We are IntechOpen,

the world’s leading publisher of

Open Access books
Built by scientists, for scientists

7,100
Open access books available
188,000
International authors and editors
205M Downloads

Our authors are among the

154
Countries delivered to
TOP 1%
most cited scientists
12.2%
Contributors from top 500 universities

Selection of our books indexed in the Book Citation Index

in Web of Science™ Core Collection (BKCI)

Interested in publishing with us?

Contact [email protected]
Numbers displayed above are based on latest data collected.
For more information visit www.intechopen.com
Chapter

Screening and Diagnosis Imagery

in Breast Cancer: Classical and
Emergent Techniques
Georgios Iatrakis, Stefanos Zervoudis, Anastasia Bothou,
Eftymios Oikonomou, Konstantinos Nikolettos,
Kyriakou Dimitrios, Nalmpanti Athanasia-Theopi,
Kritsotaki Nektaria, Kotanidou Sonia, Spanakis Vlasios,
Andreou Sotiris, Aise Chatzi Ismail Mouchterem,
Kyriaki Chalkia, Christos Damaskos, Nikolaos Garmpis,
Nikolaos Nikolettos and Panagiotis Tsikouras

Abstract

In light of the limitations of mammography, ultrasound, and breast MRI, some

other breast imaging techniques have recently been investigated to reduce false posi-
tive rates and raise breast cancer detection including (1) digital breast tomosynthesis,
(2) bilateral contrast-enhanced dual-energy digital mammography, (3) ultrasound
elastography, (4) abbreviated breast MRI, (5) magnetic resonance spectroscopy, and
(6) ductoscopy and duct cytology. The purpose of this review was to examine the
advantages and disadvantages of these six different breast cancer imaging techniques.

Keywords: breast cancer, breast imaging technologies, screening of breast cancer,

digital breast tomosynthesis, bilateral contrast-enhanced dual-energy digital
mammography, abbreviated breast MRI, magnetic resonance spectroscopy, breast
elastography, ductoscopy, duct lavage

1. Introduction

According to the National Cancer Institute, 297,790 new cases and 43,170
anticipated deaths from breast cancer are expected in 2023, making it one of the
most common and deadly malignancies for women in the US [1]. The goal of con-
tinuously investigating innovations in screening modalities is to create technology
that maximizes sensitivity and specificity while minimizing radiation exposure and
patient discomfort. According to most international groups, breast cancer screening
is suggested with annual or biennial mammography for average-risk women aged
50–74 years [2, 3]. To maximize the benefits of screening mammography and further
1
Breast Imaging – Characteristics and Emerging Technologies

reduce breast cancer mortality, breast cancer screening could start from 45 years
of age, according to the American Cancer Society and European screening guidelines
[3], or 40 years [4, 5]. However, in high-risk patients, imaging could begin as early
as 30 years of age. Despite that mammography remains the gold standard for breast
cancer screening [2] (Figures 1 and 2), its sensitivity varies from 37% to 71%, while
its specificity is approximately 95% [3]. When an abnormality is detected on screen-
ing mammography, ultrasonography is frequently utilized for diagnostic follow-up to
clarify features of a possible lesion. Although ultrasonography can be used in addi-
tion to mammography screening in women with dense breasts (e.g., to spot malig-
nancies not visible on mammography), there is insufficient evidence to support the
use of ultrasound alone in screening [3]. With a sensitivity that ranges from 70% to

Figure 1.
Early breast cancer (DCIS) in mammography (mediolateral oblique [MLO] view).

Figure 2.
Early breast cancer (DCIS) in mammography (craniocaudal [CC] view).

2
Screening and Diagnosis Imagery in Breast Cancer: Classical and Emergent Techniques
DOI: http://dx.doi.org/10.5772/intechopen.1004390

100%, breast magnetic resonance imaging (MRI) is thought to be the most sensitive
method of breast imaging. However, because of its high cost and limited availability,
MRI is typically reserved for high-risk patients and may be regarded as somewhat
inaccessible [6].
In light of the limitations of mammography, ultrasound, and breast MRI,
some other breast imaging techniques have been investigated including (1) digital
breast tomosynthesis, (2) bilateral contrast-enhanced dual-energy spectral mam-
mography, (3) abbreviated breast MRI, (4) magnetic resonance spectroscopy, (5)
microwave imaging, (6) ultrasound elastography, (7) PET/CT and PET/MRI, (8)
18F-fluoroestradiol PET, and (9) ductoscopy.

