In its volumes 12 no. 51 and 13 no. 52, “Journal of Ultrasonography” contains two important articles regarding the part played by elastography in the diagnostic imaging of the breast and a statistical comparative study of earlier publications(. However, this remarkable piece of work calls for a few remarks since it concerns an organ about which still little is known – the breast, and a technique which is recent and still innovating – elastography. Far from being critical, these remarks are meant to be constructive in order to contribute to the improvement of diagnostic performances.These remarks concern:the study of the anatomy of the breast;the choice of the vocabulary in breast ultrasound;the techniques of echography and elastography;the analysis of the size of lesions;the multifocal, multicentric or diffuse character of breast cancer;and lastly, the comparison with various recent publications.
First remark
The anatomy of the breast was briefly described by Prof. Wiesław Jakubowski in his article published in “Journal of Ultrasonography” vol. 12 no. 50(. However, in the articles in question the true nature of breast anatomy is far too sketchily drawn by: such words as lobes or lobules are not used in the two articles by Dr Katarzyna Dobruch-Sobczak. This could confuse us to believe that the technique of breast ultrasound which is used is a conventional echography carried out through orthogonal sweeping and not the radial technique. It is essential to harmonize the technique of breast ultrasound so that it can become reproducible and can be interpreted by everybody in the same way.
Second remark
The choice of vocabulary and terminology is paramount. What lies behind the word glandular tissue? The breast is made up of three basic structures: epithelial, fatty and conjunctive tissue. To which of these does the term glandular tissue refer? The word epithelium is used in one sentence, although it is the most important tissue of the breast.The group II cysts (60 lesions) belong to the “solid focal lesions” group (part I, pages 404, 406(). Are they really solid? The group II benign solid lesions (20% of benign lesions) are described as being hyper- and isoechogenic. These are traditionally described as hypoechogenic (cf. PUS Standards – no. 50, vol. 12(). Do they have a specific dimension in this study? The choice of identical criteria is essential in the description of lesions.
Third remark
Technical criteria: one of the first stumbling-blocks in the use of elastography is the lack of uniformity in the techniques which are used. The HI-RTE criteria are already rather dated and lack precision: compression and/or pressure applied. Very often, excessive pressure is applied, in relation to the handling of the probe by numerous teams of practitioners as well as among members of a same team. Training is thus essential, and a very precise description of the technique is necessary. Pressure differs according to the type of probe used, according to whether the lesion is superficial or deep-seated. Pressure can be replaced by a combination of vibration and decompression in the analysis of superficial millimetric cancers and for “minimal breast cancers.”In the enclosed series of five photographs of elastography, none of the five “boxes” is identical. Their positions are all different, only one is related to the study of FLR. It appears essential to render elastographic presentations uniform.Concerning the use of Doppler, one must not forget two essential parameters: the performance and quality of the Doppler vary considerably in relation to the age of the machines used. The most recent machines detect more vessels and many more small vessels. The second point relates to the patient's position (arm raised, oblique reclining position with compression from the pectoral muscle, or on the contrary, sitting with her arms against her body) – this considerably modifies the number of vessels visible as well as the RI or PI indices. Doppler results must be taken into account with great caution.
Fourth remark
The size of lesions: for such a study, it is desirable to indicate the size of the lesions analyzed. Elastography is highly successful in the analysis of “minimal breast cancers,” less so for pluricentimetric lesions (but is there a need for elastography in that type of cancer?). For “borderline” anomalies measuring from 2 to 4 mm, elastography is a lot less reliable.The technique has to be adapted (in terms of pressure, vibration, decompression) to the size and location of the anomalies.Surprisingly, this article describes group I breast cancers remarkably larger than group II benign lesions. What about millimetric, multifocal or multicentric cancers?
Fifth remark
None of the chapters published insists on the multiple lesions of breast cancer. It is essential to refer to various publications, among which Prof. Tibor Tot's ones with his “sick lobe theory.” The anatomopathological analysis reveals multiple or diffuse cancers in 65% of the cases. The title of his most recent book is Breast Cancer: A Lobar Disease
(. Furthermore, there is no mention of “soft” cancers (false negatives in elastography), such as colloidal, mucoidal, or mucinous cancers and some in situ cancers without stromal reaction. What category are they to be put into?
Sixth remark
One must bear in mind that in order to be able to compare various recent publications quoted and to understand some of their disparities, it is essential to compare what is comparable: the type of machine used, the type of technique used, the type of patient examined, the authors’ particular fields of specialization, etc. It would be desirable to give some data to enable the comparisons to be made.
To conclude
There is no doubt that elastography is an essential technique in breast imagery. Its contribution as a complement to mammography/echography has become indispensable as Dr. K. Dobruch-Sobczak indicates very well, and one has to be grateful to her for her work. However, numerous parameters have to be taken into account while analyzing and assessing the studies already published. It is furthermore vital to harmonize the terminology of echography and to standardize the results so as to achieve better data control thanks to the “statistical software package” (STATISTICA and IDAMS).The understanding of mammary anatomy, of the multifocal dimension of the “cancerous disease” of the breast, allied to a mastery of the techniques of diagnostic imaging will allow us to improve our diagnostic performances. Dr. Dobruch-Sobczak will, undoubtedly, soon be able to present us with a further development of her results and statistical analyses, and we are looking forward to that.