conserving therapy: Controlling pressure instead of force. United States. doi:10.1118/1.4862512.
Groot, J. E. de, E-mail: jerry.degroot@sigmascreening.com, Branderhorst, W., Grimbergen, C. A., Broeders, M. J. M., Heeten, G. J. den, and Department of Radiology, Academic Medical Center, P.O. Box 22660, 1100 DD Amsterdam. Sat . "Mammographic compression after breast conserving therapy: Controlling pressure instead of force". United States. doi:10.1118/1.4862512.
@article{osti_22251641,
title = {Mammographic compression after breast conserving therapy: Controlling pressure instead of force},
author = {Groot, J. E. de, E-mail: jerry.degroot@sigmascreening.com and Branderhorst, W. and Grimbergen, C. A. and Broeders, M. J. M. and Heeten, G. J. den and Department of Radiology, Academic Medical Center, P.O. Box 22660, 1100 DD Amsterdam},
abstractNote = {Purpose: X-ray mammography is the primary tool for early detection of breast cancer and for follow-up after breast conserving therapy (BCT). BCT-treated breasts are smaller, less elastic, and more sensitive to pain. Instead of the current force-controlled approach of applying the same force to each breast, pressure-controlled protocols aim to improve standardization in terms of physiology by taking breast contact area and inelasticity into account. The purpose of this study is to estimate the potential for pressure protocols to reduce discomfort and pain, particularly the number of severe pain complaints for BCT-treated breasts. Methods: A prospective observational study including 58 women having one BCT-treated breast and one untreated nonsymptomatic breast, following our hospital's 18 decanewton (daN) compression protocol was performed. Breast thickness, applied force, contact area, mean pressure, breast volume, and inelasticity (mean E-modulus) were statistically compared between the within-women breast pairs, and data were used as predictors for severe pain, i.e., scores 7 and higher on an 11-point Numerical Rating Scale. Curve-fitting models were used to estimate how pressure-controlled protocols affect breast thickness, compression force, and pain experience. Results: BCT-treated breasts had on average 27% smaller contact areas, 30% lower elasticity, and 30% higher pain scores than untreated breasts (allp < 0.001). Contact area was the strongest predictor for severe pain (p < 0.01). Since BCT-treatment is associated with an average 0.36 dm{sup 2} decrease in contact area, as well as increased pain sensitivity, BCT-breasts had on average 5.3 times higher odds for severe pain than untreated breasts. Model estimations for a pressure-controlled protocol with a 10 kPa target pressure, which is below normal arterial pressure, suggest an average 26% (range 10%–36%) reduction in pain score, and an average 77% (range 46%–95%) reduction of the odds for severe pain. The estimated increase in thickness is +6.4% for BCT breasts. Conclusions: After BCT, women have hardly any choice in avoiding an annual follow-up mammogram. Model estimations show that a 10 kPa pressure-controlled protocol has the potential to reduce pain and severe pain particularly for these women. The results highly motivate conducting further research in larger subject groups.},
doi = {10.1118/1.4862512},
journal = {Medical Physics},
number = 2,
volume = 41,
place = {United States},
year = {Sat Feb 15 00:00:00 EST 2014},
month = {Sat Feb 15 00:00:00 EST 2014}
}
  • Purpose: To compare outcomes of salvage mastectomy (SM) and salvage breast-conserving surgery (SBCS) and study the feasibility of SBCS. Methods and Materials: Of 2,038 patients treated with breast-conserving therapy at Yale-New Haven Hospital before 1999, 166 sustained an ipsilateral breast tumor recurrence (IBTR). Outcomes and prognostic factors of patients treated with SM or SBCS were compared. Patients were considered amenable to SBCS if the recurrence was localized on mammogram and physical examination, and had pathologic size <3 cm, confined to the biopsy site, without skin or lymphovascular invasion, and with {<=}3 positive nodes. Results: Of the 146 patients definitively managedmore » at IBTR, surgery was SM (n = 116) or SBCS (n 30). The median length of follow-up after IBTR was 13.8 years. The SM and SBCS cohorts had no significant differences, except at IBTR the SM cohort had a greater tumor size (p = 0.049). Of the SM cohort, 65.5% were considered appropriate for SBCS, and a localized relapse was predicted by estrogen-receptor positive, diploid, and detection of recurrence by mammogram. Multicentric disease correlated with BRCA1/2 mutation, estrogen-receptor negative, lymph node positive at relapse, and detection of recurrence by physical examination. Survival after IBTR was 64.5% at 10 years, with no significant difference between SM (65.7%) and SBCS (58.0%). Only 2 patients in the SBCS cohort subsequently had a second IBTR, and were salvaged with mastectomy. Conclusions: While mastectomy is considered the standard surgical salvage of IBTR, SBCS is feasible and prognostic factors are related to favorable tumor biology and early detection. Patients with BRCA1/2 germline mutations may be less appropriate for SBCS, as multicentric disease was more prevalent. Patients who underwent SBCS had comparable outcomes as those who underwent SM, but remain at continued risk for IBTR. A prospective trial evaluating repeat lumpectomy and partial breast reirradiation is discussed.« less