2. Effectiveness of investigated screening techniques

2.1 Digital breast tomosynthesis (DBT)

DBT is an imaging method [7] (Figure 3) that was created to be used with digital
mammography in order to improve its sensitivity and specificity while lowering the
false positive rate. A digital detector and moving X-ray are used in DBT to create a
three-dimensional mammography image. Actually, in DBT, individual images are
reconstructed into a series of high-resolution slices displayed individually or in a
“ciné” mode. DBT can be obtained independently using a synthetic two-dimensional
(2D) mammogram that is artificially produced from the 3D picture collection, or it
can be used in conjunction with digital mammography [3]. Compared to mammog-
raphy, DBT provides a more detailed image of the breast that helps clarify any suspi-
cious areas seen on mammograms because it allows decades of images to be taken
of the same point in the breast from various angles along an arc. This is because the
superimposed benign tissues from a two-dimensional perspective may appear more
clinically questionable [8]. Numerous studies have demonstrated the superiority of
DBT over standard full-field digital mammography in the detection of breast cancer
[9]. Specifically, some prospective clinical trials and retrospective cohort studies

Figure 3.
Digital mammography and tomosynthesis.

3
Breast Imaging – Characteristics and Emerging Technologies

indicate that tomosynthesis, as compared to digital mammography, slightly raises the

rates of cancer diagnosis and lowers the recall rates for false-positive mammography
readings [10–12].
According to a 2018 meta-analysis, DBT increased the incremental cancer
detection rate by 1.6 cases per 1000 screens (95% CI 1.1–2.0) compared to digital
mammography screening alone [13]. DBT had a poorer recall rate (pooled absolute
decrease: −2.2, 95% CI −3.0 to −1.4) than digital mammography alone. The impact of
DBT on breast cancer mortality has not been evaluated by any research.
While the patient experience with DBT is not much different from that of mam-
mography, the concern about increased radiation exposure needs to be considered
when making this decision. However, because of its better sensitivity and specificity
in cancer detection rates when compared to mammography alone, DBT is advised as a
cancer screening method, particularly in patients with dense breasts [14].

2.2 Bilateral contrast-enhanced dual-energy spectral mammography (CESM)

Twenty years ago, it was shown that bilateral CESM was a useful diagnostic
technique for breast cancer detection [15] (Figure 4). CESM combines classic mam-
mography with an iodinated contrast agent to improve diagnostic accuracy. Actually,
the method consists of high-energy and low-energy (dual-energy) digital mammog-
raphy after an intravenous injection of an iodinated contrast liquid. This enables the
creation of an “anatomical and functional” image of the breast, with the low-energy
component indicating calcifications and the subtracted image showing neovascular-
ization, which represents angiogenesis [16].
Studies indicate that, in 2D digital mammography, CESM can reveal calcifications
that would otherwise be undetected. Furthermore, there has not been any research
to support the theory that this imaging method is effective in identifying invasive
lobular carcinoma (ILC), a type of breast cancer that is known to be challenging to
diagnose as it may not manifest as a palpably noticeable mass [16].
Additionally, studies have demonstrated that when combined with mammogra-
phy, CESM is particularly helpful for detecting breast cancer in women with dense
breasts [17]. Moreover, this kind of digital mammography may be a useful alternate
technique for patients who cannot undergo a full diagnostic MRI study (e.g., patients

Figure 4.
Angiomammography CESM.

4
Screening and Diagnosis Imagery in Breast Cancer: Classical and Emergent Techniques
DOI: http://dx.doi.org/10.5772/intechopen.1004390

with a pacemaker). It should be mentioned that the use of contrast is not always the
best option for patients and is not always effective, particularly in cases of allergy or
pathological or drug-induced renal impairment. Interestingly, it should be empha-
sized that CESM has shown comparable sensitivity with other imaging modalities,
including MRI [18]. However, comparing its specificity to the current gold standard
for breast cancer screening, it has been discovered to be quite variable [19].

2.3 Abbreviated breast MRI

In contrast to a full diagnostic MRI study, which takes 15–20 minutes, an

abbreviated breast MRI (ultrafast) (Figures 5 and 6) for breast cancer screening
involves a shorter imaging protocol (with fewer sequences) that allows patients to

Figure 5.
Breast MRI.

Figure 6.
Breast MRI dynamic study.

5
Breast Imaging – Characteristics and Emerging Technologies

spend no more than 5 to 10 minutes within the MRI scanner. Compared to a full MRI,
this abbreviated protocol revealed >98% accuracy in the diagnostic setting as well as
100% accuracy in the screening setting [20].
Thus, this technology may be a useful adjunct for patients who cannot undergo a
full diagnostic MRI evaluation (e.g., claustrophobic patients). Actually, some recent
retrospective studies are showing that the abbreviated MRI protocol has comparable
sensitivity with the full diagnostic protocol of MRI [21, 22].
Furthermore, as an example of the reliability of abbreviated MRI imaging, a recent
study conducted on women who had previously undergone breast surgery revealed
that when an abbreviated MRI imaging was compared to screening mammography
and ultrasound, the abbreviated MRI imaging identified all cancers. Thus, it should
be emphasized that some cancers detected by abbreviated breast MRI were missed by
screening mammography and ultrasound [23]. Similarly, in a recent study, abbrevi-
ated MRI discovered breast cancers missed by digital breast tomosynthesis [24].
These findings suggest that abbreviated MRI may be used in screening for breast
cancer in women who have low, average, or high risk.

