The assessment of breast by imaging methods has been object of a series of recent
publications in the Brazilian radiological literature
(1-11)
. In the
present editorial, we report the international contribution, the beginnings of the
mammographic study, and a fascinating evolution of diagnostic medicine.
THE AGE OF PIONEERS
In 1913, Albert Salomon, a German surgeon, published his monograph about the utility
of
radiological studies of mastectomy specimens, demonstrating the possibility of
correlating radiological, macro and microscopic anatomy of breast diseases with
differentiation between benign and malignant entities
(12)
.
Major works followed that of A.Salomon, namely, Kleinschmidt, Warren, Vogel, Seabold,
Gerson-Cohen, Leborgne, Egan, Gallagher, Martin, Dodd, Strax, and colleagues. The
intriguing study developed by the renowned pathologist Helen Ingleby, in 1950, included
the assessment of the breast and its variations according to the patients' age and
menstrual status, besides a radiological, microand macroscopic correlation with a
technique of cross-sectional histological sections of the breast
(13,14)
. In 1949, Raul Leborgne revitalized the interest in
mammography calling the attention over the need for technical qualification for patients
positioning and over radiological parameters to be adopted. He was a pioneer in the
enhancement of imaging quality, besides putting special emphasis on the differential
diagnosis between benign and malignant calcifications
(15)
.
Special films developed by Kodak, and the high miliamperage with low kilovoltage
technique standardized by Robert Egan have led to a new level of technical
qualification. In 1962, this author reports the first 53 cases of occult breast cancer
detected at 2,000 mammograms.
At that same time, John Martin and colleagues demonstrated that excellent mammographic
studies could be performed and standardized in private clinics. Concomitantly, the
American College of Radiology (ACR) established committees and centers for training
at
countrywide level. This was the embryo for the ACR Mammography
Committee
(12-14)
.
THE AGE OF TECHNICAL PROGRESS
The so called Age of Technical Progress has Gould, Wolfe, Gross and
their collaborators amongst its major contributors. The development of xeromammography
was the result from collaboration between industry and medicine. In 1960, Howard and
Gould described imaging improvements obtained with the xeromammography technique and,
in
1966, in the 5th Conference on Mammography at Emory University (Atlanta), John Wolfe
presented his vast experience in the use of xeromammography.
The interest was so high that ACR asked Xerox to institute an advanced research program
with the method, including new clinical essays, with the contribution from Wolfe,
Martin
and Gloria Frankl. It is important to highlight that at that time Wolfe already
classified the subtle signs of breast cancer and their relationship with the breast
parenchyma density
(16)
.
In 1965, Charles Gross, from Strasbourg, France, developed the first unit dedicated
to
mammography. Ingeniously, such an apparatus presented a molybdenum x-ray tube with
a 0.7
mm focal spot, providing high differential contrast between parenchyma, fat and
microcalcifications; complemented by an appropriate compression system as a relevant
addition to the equipment. Gross has worked with great dedication, constantly calling
the attention to the great potential of mammography to detect occult
cancers
(12)
.
THE MODERN AGE
The Modern Age, as this period became known, counts on the contribution
of Price, Butler, Ostrum, Becker, Isard, Moskowitz, Sickles, Kopans, Homer, Tabár
and
collaborators, among others.
In 1970, Price and Butler, utilizing high definition intensifying screens and
mammography films, obtain great success in the reduction of radiation levels. In this
respect, the companies Kodak and Dupont are responsible for a great technical
contribution.
In 1974, Myron Moskowitz and collaborators presented preliminary results about
mammographic screening and call the attention of the medical community to the capacity
of mammography to diagnose minimally invasive cancer.
In 1977, Sickles, Kunio Doi and Genant published their results about mammography
magnification, emphasizing the permanent necessity of adding new devices to mammography
apparatuses, given the relevance of new developments in this field. Sickles insists
on
the need for technical capacitation and constant improvements, and emphasizes the
necessity of diagnosing malignant tumors with basis not only on the classical signs,
but
also on indirect and less noticeable signs. Already at that time, the concept of mobile
mammography units was popularized
(17)
.
In 1976, Frank, Ferris and Steer described a preoperative needle/wire system for marking
nonpalpable breast lesions and, in 1980, Kopans and DeLuca exemplify the improved
system
of this method. Currently, the utilized needles are named Kopans wires
(18)
.
In 1985, László Tabár and collaborators described results obtained with mammographic
screening in 134,867 women in the age range between 40 and 79 years, with a single
mediolateral oblique image, reporting a mortality decrease of 31%.
Tabár has developed tireless scientific work, with innumerable publications, conferences
and courses. Such author also promotes several courses in the areas of epidemiology,
screening, early diagnosis and establishes new concepts about
clinical-radiological-pathological correlation, with a systematic analysis of sections
of specimens and mammographic findings
(19)
. In addition to this author, innumerable other
radiologists have devoted their extensive experience to teach and divulge mammography.
In this field, the studies developed by Eklund, Feig, Logan, Alcon, and Paulus should
be
highlighted.
DIGITAL MAMMOGRAPHY
In September/1991, under the auspices of US National Institute of Health, and in
accordance with breast diagnosis specialists consensus about breast diagnosis, it
was
established a priority of investments for development of digital mammography.
At that time, developments in digital technology were already being observed in all
radiology fields, mammography inclusive.
In June/1996, the Food and Drug Administration (FDA) publishes normative guidelines
as
regards clinical essays for interested companies to obtain official approval to
commercialize digital mammography equipment. The Food and Drug Administration estimates
that a comparative study of at least 520 women (260 with abnormal findings and 260
with
normal findings) would be enough to meet the pre-established evaluation parameters.
Further studies are developed and a detailed analysis of the new system confirms the
technical excellence of the method, particularly in the acquisition, equalization,
display and post-processing of images
(14)
.
The first digital equipment
From 2000 on the Senographe 2000 D equipment was approved by FDA. The equipment for
direct digital mammographic image acquisition is composed of an x-ray generator
similar to that of the conventional system. The great innovation consists in the
introduction of a computerized control unit (with automated quality control) and the
replacement of the screen/film system by a highly differentiated electronic detector
that is effective in x-ray beam absorption.
Currently, several companies are involved in the development and commercialization
of
digital mammography apparatuses, computer-aided diagnosis (CAD) systems and breast
tomosynthesis, the latter approved in 2011 by FDA.