GebFra Science | Original Article A Standard Mammography Unit – Standard 3D Ultrasound Probe Fusion Prototype: First Results Fusionsprototyp aus einem Standard-Mammografiegerät und einem Standard-3-D-Ultraschallkopf: erste Ergebnisse Authors ABSTRACT 1 2 Rüdiger Schulz-Wendtland *, Sebastian M. Jud *, Aim The combination of different imaging modalities 2 3 4 Peter A. Fasching , Arndt Hartmann , Marcus Radicke , through the use of fusion devices promises significant diag- 2 1 2 Claudia Rauh , Michael Uder , Marius Wunderle , nostic improvement for breast pathology. The aim of this 2 2 2 Paul Gass , Hanna Langemann ,MatthiasW.Beckmann , study was to evaluate image quality and clinical feasibility of 2 Julius Emons a prototype fusion device (fusion prototype) constructed from a standard tomosynthesis mammography unit and a Affiliations standard 3D ultrasound probe using a new method of breast 1 Institute of Diagnostic Radiology, University Hospital compression. Erlangen, Erlangen, Germany Materials and Methods Imagingwasperformedon5mas- 2 Department of Gynecology and Obstetrics, University tectomy specimens from patients with confirmed DCIS or in- Hospital Erlangen, Comprehensive Cancer Center vasive carcinoma (BI-RADS™ 6). For the preclinical fusion pro- Erlangen-EMN, Friedrich-Alexander University Erlangen- totype an ABVS system ultrasound probe from an Acuson Nuremberg, Erlangen, Germany S2000 was integrated into a MAMMOMAT Inspiration (both 3 Institute of Pathology, University Hospital Erlangen, Siemens Healthcare Ltd) and, with the aid of a newly devel- Comprehensive Cancer Center Erlangen-EMN, Friedrich- oped compression plate, digital mammogram and automated Alexander University Erlangen-Nuremberg, Erlangen, 3D ultrasound images were obtained. Germany Results The quality of digital mammogram images produced 4 Siemens Healthcare GmbH, Erlangen, Germany by the fusion prototype was comparable to those produced using conventional compression. The newly developed com- Key words pression plate did not influence the applied x-ray dose. The mammography, breast ultrasound, complementary breast method was not more labour intensive or time-consuming diagnostics than conventional mammography. From the technical per- spective, fusion of the two modalities was achievable. Schlüsselwörter Conclusion In this study, using only a few mastectomy speci- Mammografie, Brustultraschall, komplementäre mens, the fusion of an automated 3D ultrasound machine Mammadiagnostik with a standard mammography unit delivered images of com- parable quality to conventional mammography. The device al- received 22.3.2017 lows simultaneous ultrasound – the second important imag- revised 26.3.2017 ing modality in complementary breast diagnostics – without accepted 27.3.2017 increasing examination time or requiring additional staff. Bibliography ZUSAMMENFASSUNG DOI https://doi.org/10.1055/s-0043-107034 Ziel Die Kombination verschiedener bildgebender Verfahren Published online 27.4.2017 | Geburtsh Frauenheilk 2017; 77: in Fusionsmaschinen verspricht, eine deutliche Verbesserung 679–685 © Georg Thieme Verlag KG Stuttgart · New York | der Brustdiagnostik mit sich zu bringen. Hier wollen wir die ISSN 0016‑5751 Bildqualität und die klinische Anwendbarkeit eines Fusions- prototypen aus einem Standard-Mammografie/Tomosynthe- Correspondence se-Gerät und einem Standard-3-D-Ultraschallkopf unter Zu- Rüdiger Schulz-Wendtland, M.D. hilfenahme einer neuen Methode der Brustkomprimierung Institute of Diagnostic Radiology, University Hospital Erlangen evaluieren. Universitätsstraße 21–23, 91054 Erlangen, Germany [email protected] Deutsche Version unter: * Both authors contributed equally to this publication. https://doi.org/10.1055/s-0043-107034 Schulz-Wendtland R et al. A Standard Mammography … Geburtsh Frauenheilk 2017; 77: 679–685 679 GebFra Science | Original Article Material und Methoden Für die Untersuchung an 5 Mast- auf die applizierte Röntgendosis. Der personelle und zeitliche ektomiepräparaten von Patientinnen mit histologisch gesi- Aufwand für die Mammografie unterscheidet sich nicht zur chertem DCIS oder invasivem Mammakarzinom (BI-RADS™ herkömmlichen Mammografie. Die Fusion aus Mammografie 6) wurde an einem präklinischen Fusionsprototyp ein Ultra- und Ultraschall lässt sich technisch umsetzen. schallkopf eines ABVS-Systems aus einem Acuson S2000 in ei- Schlussfolgerung Die Fusion eines automatisierten 3-D-Ul- nen MAMMOMAT Inspiration (beide Siemens Healthcare traschallgeräts mit einem Standard-Mammografiegerät liefert GmbH) unter Zuhilfenahme einer neu entwickelten Kompres- an unseren wenigen Mastektomiepräparaten Mammografie- sionsplatte integriert und digitale Mammografien und 3-D- aufnahmen von vergleichbarer Qualität. Darüber hinaus