2.4 Magnetic resonance spectroscopy (MRS)

MRS is a specialized an MRI imaging technique allowing the assessment of the

chemical composition of breast tissue. In fact, it was observed that malignant tumors
have elevated choline levels. Thus, MRS of the breast detects choline and its deriva-
tives in breast tumors [25].
Unfortunately, not all breast cancers express choline, and the method remains
investigational due to a substantial number of false negative results.
The method could increase the specificity of the classic breast MRI. Increasing
the specificity means fewer false positive findings and, thus, fewer biopsies in many
women. In the past, the method showed some promising results in therapy response
[26] and could have a future role in predicting outcomes after certain therapies for
breast cancer.

2.5 Microwave imaging

The method is based on the difference of certain electric parameters between

normal breast tissue and cancer within the microwave spectrum. Microwave imaging
does not expose the patient to ionizing radiation and avoids breast compression to
achieve best imaging. However, the contrast between malignant tissue, normal fatty,
and fibroglandular tissue can be as low as 10%, and, at this level, the resolution is
noticeably low resulting in blurred images. The method could be proposed in younger
women although further research is necessary as the dielectric contrast in MWI varies
greatly at different ages and between individuals. Furthermore, additional research is
needed to demonstrate the feasibility of certain techniques to improve the method [27].

2.6 Ultrasound elastography

Breast malignant tumors look larger, and benign lesions appear smaller on the
strain elastography compared to a B-mode ultrasound (Figures 7 and 8), an imag-
ing characteristic that could differentiate malignant from benign tumors in certain
cases. Furthermore, sharewave elastography is displaying relative stiffness in color
differences, distinguishing “harder” malignant tumors from the benign ones [28].
6
Screening and Diagnosis Imagery in Breast Cancer: Classical and Emergent Techniques
DOI: http://dx.doi.org/10.5772/intechopen.1004390

Figure 7.
Breast ultrasound and power Doppler.

Figure 8.
Breast ultrasound and elastography.

However, size differences and color gradients in the above methods do not provide the
information required with high sensitivity, compared to MRI, which is necessary for
cancer detection methods. Furthermore, data related to mortality, as in mammogra-
phy, are missing.
7
Breast Imaging – Characteristics and Emerging Technologies

2.7 PET/CT and PET/MRI

For breast cancer imaging, PET/CT (Figures 9 and 10) and PET/MRI may be uti-
lized for diagnosis, staging, in cases of probable metastasis at the diagnosis of breast
cancer, and evaluation of the treatment response. However, the methods are not
proposed for breast cancer screening. Compared to PET/MRI, there is significantly

Figure 9.
PET/CT multiple metastasis.

Figure 10.
PET/CT and PET/MRI bone metastasis.

8
Screening and Diagnosis Imagery in Breast Cancer: Classical and Emergent Techniques
DOI: http://dx.doi.org/10.5772/intechopen.1004390

increased radiation exposure to the patient with PET/CT. Furthermore, PET/CT

seems inferior to PET/MRI for detecting unsuspected regional or distant diseases
[29]. However, compared to PET/MRI scanners, PET/CT scanners are more widely
available, and there is a greater experience in their use for distant diseases.

2.8 18F-fluoroestradiol PET (FES-PET)

18F-fluoroestradiol (FES) is a PET tracer with high specificity for estrogen receptor
breast cancer. However, the method cannot be used in other cases (as in triple-negative
breast cancer), and its usefulness was shown mainly in oligometastatic disease [30].

2.9 Ductoscopy

Ductoscopy is an innovative diagnostic method based on the endoscopic exami-

nation of the breast ducts (Figures 11 and 12), especially in the case of pathologic
nipple discharge. Ductoscopy is performed under local anesthesia or light sedation.
The technique is completely painless and takes between 5 and 20 minutes depending
on the case. It is a short procedure in which the duct that secretes fluid is dilated, the
ductoscope penetrates the duct and the surgeon checks the inside of the duct through
the monitor. After the visual examination is completed, saline is injected into the
duct, followed by aspiration (duct lavage) for the collection of endothelial cells and

Figure 11.
Breast ductoscopy papilloma.

Figure 12.
Breast ductoscopy breast cancer.

9
Breast Imaging – Characteristics and Emerging Technologies

cytological examination [31] (Figure 13). Recently some specialists have used an
additional diagnostic procedure during ductoscopy, the “duct brushing” (Figure 14).
With a very thin brush, which is inserted into the duct through the ductoscope, the
duct walls are scraped to collect more cells (brushing). Then, the cytological exami-
nation is performed using the liquid phase technique (ThinPrep), while for greater

Figure 13.
Zervoudis’s mammary pump and duct lavage.

Figure 14.
Duct brushing.

