Publications by authors named "Rasha Kamal"

13 Publications

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The first BGICC consensus and recommendations for breast cancer awareness, early detection and risk reduction in low- and middle-income countries and the MENA region.

Int J Cancer 2021 Feb 9. Epub 2021 Feb 9.

Clinical Oncology Department, Ain shams University, Cairo, Egypt.

In low-middle income countries (LMICs) and the Middle East and North Africa (MENA) region, there is an unmet need to establish and improve breast cancer (BC) awareness, early diagnosis and risk reduction programs. During the 12th Breast, Gynecological & Immuno-oncology International Cancer Conference - Egypt 2020, 26 experts from 7 countries worldwide voted to establish the first consensus for BC awareness, early detection and risk reduction in LMICs/MENA region. The panel advised that there is an extreme necessity for a well-developed BC data registries and prospective clinical studies that address alternative modalities/modified BC screening programs in areas of limited resources. The most important recommendations of the panel were: (a) BC awareness campaigns should be promoted to public and all adult age groups; (b) early detection programs should combine geographically distributed mammographic facilities with clinical breast examination (CBE); (c) breast awareness should be encouraged; and (d) intensive surveillance and chemoprevention strategies should be fostered for high-risk women. The panel defined some areas for future clinical research, which included the role of CBE and breast self-examination as an alternative to radiological screening in areas of limited resources, the interval and methodology of BC surveillance in women with increased risk of BC and the use of low dose tamoxifen in BC risk reduction. In LMICs/MENA region, BC awareness and early detection campaigns should take into consideration the specific disease criteria and the socioeconomic status of the target population. The statements with no consensus reached should serve as potential catalyst for future clinical research.
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http://dx.doi.org/10.1002/ijc.33506DOI Listing
February 2021

Fetal heart examination at the time of 13 weeks scan: a 5 years' prospective study.

J Perinat Med 2019 Oct;47(8):871-878

Fetal Medicine Unit, Department of Obstetrics and Gynecology, Cairo University, Cairo, Egypt.

Objective To evaluate our ability in classifying the fetal heart as normal or abnormal during the 1st trimester scan through fetal cardiac examination and determining the best time for this examination. Methods This was a prospective study performed on 3240 pregnant women to examine the fetal heart. Four chambers view and ventricular outflow tracts were mainly examined during the scan. We used grayscale and color mapping in the diagnosis. Color Doppler was used if additional information was needed, and all patients were rescanned during the 2nd trimester to confirm or negate our diagnosis. Results The cardiac findings were normal at both scans in 3108 pregnancies. The same cardiac abnormality was detected at both scans in 79 cases. In 36 cases there was false-positive diagnosis at the early scan; in 20 of these cases, there were mildly abnormal functional findings early in pregnancy with no abnormality found later. In 17 fetuses, there was discordance between the early and later diagnosis due to missed or incorrect diagnoses. The best time to do fetal heart examination during 1st trimester is between 13 and 13 + 6 weeks. Conclusion A high degree of accuracy in the identification of congenital heart disease (CHD) can be achieved by a 1st trimester fetal echocardiography.
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http://dx.doi.org/10.1515/jpm-2019-0222DOI Listing
October 2019

Methylene blue 1% as a sensitive and safe alternative for sentinel lymph node biopsy in early stage breast cancer: Results of a large pilot study.

Breast J 2019 09 13;25(5):1017-1019. Epub 2019 Jun 13.

Breast Cancer Unit, Faculty of Medicine, Cairo University, Cairo, Egypt.

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http://dx.doi.org/10.1111/tbj.13401DOI Listing
September 2019

Ovarian cancer screening-ultrasound; impact on ovarian cancer mortality.

Br J Radiol 2018 Oct 4;91(1090):20170571. Epub 2018 Sep 4.

2 Radiology Department, Faculty of Medicine, Beni Suef University , Beni Suef , Egypt.

Although ovarian cancer (OC) is the most lethal of all female malignancies, debate still exists concerning the benefits and harms of the screening programs and their impact on long-term survival and mortality from the disease. The most widely tested screening strategies have focused on transvaginal ultrasound (TVU) and on algorithms that measure serum levels or interval changes of cancer antigen-125 (CA-125) either individually or in combination. Transvaginal ultrasound can identify size and morphology changes of the ovary that may signal a developing malignancy; yet, it is still accused of having a low specificity. There is preliminary evidence that screening can improve survival, but the impact of screening on mortality from OC is still unclear and warrants further validation. In spite of having many published prospective studies, up to-date, none have been able to demonstrate conclusively a reduction in mortality from OC both in the screened general or high-risk population. Data from the US Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial has not shown survival or mortality benefits in the general population. Most prospective trials have reported a decrease in stage at detection (with the exception of the PLCO trial), thereby allowing treatment to be initiated when the disease is most curable. Research is in progress to develop new diagnostic tests and novel biomarkers, which when used in combination can increase the accuracy and outcomes of screening. In this review article, we will discuss the debate provoked on OC screening programs and the impact of using ultrasound on the reduction of OC-related mortality.
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http://dx.doi.org/10.1259/bjr.20170571DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6350495PMC
October 2018

Mammographic density and ageing: A collaborative pooled analysis of cross-sectional data from 22 countries worldwide.