er- Bilder per automatisiertem Ultraschall aufgenommen. möglicht das Gerät den simultanen Ultraschall als 2. Bildmo- Ergebnisse Die durch den Fusionsprototyp aufgenommenen dalität der komplementären Mammadiagnostik ohne einen digitalen Mammografien sind von vergleichbarer Qualität wie signifikanten Zeit- und zusätzlichen Untersucheraufwand. unter herkömmlicher Kompression entstandene Aufnahmen. Die neu entwickelte Kompressionsplatte hat keinen Einfluss In contrast to previous studies in which principally analogue Introduction images were acquired [12,15,16] this study was based on digital mammography and 3D ultrasound examination. Multimodal imaging continues to be standard for the diagnosis of The aim was to validate a functional fusion prototype using a malignant tumours of the breast. There are however various prob- small number of mastectomy specimens. lems, discussion points and challenges regarding the different imaging modalities (mammography/tomosynthesis, ultrasound and MRI) in their individual areas of clinical application. In the Methods screening domain, where mammography is used exclusively [1], the high diagnosis rate of non-lethal tumours (overdiagnosis) is Development of a novel gauze compression device cited [2,3]. And tumours that are missed on mammogram alone, A compression device for breast immobilisation is an essential re- e.g. due to high mammographic density, are also a problem quirement for a combination unit required to perform both ultra- (underdiagnosis) [4,5]. In the diagnostic domain, where comple- sound and mammography/tomosynthesis in a single examination mentary breast imaging with both ultrasound and mammography session. The mammogram is performed according to radiological is standard [6], spatial mapping requires further optimisation. standards [17] as stipulated in the mammography screening Current strategies to optimise diagnostic imaging include im- guidelines [6,18]. X-rays and ultrasound waves should not be im- proving the quality of the individual modalities, integrating com- peded and the quality of images not compromised. Breast cover- puter-assisted evaluation [7], focusing on three-dimensional mo- age should be as complete as possible for both the mammogram dalities [8] and combining the different modalities (fusion) [9, 10]. and ultrasound examination components. A newly developed Since the development of three-dimensional mammography (to- compression device consisting of an elastic gauze mounted onto mosynthesis) and ultrasound (automated breast ultrasound) in- a frame provided the required breast compression (up to 100 terest has especially focused on fusion devices, as the character- Newton [N] [19]) (▶ Fig. 1). isation of breast lesions can be difficult when these modalities are used independently. The error rate on correlation between le- Integration into the mammography unit sions detected on mammogram compared to hand-held ultra- The MAMMOMAT Inspiration served as the basic unit. Ultrasound sound is around 10% [11]. The combination of modalities in a sin- imaging was carried out by a probe from an Acuson S2000 ABVS gle continuous examination of the immobilised breast could help machine (both Siemens Healthcare Ltd). The ultrasound probe- to reduce these problems. gauze unit is flanged-mounted to the mammography unit via a The fusion approach to improve breast diagnostic imaging horizontal lowerable holder instead of the standard compression whereby multiple imaging modalities such as mammography, plate (▶ Fig. 2). The entire unit can hereby be moved up or down breast ultrasound, MRI and tomosynthesis are combined – the enabling variation of the compression force applied to the breast. strengths of the one compensating for the weaknesses of the oth- The prototype described here is a research tool and is not com- er – is not new [10, 12–14]. Combining modalities, however, mercially available. presents new challenges such as how to perform multiple imag- ing procedures on the compressed breast in series or simulta- Specimens neously without changing its position. This is essential for precise The mastectomy specimens were obtained during the iMODE‑B localisation of regions of interest (ROI). Combined imaging is cur- study (Imaging and Molecular Detection study Breast). All the pa- rently not yet part of routine clinical practice due to an unfavour- tients were fully informed and gave written consent to study in- able cost-benefit ratio and a lack of technical feasibility [10]. clusion. The study was approved by the medical faculty ethics commission of the Friedrich-Alexander University, Erlangen-Nürn- berg. 680 Schulz-Wendtland R et al. A Standard Mammography … Geburtsh Frauenheilk 2017; 77: 679–685 Fusion prototype imaging was performed on unfixed abladates