10
Screening and Diagnosis Imagery in Breast Cancer: Classical and Emergent Techniques
DOI: http://dx.doi.org/10.5772/intechopen.1004390

collection of cells for diagnosis, fluid is also taken from the nipple, using a special
pump (Zervoudis’s mammary pump) [32] (Figure 13).
Ductoscopy is an emergent complementary technique of mammography and
breast ultrasound used in women with nipple discharge and also to detect breast
cancer in patients with very early breast cancer and patients with a heavy family
history. Also, if the intraductal tumor needs to be removed, ductoscopy guides the
microsurgical procedure of removal (pyramidectomy and microdolicectomy).
Given the diagnostic efficiency of more than 75% and affordable cost, ductoscopy
becomes an additional powerful procedure for the surgeon.
The accuracy of the diagnosis is increased when ductoscopy, duct lavage, and duct
brushing are combined [33–34]. According to a recent meta-analysis, although liquid
cytology has a modest sensitivity, it is a valuable diagnostic tool for the high-specific-
ity detection of breast cancer in patients with pathological nipple discharge [35].

3. Harms of breast cancer screening

In addition to the discomfort and hazards associated with the screening process,
false-positive or false-negative results from breast cancer screening can be harmful.
Furthermore, an overdiagnosis of breast cancer could be harmful to women. The term
“overdiagnosis” describes the diagnosis of illnesses that, had screening not been used,
would not have progressed to a clinically important stage. Overdiagnosis results in
unneeded testing and therapy, as well as psychological effects and further repercus-
sions from receiving a cancer diagnosis and treatment [3].

3.1 False-positive tests

While test sensitivity and specificity are both significant, false-positive results
are frequently the source of greatest concern for patients and physicians. The advice
for further testing and procedures if a woman does not have cancer is the clinical
consequence. Because breast cancer is less common and the tests are less specific,
false-positive findings are more common in younger women [36].
Consequently, even if fewer tumors are discovered, younger women will undergo
more follow-up procedures. Interestingly, in a retrospective cohort study of 2400
women, the calculated cumulative risk of a false-positive result following 10 mammo-
grams was 49.1%, and following 10 clinical breast exams (CBEs), it was 22.3% [37].
In a different study, it was estimated that 61.3% of women starting at age 40 who
underwent annual mammography would require recall for at least one scan over 10
years, and 7% percent would undergo biopsy in the event of a false-positive reading.
For women having biennial (every other year) mammography, the estimated rate of
recall was 41.6%, and the rate of biopsy over 10 years was 4.8% [38].
The risk of a false-positive study at the first, and by the ninth, screening mam-
mogram was 98 and 100% in those women with the highest risk variables (young age,
prior breast biopsies, a family history of breast cancer, current hormonal therapy, 3 years
between screenings, no comparison to prior mammograms, and the tendency of the radi-
ologist to call mammograms abnormal [radiologist’s random effect]). On the other hand,
the predicted risks for the first and ninth mammograms were 0.7 and 4.6%, respectively,
for those with the lowest risk characteristics. The scientists hypothesized that women
could have less worry when abnormal mammography was reported if they were aware of
their relative risk of a false-positive study based on these characteristics [39].
11
Breast Imaging – Characteristics and Emerging Technologies

3.2 Anxiety related to false-positive findings

There is no proof that having false-positive findings will have long-term, persis-
tently unpleasant psychological effects. However, there are short-term, detrimental
psychological effects that could last days to weeks [40].

3.3 False-negative tests can delay diagnosis and breast cancer treatment

Screening exams and other medical examinations are not infallible. Sometimes
screening mammography results are regarded as negative, yet at the time of the test,
the breast does indeed contain cancer. The radiologist may have overlooked these
malignancies, or the lesions may not have been obvious on a retrospective imaging
examination [41]. A combination of these factors results in the missing diagnosis of
about one in eight breast cancers during screening mammography [42]. A false-neg-
ative test result is more likely to occur in women who are younger, have dense breasts,
have hormone-independent cancer, or have cancer that is proliferating. Consequently,
even after a recent negative screening imaging scan, women who exhibit worrying
signs or symptoms (e.g., palpable breast lump and new nipple retraction) should have
a follow-up evaluation, preferably with a breast surgeon or breast cancer expert.

3.4 Overdiagnosis

The identification of an illness that, had it not been discovered, would not have
resulted in morbidity or death is known as overdiagnosis [42]. Certain tumors develop
slowly, and some may even go into remission. Overdiagnosis can only be estimated
using one of the several methods; it cannot be assessed directly. The percentage of
women who receive a false positive for breast cancer ranges from 10% to over 50%,
depending on the definition used (e.g., whether ductal carcinoma in situ [DCIS] is
included and what age women are studied), as well as the methods used for study
design, measurement, and estimation. A perfect screening test would differentiate
between malignancies with high or low risk, enabling tailored treatment based on
tumor biology [43]. There is not any testing like that accessible. As it is impossible to
accurately determine which cancers in a given patient will never progress, treatment
is almost always advised.