PLoS Med 2017 Jun 30;14(6):e1002335. Epub 2017 Jun 30.

Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France.

Background: Mammographic density (MD) is one of the strongest breast cancer risk factors. Its age-related characteristics have been studied in women in western countries, but whether these associations apply to women worldwide is not known.

Methods And Findings: We examined cross-sectional differences in MD by age and menopausal status in over 11,000 breast-cancer-free women aged 35-85 years, from 40 ethnicity- and location-specific population groups across 22 countries in the International Consortium on Mammographic Density (ICMD). MD was read centrally using a quantitative method (Cumulus) and its square-root metrics were analysed using meta-analysis of group-level estimates and linear regression models of pooled data, adjusted for body mass index, reproductive factors, mammogram view, image type, and reader. In all, 4,534 women were premenopausal, and 6,481 postmenopausal, at the time of mammography. A large age-adjusted difference in percent MD (PD) between post- and premenopausal women was apparent (-0.46 cm [95% CI: -0.53, -0.39]) and appeared greater in women with lower breast cancer risk profiles; variation across population groups due to heterogeneity (I2) was 16.5%. Among premenopausal women, the √PD difference per 10-year increase in age was -0.24 cm (95% CI: -0.34, -0.14; I2 = 30%), reflecting a compositional change (lower dense area and higher non-dense area, with no difference in breast area). In postmenopausal women, the corresponding difference in √PD (-0.38 cm [95% CI: -0.44, -0.33]; I2 = 30%) was additionally driven by increasing breast area. The study is limited by different mammography systems and its cross-sectional rather than longitudinal nature.

Conclusions: Declines in MD with increasing age are present premenopausally, continue postmenopausally, and are most pronounced over the menopausal transition. These effects were highly consistent across diverse groups of women worldwide, suggesting that they result from an intrinsic biological, likely hormonal, mechanism common to women. If cumulative breast density is a key determinant of breast cancer risk, younger ages may be the more critical periods for lifestyle modifications aimed at breast density and breast cancer risk reduction.
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http://dx.doi.org/10.1371/journal.pmed.1002335DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5493289PMC
June 2017

Mammographic density assessed on paired raw and processed digital images and on paired screen-film and digital images across three mammography systems.

Breast Cancer Res 2016 12 19;18(1):130. Epub 2016 Dec 19.

Section of Environment and Radiation, International Agency for Research on Cancer, 150 cours Albert Thomas, 69372, Lyon, Cedex 09, France.

Background: Inter-women and intra-women comparisons of mammographic density (MD) are needed in research, clinical and screening applications; however, MD measurements are influenced by mammography modality (screen film/digital) and digital image format (raw/processed). We aimed to examine differences in MD assessed on these image types.

Methods: We obtained 1294 pairs of images saved in both raw and processed formats from Hologic and General Electric (GE) direct digital systems and a Fuji computed radiography (CR) system, and 128 screen-film and processed CR-digital pairs from consecutive screening rounds. Four readers performed Cumulus-based MD measurements (n = 3441), with each image pair read by the same reader. Multi-level models of square-root percent MD were fitted, with a random intercept for woman, to estimate processed-raw MD differences.

Results: Breast area did not differ in processed images compared with that in raw images, but the percent MD was higher, due to a larger dense area (median 28.5 and 25.4 cm respectively, mean √dense area difference 0.44 cm (95% CI: 0.36, 0.52)). This difference in √dense area was significant for direct digital systems (Hologic 0.50 cm (95% CI: 0.39, 0.61), GE 0.56 cm (95% CI: 0.42, 0.69)) but not for Fuji CR (0.06 cm (95% CI: -0.10, 0.23)). Additionally, within each system, reader-specific differences varied in magnitude and direction (p < 0.001). Conversion equations revealed differences converged to zero with increasing dense area. MD differences between screen-film and processed digital on the subsequent screening round were consistent with expected time-related MD declines.

