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SHORT HISTORY OF MAMMOGRAPHY (31/90) Click here to see our objects about Breast Introduction The first attempts to use radiography for the diagnosis of breast abnormalities were made in the late 1920's, but mammography as we understand it nowadays, using dedicated X-ray units, was developed in the 1960's. In this contribution we briefly overview the three major periods : the foundations made the observations of a German surgeon from 1913 on, followed by the development of the technique by radiologists and later by industry from 1940 to around 1970, and the last quarter of the 20th century dominated by the arrived of breast cancer screening, the use of ultrasound and magnetic resonance imaging and nowadays the transition to digital mammography systems. We can observe three periods in the history of the evolution of mammography. The first period goes from 1913 till 1940. This period is characterised by the originality of the important contributions of a surgeon of Berlin, A. Salomon (1913) (1). The originality resides in the anatomo-radiological confrontation of 3000 mastectomy pieces. The foundations of mammography reside in the confrontation of this first time semiology of macroscopic anatomy with microscopic examinations. During one quarter of a century, some publications report on the tryout to apply this method to the radiology of the breast. Among others, the works of the German doctors O. Kleinschmidt (1927) (2) and W. Vogel (1930) (3), these of the Spanish J. Goyanes et al (1929) (4), these of S.L. Warren (5) and Gershon-Cohen (1937) (6) in the USA. The latter one explores further this field and publishes later in the sixties a textbook, still well-known (7). The second period extends from 1940 till 1970. It is an auspicious period for the confirmation of mammography. Nevertheless, it must be emphasized that the method, result of research by a surgeon, has been refuted by the surgery community, even when the reliability and the quality of the images were unquestionable when the method was used in conformity of the indications given by the pioneers. R. Leborgne, living in Montevideo, devoted to mammography since 1940, provides us the essential data of this technique and the interpretation of the images (8). During this period, each publication on breast radiology, be it by the didactic quality or personal observations on the technique, equipment or choice of film, contributed more or less to the development of mammography. It is important to emphasize the preponderant position taken, in France, from the 60s on, by F. B Baclesse and A. Willemin of Paris (9) and by Ch. Gros (10) in Strasbourg, and we may not forget R. Egan (1964) (11) in the USA. We will not develop here the technical aspects ( « cooking recipes » well-known by the specialists), but we find it opportune to mention that the French words "sénologues" and "sénologie" were a legacy of Ch. Gros, who trained many Belgian radiologists. On the other hand, we can not hide the importance of the participation of radiological industry to the development of mammography. Under impulse of Ch. Gros, from 1965 on, the « Compagnie Générale de Radiologie (CGR) » started the building of the "Sénographe". This apparatus, equipped with a special molybdenum anode designed for imaging the breast, was worked out by Ch. Gros, not forgetting he was also a physicist. First builder of this type of equipment, CGR had sold in 1970 around 2000 Senographs throughout the world. Meantime, the film industry becomes devoted to improve the quality of the sensitive layer and to extend the possibility to vary the contrast, to improve the examination of mammal glands of young women. Their contribution was also essential to respond to the concern of reducing radiation doses. The marketing of mammography equipment in 1967 induces a revolution in breast imaging. Previously this was done with an ordinary X-ray tube used for bone radiography, and the radiological film placed directly under the skin of the breast ! The third period covers the last quarter of the 20th century. Indeed, from 1970, it is suggested to make mammography the most appropriate technique for breast cancer screening. One of the pioneers was undoubtly the Swedisch L. Tabar and P. Dean (12) who examined over 130.000 patients. Women undergoing a mammography mainly did so for evaluation of a discovered nodule. A biopsy of the nodule was performed, to retrieve some cells to be analysed by using a thin needle (13). Often this procedure provided no diagnostic information, especially in the case