3.5 Radiation

Although ionizing radiation raises the risk of breast cancer, the majority of
cohort studies investigating the issue have included women who were exposed to
radiation doses significantly higher than the average glandular dosage for a two-view
digital mammography performed at facilities authorized by the American College of
Radiology [44]. According to a study conducted in 2015, which supported the adjust-
ment of the US Preventive Services Task Force breast cancer screening guidelines, 16
out of 100,000 women will die from radiation-induced cancer as a result of annual
mammography screening throughout their lifetimes [45].

3.6 Ductal carcinoma in situ

DCIS (Figures 1 and 2) accounts for about 16% of breast cancer diagnoses in the
US. Over 48,000 women in the US received a DCIS diagnosis in 2019 [46]. About 50%
12
Screening and Diagnosis Imagery in Breast Cancer: Classical and Emergent Techniques
DOI: http://dx.doi.org/10.5772/intechopen.1004390

of DCIS cases may not progress to aggressive malignancy, and the natural history
of the condition is unclear [47]. It is unknown which cases of DCIS may advance to
invasive illness; hence, concerns have been expressed that the discovery of DCIS by
mammography may result in overdiagnosis and overtreatment. Typically, the diagno-
sis leads to surgery and systemic therapy. Suboptimal concordance (84% agreement)
across pathologists in identifying DCIS in a breast biopsy sample is another cause for
worry. Study pathologists misinterpreted DCIS as invasive breast cancer, and over-
interpreted it as benign with or without atypia [48].

3.7 Other possible harms

Another potential harm of breast cancer screening is discomfort, especially during

mammography. According to a well-conducted study, patient-controlled breast
compression improved the image quality and decreased patient pain [49]. There was
a stronger intention to return for another screening assessment when there was less
discomfort.
Furthermore, there are more possible risks connected to alternative screening
methods. For example, women may not be able to tolerate intravenous gadolinium
injection (e.g., because of an allergic response or kidney failure) or may experience
claustrophobia, which makes breast MRI unfeasible [50].

3.8 Discussion

Mammography is the gold standard for breast cancer screening [2]. However, its
sensitivity is relatively low. Thus, if an abnormality is detected on screening mam-
mography, other imaging techniques are necessary to clarify the initial findings.
These techniques include ultrasonography, digital breast tomosynthesis, classic or
abbreviated breast MRI, bilateral contrast-enhanced dual-energy spectral mammog-
raphy, magnetic resonance spectroscopy, microwave imaging, ultrasound elastogra-
phy, PET/CT, PET/MRI, 18F-fluoroestradiol PET, and ductoscopy. However, it should
be emphasized that annual mammography proved beneficial for most women in
terms of reduced mortality from breast cancer [51], a finding not yet related to other
imaging techniques.

4. Conclusion

The primary key to women’s survival from breast cancer is early detection and
treatment. As a result, imaging is essential in the diagnosis and management of
breast cancer cases. In recent years, DBT, CESM, abbreviated breast MRI, MRS, and
breast ductoscopy have become more heavily investigated. Given its potential effects
on health and society, research on new breast imaging technologies is crucial. Many
patients worry when undergoing breast cancer screening, and any progress made in
reducing the financial burden, scan-to-result time, and accuracy will lessen patient
anxiety. Although it is clear that no screening technique has yet been created that
is more practical or dependable than mammography, advancements in this area are
significant enough to warrant further research in the hopes of improving the manage-
ment of all breast cancer cases.

13
Breast Imaging – Characteristics and Emerging Technologies

Author details

Georgios Iatrakis1, Stefanos Zervoudis1,2, Anastasia Bothou1,3, Eftymios Oikonomou4,

Konstantinos Nikolettos4, Kyriakou Dimitrios4, Nalmpanti Athanasia-Theopi4,
Kritsotaki Nektaria4, Kotanidou Sonia4, Spanakis Vlasios4, Andreou Sotiris4,
Aise Chatzi Ismail Mouchterem4, Kyriaki Chalkia4, Christos Damaskos5,
Nikolaos Garmpis6, Nikolaos Nikolettos4 and Panagiotis Tsikouras4*

1 University of West Attica, Athens, Greece

2 Rea Maternity Hospital: Breast Unit, Athens, Greece

3 Breast Department of Alexandra General Hospital, Athens, Greece

4 Department of Obstetrics and Gynecology, Democritus University of Thrace,

Greece

5 Second Department of Propedeutic Surgery, Laiko General Hospital, Medical

School, National and Kapodistrian University of Athens, Athens, Greece

6 Renal Transplatation Unit, Laiko General Hospital, Athens, Greece

*Address all correspondence to: [email protected]

© 2024 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of
the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided
the original work is properly cited.
14
Screening and Diagnosis Imagery in Breast Cancer: Classical and Emergent Techniques
DOI: http://dx.doi.org/10.5772/intechopen.1004390