Conclusions: MD was slightly higher when measured on processed than on raw direct digital mammograms. Comparisons of MD on these image formats should ideally control for this non-constant and reader-specific difference.
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http://dx.doi.org/10.1186/s13058-016-0787-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5168805PMC
December 2016

Diffusion-weighted MR imaging and assessment of ovarian carcinomas with vaginal deposit accidentally detected during pregnancy.

BJR Case Rep 2017 14;3(1):20150411. Epub 2016 Oct 14.

Faculty of Medicine, Radiology Department (Women's Imaging Unit), Cairo University, Cairo, Egypt.

Ovarian cancer during pregnancy is a complex situation that endangers the lives of both the pregnant female and the fetus. We present a 40-year-old pregnant female in the third trimester with bilateral undifferentiated ovarian adenocarcinoma and vaginal metastasis. The case was evaluated by ultrasound and MRI supported with diffusion-weighted sequence.
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http://dx.doi.org/10.1259/bjrcr.20150411DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6159271PMC
October 2016

Can we apply the MRI BI-RADS lexicon morphology descriptors on contrast-enhanced spectral mammography?

Br J Radiol 2016 Aug 21;89(1064):20160157. Epub 2016 Jun 21.

4 Department of Biostatistics and Cancer Epidemiology, National Cancer Institute, Cairo University, Egypt.

Objective:: To assess the feasibility of using the MRI breast imaging reporting and data system (BI-RADS) lexicon morphology descriptors to characterize enhancing breast lesions identified on contrast-enhanced spectral mammography (CESM).

Methods:: The study is a retrospective analysis of the morphology descriptors of 261 enhancing breast lesions identified on CESM in 239 patients. We presented the morphological categorization of the included lesions into focus, mass and non-mass. Further classifications included (1) the multiplicity for "focus" category, (2) the shape, margin and internal enhancement for "mass" category and (3) the distribution and internal enhancement for "non-mass" category. Each morphology descriptor was evaluated individually (irrespective of all other descriptors) by calculating its sensitivity, specificity, positive-predictive value (PPV) and negative-predictive value (NPV) and likelihood ratios (LRs).

Results:: The study included 68/261 (26.1%) benign lesions and 193/261 (73.9%) malignant lesions. Intensely enhancing foci, whether single (7/12, 58.3%) or multiple (2/12, 16.7%), were malignant. Descriptors of "irregular"-shape (PPV: 92.4%) and "non-circumscribed" margin (odds ratio: 55.2, LR positive: 4.77; p-value: <0.001) were more compatible with malignancy. Internal mass enhancement patterns showed a very low specificity (58.0%) and NPV (40.0%). Non-mass enhancement (NME) was detected in 81/261 lesions. Asymmetrical NME in 81% (n = 52/81) lesions was malignant lesions and internal enhancement patterns indicative of malignancy were the heterogeneous and clumped ones.

Conclusion:: We can apply the MRI morphology descriptors to characterize lesions on CESM, but with few expectations. In many situations, irregular-shaped, non-circumscribed masses and NME with focal, ductal or segmental distribution and heterogeneous or clumped enhancement are the most suggestive descriptors of malignant pathologies.

Advances In Knowledge:: (1) The MRI BI-RADS lexicon morphology descriptors can be applied in the characterization of enhancing lesions on CESM with a few exceptions. (2) Multiple bilateral intensely enhancing foci should not be included under the normal background parenchymal enhancement unless they are proved to be benign by biopsy. (3) Mass lesion features that indicated malignancy were irregular-shaped, spiculated and irregular margins and heterogeneous internal enhancement patterns. The rim enhancement pattern should not be considered as a descriptor of malignant lesions unless CESM is coupled with an ultrasound examination.
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http://dx.doi.org/10.1259/bjr.20160157DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5124889PMC
August 2016

International Consortium on Mammographic Density: Methodology and population diversity captured across 22 countries.

Cancer Epidemiol 2016 Feb 24;40:141-51. Epub 2015 Dec 24.

Princess Margaret Cancer Centre, Toronto, Canada.

Mammographic density (MD) is a quantitative trait, measurable in all women, and is among the strongest markers of breast cancer risk. The population-based epidemiology of MD has revealed genetic, lifestyle and societal/environmental determinants, but studies have largely been conducted in women with similar westernized lifestyles living in countries with high breast cancer incidence rates. To benefit from the heterogeneity in risk factors and their combinations worldwide, we created an International Consortium on Mammographic Density (ICMD) to pool individual-level epidemiological and MD data from general population studies worldwide. ICMD aims to characterize determinants of MD more precisely, and to evaluate whether they are consistent across populations worldwide. We included 11755 women, from 27 studies in 22 countries, on whom individual-level risk factor data were pooled and original mammographic images were re-read for ICMD to obtain standardized comparable MD data. In the present article, we present (i) the rationale for this consortium; (ii) characteristics of the studies and women included; and (iii) study methodology to obtain comparable MD data from original re-read films. We also highlight the risk factor heterogeneity captured by such an effort and, thus, the unique insight the pooled study promises to offer through wider exposure ranges, different confounding structures and enhanced power for sub-group analyses.
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http://dx.doi.org/10.1016/j.canep.2015.11.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4738079PMC
February 2016

Breast imaging in the young: the role of magnetic resonance imaging in breast cancer screening, diagnosis and follow-up.