of benign lesions. In most cases, the diagnosis was provided by surgical resection of the nodule, fortunately often benign. Since the start of the programme “Europe against Cancer” of the European Union in 1987, we observe a generalisation of the screening campaigns, and through a increased control, a homogeneity and higher quality of mammography (14). Today, the perfection of the mammography equipment, films and even the technique and procedure of imaging, results in a radiological image of the breast of extreme quality with an exposure about 10 times lower than 30- years ago. Mid seventies, ephemere techniques such as thermography and xerography appeared for a short period (15). End of the 70s, sonography of the breast is developed, and progressively becomes a complement to mammography, but can not replace mammography since microcalcifications – sometimes the only indication of a developing cancer- can not be detected by ultrasound. But this technique is still used, mainly for cystic liquid lesions. At the end of the 80s, magnetic resonance imaging (MRI) of the breast comes up together with sonography for additional examination technique to mammography. MRI is clearly more expensive and also can not detect microcalcifications. This technique is primarily used for particular problems we will not cover here (16). Introduced about 10 years ago, digital mammography nowadays is in full expansion (17). Reducing even further the dose, this digital method offers an image richer in contrast, with a quality approaching film-screen capability of detection of details. The major advantage resides in the digitalisation, so the image and its magnification can be changed, a rapid transfer can be made between stations (“Telemammography”), a copy can be archived that later on can be used for comparison. Digital images also allow creation of databanks. Ongoing research show a potentiality of development of digital mammography; screen-film mammography no longer represents the best quality of diagnostic imaging service for patients requiring mammography. Conclusion It took more than half a century to make mammography accepted by the surgery community. From the 60's on, French, Swedish and North-American radiologists made mammography a well established technique, and radiological industry developed dedicated apparatus with special anode increasing contrast and lowering radiation dose to the breast. Nowadays a high quality of mammography with even lower dose is achieved by digital systems, to the benefit of women, be it for diagnostic or screening purpose. BIBLIOGRAPHY 1. Salomon A. : Beiträge zur Pathologie und Klinik der Mammakarzinome. Arch Klin Chir 1913, 101 : 573-668. 2. Kleinschmidt O. : Brustdrüse. In : Die Klinik der bösartigen Geschwülste. Zweife P., Payr E. and Hirzel S. Leipzig. 1927, pp.5-90. 3. Vogel W. : Die Röntgendarstellung der Mammatumoren. Arch Klin Chir 1932, 171 : 618-626. 4. Goyanes J., Gentil D. F. and Guedes B. : Sobre la radiografia de la glándula mamária y su valor diagnóstico. Arch Espań de Oncologica. 1931, 2 : 111-142. 5. Warren S. L. : A roengenologic study of the breast. AJR 1930, 24:113-124. 6. Gershon-Cohen J., Colcher A.E. : Evaluation of roentgen diagnosis of early carcinoma of breast. JAMA 1937, 108 : 867-871. 7. Gershon-Cohen J., : Atlas of mammography. Springer-Verlag, Berlin, New-York, Heidelberg. 1970. 8. Leborgne R. : The breast in roentgen diagnosis. Impressora Uruguay, Montevideo 1953. 9. Baclesse F., Willemin A. : Atlas de mammographie. Librairie de la Faculté des Sciences, Paris. 1965. 10. Gros Ch. : Les maladies du sein. Masson, Paris. 1963. 11. Egan R. : Mammography Thomas, Chicago. 1964. 12. Tabár L., Dean P., : Teaching atlas of mammography. 2nd ed. Thieme Verlag, New-York. 1985. 13. Dodd GD., Fry K., Delany W., : Pre-op localization of occult carcicoma of the breast. In : Nealon TF, ed. Management of the patient with breast cancer. Saunders, Philadelphia. 1965, 88-113. 14. Zoetelief J., Fitzgerald M., Leitz W., Säbel M. : European protocol on dosimetry in mammography. European Commission. 1996. 15. Gould HR., Ruzicka FF., Sanchez R. et al. : Xeroradiography of the breast. AJR 1960, 84 : 220-223. 16. EL Youssef SJ., Alfidi RJ., Duschesneau, RH. et al. : Initial experience with nuclear magnetic resonance (NMR) imaging of the human breast. J Comput Assist Tomogr, 1983, 7 : 215-218. 17. Freedman MT., Pe E., Zuurbier R. et al. : Image processing in digital mammography. In : Kim Y (ed) Proc SPIE Image Capture, Formatting and Display 2164. Bellingham, Washington : Soc Photo-Optical Instr Engs 1993, 537-554. |