References

[1] Cancer Stat Facts: Female Breast [8] Chong A, Weinstein S, McDonald E,
Cancer. 2023. Available from: https://seer. Conant E. Digital breast tomosynthesis:
cancer.gov/statfacts/html/breast.html. Concepts and clinical practice.
Radiology. 2019;292(1):1-14.
[2] Zervoudis S, Iatrakis G, Tomara E, DOI: 10.1148/radiol.2019180760
Bothou A, Papadopoulos G, Tsakiris G.
Main controversies in breast cancer. [9] Nakajima E, Tsunoda H, Ookura M,
World Journal of Clinical Oncology. Ban K, Kawaguchi Y, Inagaki M, et al.
2014;5(3):359-373. DOI: 10.5306/wjco. Digital breast tomosynthesis complements
v5.i3.359 two-dimensional synthetic
mammography for secondary
[3] Elmore JG, Lee CI. Screening for examination of breast cancer. Journal
Breast Cancer: Evidence for Effectiveness of the Belgian Society of Radiology.
and Harms. Waltham, MA: UpToDate; 2021;105(1):63. DOI: 10.5334/jbsr.2457
2023
[10] Skaane P, Bandos AI, Gullien R,
Eben E, Ekseth U, Haakenaasen U, et al.
[4] Bastardis-Zakas K, Iatrakis G,
Comparison of digital mammography
Navrozoglou I, Peitsidis P, Salakos N,
alone and digital mammography
Malakassis P, et al. Maximizing the
plus tomosynthesis in a population-
benefits of screening mammography
based screening program. Radiology.
for women 40-49 years old. Clinical and
2013;267(1):47-56. DOI: 10.1148/
Experimental Obstetrics & Gynecology.
radiol.12121373
2010;37(4):278-282
[11] Ciatto S, Houssami N, Bernardi D,
[5] Duffy SW, Vulkan D, Cuckle H,
Caumo F, Pellegrini M, Brunelli S,
Parmar D, Sheikh S, Smith RA, et al. et al. killIntegration of 3D digital
Effect of mammographic screening mammography with tomosynthesis
from age 40 years on breast cancer for population breast-cancer screening
mortality (UK age trial): Final results (STORM): A prospective comparison
of a randomised, controlled trial. The study. The Lancet Oncology.
Lancet Oncology. 2020;21(9):1165-1172. 2013;14(7):583-589. DOI: 10.1016/
DOI: 10.1016/S1470-2045(20)30398-3 S1470-2045(13)70134-7
[6] Sung J, Lebron L, Keating D, [12] Friedewald SM, Rafferty EA,
D'Alessio D, Comstock C, Lee C, et al. Rose SL, Durand M, Plecha D,
Performance of dual-energy contrast- Greenberg J, et al. Breast cancer
enhanced digital mammography for screening using tomosynthesis in
screening women at increased risk of combination with digital mammography.
breast cancer. Radiology. 2019;293(1):81- Journal of the American Medical
88. DOI: 10.1148/radiol.2019182660 Association. 2014;311(24):2499-2507.
DOI: 10.1001/jama.2014.6095
[7] Zervoudis S, Iatrakis G, Malakassis P,
Tomara E, Bouga A, Grammatikakis I, [13] Marinovich M, Hunter K, Macaskill P,
et al. Tomosynthesis improves breast Houssami N. Breast cancer screening
cancer detection: Our experience. using tomosynthesis or mammography:
European Journal of Gynaecological A meta-analysis of cancer detection
Oncology. 2014;35(6):666-669 and recall. Journal of the National
15
Breast Imaging – Characteristics and Emerging Technologies