  • Background: It is generally believed that ipsilateral breast failures (IBFs) after breast-conserving therapy (BCT) develop from incompletely eradicated carcinoma. We previously suggested that monomorphic epithelial proliferations (MEPs) in the breast may be a pool of partially transformed clones from which breast carcinomas can arise and that radiation therapy (RT) may also reduce the risk of IBF by eradicating MEPs. We examined salvage mastectomy specimens in patients experiencing an IBF to define the relationship between MEPs and IBFs and an additional potential mechanism for IBF risk reduction by RT. Methods and Materials: The location, number, and distribution of radiation changes andmore » MEPs relative to 51 IBFs were mapped in salvage mastectomy specimens from BCT patients with adequately excised, initial carcinomas (negative lumpectomy margins). Results: All 51 salvage mastectomies had diffuse, late radiation changes. None had active fibrocystic lesions. MEPs were predominantly located in the immediate vicinity of the IBFs. A mean of 39% of MEP cases were located within the IBF, 46% were located within 2 cm of the IBF, and 14% were 2-3 cm from the IBF. Conclusions: MEPs appear to be a pool of partially transformed precursor lesions that can give rise to ductal carcinoma in situ and invasive carcinomas (CAs). Many IBFs may arise from MEPs that reemerge after RT. Radiation may also reduce IBF risk after BCT (including in patients with negative margins) by primarily eradicating MEPs.« less
  • Purpose: To objectively evaluate the radiation dermatitis caused by accelerated partial breast irradiation (APBI) using high-dose-rate interstitial brachytherapy. Patients and Methods: The skin color and moisture changes were examined using a newly installed spectrophotometer and corneometer in 22 patients who had undergone APBI using open cavity implant high-dose-rate interstitial brachytherapy (36 Gy in six fractions) and compared with the corresponding values for 44 patients in an external beam radiotherapy (EBRT) control group (50-60 Gy in 25-30 fractions within 5-6 weeks) after breast conserving surgery. Results: All values changed significantly as a result of APBI. The extent of elevation in amore » Asterisk-Operator (reddish) and reduction in L Asterisk-Operator (black) values caused by APBI were similar to those for EBRT, with slightly delayed recovery for 6-12 months after treatment owing to the surgical procedure. In contrast, only APBI caused a change in the b Asterisk-Operator values, and EBRT did not, demonstrating that the reduction in b Asterisk-Operator values (yellowish) depends largely on the surgical procedure. The changes in moisture were less severe after APBI than after EBRT, and the recovery was more rapid. The toxicity assessment using the Common Toxicity Criteria, version 3, showed that all dermatitis caused by APBI was Grade 2 or less. Conclusion: An objective analysis can quantify the effects of APBI procedures on color and moisture cosmesis. The radiation dermatitis caused by APBI using the present schedule showed an equivalent effect on skin color and a less severe effect on moisture than the effects caused by standard EBRT.« less
  • Purpose: To update the previous report from 2 randomized clinical trials, now with a median follow-up of 16 years, to analyze the effect of radiation therapy timing on local failure and disease-free survival. Patients and Methods: From July 1986 to April 1993, International Breast Cancer Study Group trial VI randomly assigned 1475 pre-/perimenopausal women with node-positive breast cancer to receive 3 or 6 cycles of initial chemotherapy (CT). International Breast Cancer Study Group trial VII randomly assigned 1212 postmenopausal women with node-positive breast cancer to receive tamoxifen for 5 years, or tamoxifen for 5 years with 3 early cycles of initial CT. Formore » patients who received breast-conserving surgery (BCS), radiation therapy (RT) was delayed until initial CT was completed; 4 or 7 months after BCS for trial VI and 2 or 4 months for trial VII. We compared RT timing groups among 433 patients on trial VI and 285 patients on trial VII who received BCS plus RT. Endpoints were local failure, regional/distant failure, and disease-free survival (DFS). Results: Among pre-/perimenopausal patients there were no significant differences in disease-related outcomes. The 15-year DFS was 48.2% in the group allocated 3 months initial CT and 44.9% in the group allocated 6 months initial CT (hazard ratio [HR] 1.12; 95% confidence interval [CI] 0.87-1.45). Among postmenopausal patients, the 15-year DFS was 46.1% in the no-initial-CT group and 43.3% in the group allocated 3 months initial CT (HR 1.11; 95% CI 0.82-1.51). Corresponding HRs for local failures were 0.94 (95% CI 0.61-1.46) in trial VI and 1.51 (95% CI 0.77-2.97) in trial VII. For regional/distant failures, the respective HRs were 1.15 (95% CI 0.80-1.63) and 1.08 (95% CI 0.69-1.68). Conclusions: This study confirms that, after more than 15 years of follow-up, it is reasonable to delay radiation therapy until after the completion of standard CT.« less
  • It is often suggested in the literature that thermography is able to diagnose a recurrence in the breast after breast-conserving therapy by a rise in breast temperature much earlier than other diagnostic tools, but no thermographic values are presented. The thermographic data of a prospective study of 309 women after breast-conserving therapy were evaluated. Seventeen of these women had an intramammary recurrence. A total of 2432 individual measured values were evaluated from 292 patients without evidence of a recurrence and 146 measured values from 17 patients with intramammary recurrence. The thermographic behavior of the breast after breast-conserving therapy is notmore » uniform. However, the breast temperatures of the patients with intramammary recurrences were not significantly different from those without recurrences. This means that thermography is of no value in the care after breast-conserving therapy.« less