J Thorac Dis 2013 Jun;5 Suppl 1:S9-S18

Women's Imaging Unit, Cairo University, Egypt.

Diagnosis of breast cancer in young individuals (younger than 40 years old) poses a real challenge to breast radiologists because their breast tissue is often denser than the breast tissue of older women. Magnetic Resonance Imaging (MRI) may be particularly helpful in such situations. The American Cancer Society (ACS) recommended breast MRI screening as an adjunct to mammography for: BRCA mutation carriers and their first-degree relatives; women with a lifetime breast cancer risk ≥20% to 25%; women with a history of chest radiation between ages of 10 and 30 years; and women with predisposing genetic syndromes. Currently, breast MRI demonstrates a high sensitivity in the range of 93-100%. As many benign lesions also show enhancement or other atypical features on MRI, the primary weakness of contrast enhanced MRI remains in its low specificity, reported to be in the range of 37-97%. Breast MRI is helpful in demonstrating the true tumor size initially, as well as identifying residual tumor following the completion of neo-adjuvant therapy. In general, sensitivities ranging from 61% to 86% for detecting residual disease have been reported. The absence of enhancement virtually excludes a recurrence and the presence of enhancement is very specific for tumor even in the radiated breast. MRI is also the preferred modality for assessment of the breast after re- constructive surgery. The role of Magnetic Resonance Imaging (MRI) in breast diagnosis will continue to evolve as technology improves and clinical experience with new techniques expands.
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http://dx.doi.org/10.3978/j.issn.2072-1439.2013.05.02DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3695543PMC
June 2013

Classification of inflammatory breast disorders and step by step diagnosis.

Breast J 2009 Jul-Aug;15(4):367-80. Epub 2009 May 22.

Woman Imaging Unit, Radiodiagnosis Department, Kasr El Aini, Cairo University Hospitals, Cairo, Egypt.

In this study, the authors proposed a classification of inflammatory breast disorders based on which a practical systematic scheme in diagnosis was applied aiming to differentiate simple forms of mastitis from more complicated and malignant forms. The study population included 197 female patients who were clinically or pathologically diagnosed as having mastitis. All patients underwent Ultrasound examination. Mammography was performed for 133/197 cases. Cases of simple mastitis and periductal mastitis were followed up to ensure complete resolution. Abscess cavities and postoperative collections were drained. Other cases were biopsied to confirm diagnosis and were managed accordingly by their treating physicians. Statistical analysis was performed by the Statistical Package for Social Science. Nominal Data were expressed as frequency and relative frequencies (percentage). Ultrasound and Mammography categorical results were compared using the Pearson Chi Square and Fisher's exact test. Patients were classified into three groups; infectious, noninfectious and malignant mastitis. Simple and malignant forms of mastitis showed many signs in common. The presence of ill defined collections and abscess cavities on ultrasound favored simple over malignant forms of mastitis while extensive skin thickening and infiltrated malignant nodes favored malignant forms. Interstitial edema, edematous fat lobules, abscess cavities, skin thickening seen on ultrasound examination were significantly lower in noninfectious than simple and malignant mastitis. Mammography signs were less discriminating. Diffuse skin thickening and increased density favored malignant mastitis while dilated retro areolar ducts and characteristic calcification patterns favored noninfectious forms. Simple mastitis showed nonspecific signs. Ultrasound examination in mastitis cases shows more specific signs in differentiating between the three forms of mastitis and is useful in monitoring treatment, excluding complications and guide for interventional procedures. Mammography should be performed whenever complicated, malignant and uncommon forms of mastitis are suspected.
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http://dx.doi.org/10.1111/j.1524-4741.2009.00740.xDOI Listing
November 2009

Women Health Outreach Program; a New Experience for all Egyptian Women.

J Egypt Natl Canc Inst 2008 Dec;20(4):313-22

The Department of Radiology, Women Imaging Unit, Cairo University. Senior Consultant, Cairo Radiology Center, Radiology Consultant for The Ministry of Health, GM of Women's Health Outreach Program (WHOP), President of National Foundation for Breast Cancer Elimination, Secretary General of Egyptian Society of Women's Imaging and Health Care (ESWIH).