Cancer Institute. 2018;110(9):942-949. Implementation of abbreviated breast

DOI: 10.1093/jnci/djy121 MRI in diagnostic and screening settings.
Acta Radiologica. 2023;64(3):987-992.
[14] Venkataraman S, Slanetz P, Lee C. DOI: 10.1177/02841851221114434
Breast Imaging for Cancer Screening:
Mammography and Ultrasonography. [21] Chen SQ , Huang M, Shen YY,
UpToDate; 2022 Liu CL, Xu CX. Application of
abbreviated protocol of magnetic
[15] Lewin JM, Isaacs PK, Vance V, resonance imaging for breast cancer
Larke FJ. Dual-energy contrast-enhanced screening in dense breast tissue.
digital subtraction mammography: Academic Radiology. 2017;24(3):316-320.
Feasibility. Radiology. 2003;229(1):261- DOI: 10.1016/j.acra.2016.10.003
268. DOI: 10.1148/radiol.2291021276
[22] Panigrahi B, Mullen L, Falomo E,
[16] Sorin V, Sklair-Levy M. Dual- Panigrahi B, Harvey S. An abbreviated
energy contrast-enhanced spectral protocol for high-risk screening breast
mammography (CESM) for breast cancer magnetic resonance imaging: Impact
screening. Quantitative Imaging in on performance metrics and BI-RADS
Medicine and Surgery. 2019;9(11):1914- assessment. Academic Radiology.
1917. DOI: 10.21037/qims.2019.10.13 2017;24(9):1132-1138. DOI: 10.1016/j.
acra.2017.03.014
[17] Cheung YC, Lin YC, Wan YL,
[23] Choi BH, Choi N, Kim MY,
Yeow KM, Huang PC, Lo YF, et al.
Yang JH, Yoo YB, Jung HK. Usefulness
Diagnostic performance of dual-
of abbreviated breast MRI screening
energy contrast-enhanced subtracted
for women with a history of breast
mammography in dense breasts
cancer surgery. Breast Cancer Research
compared to mammography alone:
and Treatment. 2018;167(2):495-502.
Interobserver blind-reading analysis.
DOI: 10.1007/s10549-017-4530-z
European Radiology. 2014;24(10):2394-
2403. DOI: 10.1007/s00330-014-3271-1 [24] Weinstein SP, Korhonen K, Cirelli C,
Schnall MD, McDonald ES, Pantel AR,
[18] Fallenberg EM, Dromain C, et al. Abbreviated breast magnetic
Diekmann F, Engelken F, Krohn M, resonance imaging for supplemental
Singh JM, et al. Contrast-enhanced screening of women with dense breasts
spectral mammography versus MRI: and average risk. Journal of Clinical
Initial results in the detection of breast Oncology. 2020;38(33):3874-3882.
cancer and assessment of tumor size. DOI: 10.1200/JCO.19.02198
European Radiology. 2014;24(1):256-264.
DOI: 10.1007/s00330-013-3007-7 [25] Sardanelli F, Fausto A, Di Leo G,
de Nijs R, Vorbuchner M, Podo F. In vivo
[19] Spick C, Pinker-Domenig K, proton MR spectroscopy of the breast
Rudas M, Helbich T, Baltzer P. MRI- using the total choline peak integral as a
only lesions: Application of diffusion- marker of malignancy. American Journal
weighted imaging obviates unnecessary of Roentgenology. 2009;192(6):1608-
MR-guided breast biopsies. European 1617. DOI: 10.2214/AJR.07.3521
Radiology. 2014;24(6):1204-1210.
DOI: 10.1007/s00330-014-3153-6 [26] Tozaki M, Sakamoto M, Oyama Y,
O’uchi T, Kawano N, Suzuki T, et al.
[20] Ahmadinejad N, Azhdeh S, Monitoring of early response to
Arian A, Eslami B, Mehrabinejad MM. neoadjuvant chemotherapy in breast
16
Screening and Diagnosis Imagery in Breast Cancer: Classical and Emergent Techniques
DOI: http://dx.doi.org/10.5772/intechopen.1004390

cancer with (1)H MR spectroscopy: (Bucur). 2020;115(3):334-340.

Comparison to sequential DOI: 10.21614/chirurgia.115.3.334
2-[18F]-fluorodeoxyglucose positron
emission tomography. Journal of Magnetic [34] Bothou A, Iatrakis G, Zervoudis S,
Resonance Imaging. 2008;28(2):420-427. Tsatsaris G, Lykeridou K, Deuteraiou D,
DOI: 10.1002/jmri.21454 et al. Breast milk suction pumping and
a possible relation to breast cancer:
[27] Akbari-Chelaresi H, Alsaedi D, A bicentric study. Review Clinical
Mirjahanmardi SH, El Badawe M, Pharmacology and Pharmacokinetics,
Albishi AM, Nayyeri V, et al. International Edition. 2020;34(1):
Mammography using low-frequency 5-8. DOI: https://doi.org/10.5281/
electromagnetic fields with deep learning. zenodo.10040437
Scientific Reports. 2023;13(1):13253. DOI:
10.1038/s41598-023-40494-x [35] Li XQ , Xu F, Lei CQ , Li J, Jiang HC.
Accuracy for cytological evaluation
[28] Barr RG. Future of breast elastography. in the detection of breast cancer
Ultrasonography. 2019;38(2):93-105. among patients with pathologic nipple
DOI: 10.14366/usg.18053 discharge: A PRISMA-compliant meta-
analysis. Chinese Medical Journal.
[29] Fowler AM, Strigel RM. Clinical 2020;133:435-443. DOI: 10.1097/
advances in PET/MRI for breast CM9.0000000000000643
cancer. The Lancet Oncology.
2022;23(1):e32-e43. DOI: 10.1016/ [36] Lidbrink E, Elfving J, Frisell J,
S1470-2045(21)00577-5 Jonsson E. Neglected aspects of false
positive findings of mammography in
[30] Denton M, Taubman K, breast cancer screening: Analysis of
Sutherland T. 18F-Fluoroestradiol PET false positive cases from the Stockholm
in the evaluation of probable trial. BMJ. 1996;312(7026):273-276.
oligometastatic breast cancer. Journal DOI: 10.1136/bmj.312.7026.273
of Medical Imaging and Radiation
Oncology. 2021;65(3):333-334. [37] Elmore J, Barton M, Moceri V, Polk S,
DOI: 10.1111/1754-9485.13136 Arena P, Fletcher S. Ten-year risk of
false positive screening mammograms
[31] Zervoudis S, Tamer V, Iatrakis G, and clinical breast examinations. The
Bothou A, Tokou X, Augoulea A, et al. New England Journal of Medicine.
Improving ductoscopy with duct 1998;338(16):1089-1096. DOI: 10.1056/
lavage and duct brushing. European NEJM199804163381601
Journal of Gynaecological Oncology.
2014;35(5):548-553 [38] Hubbard R, Kerlikowske K, Flowers C,
Yankaskas B, Zhu W, Miglioretti D.
[32] Zervoudis S. A simple tool Cumulative probability of false-positive
complementary for the diagnosis of recall or biopsy recommendation after
breast diseases: The mammary pump. 10 years of screening mammography:
The Breast Journal. 2003;9(5):445-447. A cohort study. Annals of Internal
DOI: 10.1046/j.1524-4741.2003.09524.x Medicine. 2011;155(8):481-492.
DOI: 10.7326/0003-4819-155-8-
[33] Zervoudis S, Iatrakis G, Daures JP, 201110180-00004
Bothou A, Aranitis V, Patralexis X,
et al. Ductoscopy coupled to duct lavage [39] Christiansen C, Wang F, Barton M,
and duct brushing in pathologic nipple Kreuter W, Elmore J, Gelfand A, et al.
discharge: Our experience. Chirurgia Predicting the cumulative risk of
17
Breast Imaging – Characteristics and Emerging Technologies

