Australia's contributions to breast ultrasound
By George Kossoff

Excerpted from: Breast News: Newsletter of the NHMRC National Breast Cancer Centre
Vol. 6, No. 1, Spring 2000

Australia can be proud of the international standing that it has in breast ultrasound. For many years we led the world in developments in technology, and we have played a major role in establishing its current position in clinical practice.

High-frequency ultrasonic flaw detection equipment was developed by the military during World War II. This equipment was released for general use after the war, and Dr John Wild, an English physician living in the US, was the first clinician to use it to study the breast. His original article published in 1951 illustrated the ultrasonic appearance of normal, benign and malignant tissues and showed that abnormal tissues could be distinguished by the method 1. The following year Wild joined forces with engineer Dr Jack Reid and together they introduced major advances describing cross-sectional imaging obtained with contact, transvaginal/transrectal and water-immersion scanners. Unfortunately Wild was not able to maintain his funding and their research ceased in the late 1950s. The importance of the contributions made by Wild have since been recognised and he has been awarded numerous international prizes for his research.

In Australia, the NHMRC set up an Ultrasonics Committee in 1955 to set up standards for and to control the use of ultrasonic therapy apparatus. Mr Norman Murray, Director of the Commonwealth Acoustics Laboratory (CAL), was appointed Convenor of the committee. Murray interpreted his brief to include a watch over developments in diagnostic ultrasound. Publications by Wild and by the Scottish obstetrician Professor Ian Donald, on results in obstetrics and gynaecology, led Murray to recommend a physicist position be created to "provide research and advisory services to the use of ultrasound in the diagnosis and treatment of diseases". A raw graduate in electrical engineering, I was appointed to this position in March 1959.

Discussions regarding a joint research program into breast ultrasound were undertaken with Drs Freeborn and Ingram at the Medical Research Institute, Royal North Shore Hospital (RNSH), NSW in 1961. Professor Tom Reeve joined the program as clinical consultant in 1963, and work to design and construct a scanner commenced that year. Dr Jack Jellins joined CAL in 1965 as scientist responsible for the technology.

The equipment was installed at the RNSH in 1966. It was a bi-stable machine capable of imaging in linear, sector and compound scanning modes. The patient lay supine and a large waterbag was lowered onto the patient's chest. The weight caused tissue distortion and patient discomfort, but despite these disadvantages the scanner provided images of the breast with recognisable internal structures. These allowed us to demonstrate characteristics of cancers that are used in diagnosis today. The coupling was later modified to the more comfortable position where the patient lay prone and the breasts were freely dependent in the water tank.

A dramatic improvement was obtained in 1969 through our introduction of grey-scale imaging. This was a major Australian first that today is used in all ultrasound equipment. Our research into factors affecting the magnitude of echoes showed that the clinically relevant magnitude comes from the internal texture of soft tissue, and in grey-scale imaging we optimised the signal processing to display this textural information. For the first time images began to resemble anatomical sections and we began to issue clinical reports on the results of the examination 2. The development of a comprehensive range of diagnostic interpretative criteria followed. These included disruption of architecture, internal echo content, boundary detail, central shadowing, refractive edge shadowing and shape. Later, distortion of skin outline, skin involvement, thickened Cooper's ligaments and attachments to surrounding tissue were added 3. Members of clinical staff of the hospital, in particular Drs Bruce Barraclough and Richard Picker, and our sonographers Kaye Griffiths and Margaret Tabrett contributed to many of these developments.

In the mid-1970s, our research into ultrasound technology led to the development of a general purpose UI Octoson scanner. The patient was examined lying prone on a waterbed. Eight submerged transducers provided a panoramic compound image in nearly a second. The scanner received considerable interest and an Australian company, Ausonics Pty Ltd, was formed to manufacture and distribute it. More than 200 of these scanners were sold worldwide, generating significant export revenue for Australia. A high-frequency version of this scanner was built for Dr Joan Croll, Sydney Square Diagnostic Breast Clinic (SSDBC). Dr Croll developed a wealth of clinical material and rapidly became a frequently invited speaker at local and international meetings.

Ausonics subsequently produced a four-transducer version of this scanner designed primarily to examine the breast. More than 100 of these units were sold worldwide. The company put together an excellent education program, and many international radiologists who purchased the scanner came to Australia for training by our Laboratory, the RNSH and the SSDBC.

In the early 1980s, Professor John McCaffrey, of the Royal Brisbane Hospital (RBH), and scientists from the Queensland Institute of Technology obtained a major grant from the Commonwealth Government to investigate ultrasound transmission attenuation and velocity imaging using reconstruction techniques similar to those used in X-ray CT. The equipment was built by Ausonics and, following initial assessment at the RBH, was sent to Emory University for independent clinical evaluation by Dr Marjorie McSweeney. The equipment performed well and transmission imaging was found to be particularly useful in identifying malignancies in the fatty breast.

In the mid-1980s, water path equipment was overtaken by developments in contact, real-time scanners. The initially poor imaging performance of this equipment was vastly improved, it functioned in real-time, it cost less and it could be used to guide biopsy procedures. Australia quickly switched to use this technology.

Through the educational efforts of the previously mentioned organisations, the Australasian Society for Ultrasound in Medicine and of the medical colleges, the practice of breast ultrasound in Australia remains second to none, and Australia continues to make important contributions in this field.

References:
Lancet, 1951;1:655-657
MJA, 1971;1:305-307
Ultrasound Med Biol, 1975;1:393-404

George Kossoff AO, FTSE, DscEng is the former Head, Ultrasonics Laboratory, Division of
Telecommunications and Industrial Physics, CSIRO, Sydney.

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