Unlabelled: The global health community faces a challenge with breast cancer being the most common cause of cancer related death among women around the globe. Since breast cancer's pathogenesis is poorly understood, primary prevention is still a distant goal. Thus secondary prevention through early detection is the only feasible approach at present. With this strong conviction, the launching of the first Egyptian national screening program "Women Health Outreach Program" (WHOP), was announced on October 30th 2007. This project is a government- funded program that offers free breast screening for all Egyptian women above the age of 45 years. In addition to free mammograms, the program gives the participants a chance to be screened for diabetes, hypertension and obesity as well. Positively detected cases are also offered the option of free management. During the period from October 30th, 2007, up to February 9th, 2009, 20, 098 women in Cairo, Alexandria and Suez governorates were screened for breast cancer, diabetes, hypertension and obesity through the program. In this article we will represent the achievements, challenges and services delivered by WHOP.

Key Words: Breast cancer - Breast screening - Early detection - Breast biopsy.
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December 2008

Missed breast carcinoma; why and how to avoid?

J Egypt Natl Canc Inst 2007 Sep;19(3):178-94

The Departments of Radiodiagnosis, Cairo University and General Surgery, National Cancer Institute.

Introduction : Despite the advances in mammography techniques, it still has a number of limitations. It is estimated that about 10 to 25% of lesions are overlooked in mammograms out of which about two thirds are detected retrospectively by radiologists and oncologists. Causes of missed breast cancer on mammography can be secondary to many factors including those related to the patient (whether inherent or acquired), the nature of the malignant mass itself, poor mammographic techniques, provider factors or interpretive skills of radiologists and oncologists (including perception and interpretation errors). Aim of Work : The aim of this study is to investigate the aforementioned factors hindering early breast cancer detection and in turn lowering mammographic sensitivity and to outline the major guidelines to overcome these factors aiming to an optimum mammographic examination and interpretation by radiologists and oncologists. Subject and Methods : We conducted this multicenter study over a two-year interval. We included 152 histopathologicaly proven breast carcinomas that were initially missed on mammography. The cases were subjected to mammography, complementary US, MRI and digital mammography in some cases and all cases were histopathologically proven either by FNAB, CNB or open biopsy. Results : Revision of the pathological specimens of these 152 cases revealed 121 infiltrating ductal carcinomas, 2 lobular, 4 mucinous, 14 inflammatory carcinomas, 6 carcinomas in situ (3 of which were intracystic), 2 intraductal papillary carcinomas and 3 cases with Paget's disease of the nipple. In analyzing the causes responsible for misdiagnosis of these carcinomas we classified them into 4 causative factors; patient, tumor, technical or provider factors. Tumor factors were the most commonly encountered, accounting for 44.1%, while provider factors were the least commonly encountered in 14.5 %. Carcinomas were detected using several individual or combined complementary techniques. These techniques mainly included double reading, additional mammography views, ultrasound and MRI examinations. Forty four carcinomas were detected on double and re-reading by more experienced radiologists. Additional mammographic views were recommended in 35 (23%) cases. Complementary ultrasound examination was performed for all 152 cases (100%) and showed a higher sensitivity than mammography in carcinoma detection. It was diagnostic in 138 (90.8%) cases only. In the remaining 14 cases, further MRI and biopsy were performed. Conclusion : Why can breast carcinoma be missed? Four main factors are responsible for missing a carcinoma: (1) Patient factors (Inherently dense breasts or acquired dense breasts). (2) Tumor factors (subtle carcinoma, masked carcinoma, multifocal carcinoma and multicentric carcinoma). (3) Technical factors (bad exposure factors, malpositioned breasts and bad processing quality). (4) Provider factors (bad perception and misinterpretation). How to avoid missing a breast carcinoma? Review clinical data and use US and other adjunct techniques as MRI and biopsy to assess a palpable or mammographically detected mass. Be strict about positioning and technical factors. Try to optimize image quality. Be alert to subtle features of breast cancers. Always consider the well defined carcinoma. Compare current images with multiple prior studies to look for subtle increases in lesion size. Look for other lesions when one abnormality is seen. Judge a lesion by its most malignant features. Double reading and the use of computer aided diagnosis (CAD) and finally FFDM (Full Field Digital Mammography). Close cooperation between the oncologist, radiologist and pathologist is essential to avoid missing any case of breast carcinoma. Key Words : Missed breast carcinoma -Mammography - Ultrasonography -MRI.
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September 2007