false-positive mammograms. Journal www.uspreventiveservicestaskforce.

of the National Cancer Institute. org/Page/Document/modeling-report-
2000;92(20):1657-1666. DOI: 10.1093/ radiation-induced-breast-cancer-and-
jnci/92.20.1657 breast-c/breast-cancer-screening1
[Accessed on June 26, 2015]
[40] Tyndel S, Austoker J, Henderson B,
Brain K, Bankhead C, Clements A, et al. [46] American Cancer Society. Breast
What is the psychological impact of Cancer Facts & Figures 2019-2020.
mammographic screening on younger Available from: https://www.cancer.
women with a family history of breast org/content/dam/cancer-org/research/
cancer? Findings from a prospective cancer-facts-and-statistics/breast-
cohort study by the PIMMS Management cancer-facts-and-figures/breast-cancer-
Group. Journal of Clinical Oncology. facts-and-figures-2019-2020.pdf
2007;25(25):3823-3830. DOI: 10.1200/ [Accessed on November 30, 2020]
JCO.2007.11.0437
[47] Welch H, Woloshin S, Schwartz L.
[41] Lamb L, Mohallem Fonseca M, The sea of uncertainty surrounding ductal
Verma R, Seely J. Missed breast cancer: carcinoma in situ--the price of screening
Effects of subconscious bias and mammography. Journal of the National
lesion characteristics. Radiographics. Cancer Institute. 2008;100(4):228-229.
2020;40(4):941-960. DOI: 10.1148/ DOI: 10.1093/jnci/djn013
rg.2020190090
[48] Elmore J, Longton G, Carney P,
[42] Lehman C, Arao R, Sprague B, Lee J, Geller B, Onega T, Tosteson A, et al.
Buist D, Kerlikowske K, et al. National Diagnostic concordance among
performance benchmarks for modern pathologists interpreting breast biopsy
screening digital mammography: Update specimens. Journal of the American
from the breast cancer surveillance Medical Association. 2015;313(11):1122-
consortium. Radiology. 2017;283(1):49- 1132. DOI: 10.1001/jama.2015.1405
58. DOI: 10.1148/radiol.2016161174
[49] Kornguth P, Rimer B, Conaway M,
[43] Esserman L, Shieh Y, Thompson I. Sullivan D, Catoe K, Stout A, et al.
Rethinking screening for breast cancer Impact of patient-controlled compression
and prostate cancer. Journal of the on the mammography experience.
American Medical Association. Radiology. 1993;186(1):99-102.
2009;302(15):1685-1692. DOI: 10.1001/ DOI: 10.1148/radiology.186.1.8416595
jama.2009.1498
[50] Monticciolo D. Magnetic resonance
[44] Ronckers C, Erdmann C, Land C. imaging of the breast for cancer diagnosis
Radiation and breast cancer: A review and staging. Seminars in Ultrasound,
of current evidence. Breast Cancer CT, and MR. 2011;32(4):319-330.
Research. 2005;7(1):21-32. DOI: 10.1186/ DOI: 10.1053/j.sult.2011.02.005
bcr970
[51] Park HL, Chang J, Haridass V,
[45] Modeling Report: Radiation-Induced Wang SS, Ziogas A, Anton-Culver H.
Breast Cancer and Breast Cancer Mammography screening and mortality
Death from Mammography Screening. by risk status in the California teachers
Supporting document for U.S. Preventive study. BMC Cancer. 2021;21(1):1341.
Services Task Force; Breastcancer DOI: 10.1186/s12885-021-09071-1
screening draft recommendations. http://
18