Although breast volume determination is of great importance in the diagnosis and treatment of breast disease, it has not been fully appreciated by many clinicians. The main reason why such an important measurement has not been routinely applied is the absence of a standardized simple, inexpensive, and accurate method.
In the present study, an approach was planned to provide a solution to these problems. We investigated five different methods of breast volume determination in terms of accuracy, convenience, and cost. We evaluated reproducibility from the literature, because it was overlooked in our study.
The studies carried out so far () did not have control groups11,13
or used another method as a control.5,14,15
In studies that used specimen volume as the control group,6,16,17
only a single method was evaluated. There was no control group in one of the three studies comparing more than one method,13
while one study used mammography14
and the other study used magnetic resonance imaging as the control group.5
The most significant feature of the present study is that mastectomy specimen volume was used as the control group, and the results of five classical measurement methods, except three-dimensional imaging, were compared.
Thus far, no study has been reported comparing the six different methods of breast volume measurement. The only study available compared four different methods,14
and used mammography as the control group, making it difficult to draw a meaningful conclusion. Bulstrode et al reported that anthropometric and casting methods yielded results similar to mammographic values, while magnetic resonance imaging and the Archimedes procedure were less accurate. Because mammographic volume calculation was made by the formula of a cone in this study instead of the formula of a half-elliptic cylinder, which has a wide acceptance,6
the validity of the study results are debatable.
Of the three studies that used specimen volume as the control group, three6,16
confirmed the high accuracy of the mammographic method and one17
confirmed the accuracy of three-dimensional imaging (r = 0.975). The study conducted by Kovacs et al,5
in which magnetic resonance imaging served as the control group, showed that three-dimensional imaging was the best method. They also reported that the anthropometric method was adequate, but the casting method was relatively less accurate.
Caruso et al13
investigated magnetic resonance imaging, casting, and Grossman-Roudner device methods in terms of costs, but did not make comparisons because they did not have a control group. Mammography was determined to be the most accurate method in this study, followed by the Archimedes procedure and the anthropometric method. While the results yielded by the Grossman-Roudner device were moderately accurate, the results of casting method were less accurate ().
Each measurement was repeated 10 times in the study by Kovacs et al,5
four times by Fowler et al,12
three times by Caruso et al,13
twice by Losken et al,17
Kalbhen et al,6
and Edsander-Nord et al,10
while we and other authors11,14–16
performed volume measurements only once (). Reproducibility could not be assessed in studies with a single measurement. In terms of reproducibility, magnetic resonance imaging,12
and three-dimensional imaging17
were demonstrated to be adequate.
Kovacs et al5
demonstrated breast volume measurement using magnetic resonance imaging to be more reproducible when compared with three-dimensional imaging, anthropometry, and casting methods. Caruso et al13
also established magnetic resonance imaging to be the most reproducible method, while the Grossman-Roudner device had moderate reproducibility and the casting method had the lowest level of reproducibility. Edsander-Nord et al10
reported a 6% standard deviation (SD) after two measurements with the casting method, and claimed that casting was a quite reproducible method. Similarly, Malini et al18
claimed that ultrasound had good reproducibility, with an 8% SD in three measurements.
Bulstrode et al4
investigated and scored the acceptability of five different methods by patients and doctors. The most convenient method was the anthropometric measurement for patients. While the patients reported that mammography was intolerable, MRI, the Archimedes procedure, and casting methods were moderately tolerable. For the doctors, on the other hand, the anthropometric and casting methods were reported to be the easiest, while mammography was moderately difficult, and magnetic resonance imaging and the Archimedes procedure were difficult. Evaluation of the combined scores of patients and doctors revealed that the best method was the anatomic method, followed by casting, magnetic resonance imaging, the Archimedes procedure, and mammography. Unfortunately, the Grossman-Roudner device method was not included in this study. Although Kovacs et al5,19
did not compare the four different methods in terms of convenience and comfort, they claimed that three-dimensional imaging was the ideal method because it was simple and did not require pressure on the breast or contact with the patient. In our study, the most comfortable method was the Grossman-Roudner device, followed by anthropometry. Mammography and the Archimedes procedure were rather uncomfortable, and casting was the most uncomfortable one.
The only study comparing breast volume measurement methods in terms of duration was reported by Caruso et al13
(). They showed that the shortest method was the Grossman-Roudner device. In our study, the Grossman-Roudner device was also the shortest, and the anatomic method was the second shortest procedure. Mammography and the Archimedes procedure were slightly longer procedures as a volume measurement method. Kovacs et al claimed that although three-dimensional imaging was time-consuming initially, when performed by experienced staff and with sufficient technical infrastructure, three-dimensional imaging took very little time.5,19
We believe that this claim needs to be confirmed by other authors.
Time required for breast volume measurement in different methods.
The only available data concerning the cost of the procedure was reported in a study performed by Caruso et al13
(). The Archimedes, anthropometric, and Grossman-Roudner device methods were reported to have almost no cost. We confirmed that the same results in our study. The cost changing to the selected material of casting method, is approximately 20 USD.15
Although mammography has a considerable cost, it has been suggested that its cost should be accepted as zero in a routine screening program.8
However, cost becomes a problem if mammography is performed for younger women (<40 years of age) with no prior mammographic studies. Moreover, it has been claimed that volume measurement by ultrasound may lead to additional cost,6
but providing the required software and experienced staff may decrease the cost.18
Magnetic resonance imaging is a very expensive method, and causes problems for claustrophobic patients.12
Cost of breast measurement methods in US dollars.
In the present study, a significant correlation was established between mammographic pattern and mean breast density (). The studies in the literature on breast density also reported similar results; specifically Katariya et al16
reported breast density to be 0.8–0.95–1.0, which is consistent with our results (), although Aslan et al20
reported parenchymal density to be approximately 2.5 g/cm3
in gynecomastia and proposed that this fact must be taken into consideration in breast volume calculations. Their suggestion has not been supported by other investigators as yet.
Relationship between mammographic pattern and breast density.
In the present study, the overall evaluation of breast volume measurement methods was performed based on data gathered from the literature. Data on the methods were scored by us as best (3 points), moderate (2 points), and worst (1 point, ).
Overall evaluation of different breast volume measurement methods.
Magnetic resonance imaging and three-dimensional imaging methods are ideal in terms of accuracy and reproducibility. However, these methods are complex and expensive.
Although mammography offers a high level of accuracy and reproducibility, it leads to additional costs for patients <40 years of age, because compression thickness is not reported routinely in mammography reports. On the other hand, Fung et al developed a formula for accurate mammographic measurement which did not need compression thickness. 21
However, this will need to be confirmed by future studies. Furthermore, the mammographic method is associated with poor patient tolerability.
Although anatomic methods are quite accurate and reproducible, selection of the appropriate formula is still a problem, and doing calculations is impractical.
Casting and water displacement methods have not become routine practices due to low patient comfort, complications in their application, and additional costs, as well as their relatively low levels of accuracy. The Grossman-Roudner device, on the other hand, is a simple, rapid, and painless measurement method, which does not lead to additional costs. Moreover, the Grossman-Roudner device offers a high level of accuracy, especially for breast volumes below 500 mL.
We suggest that the Grossman-Roudner device method can be accepted as the standard approach in breast volume measurement because it yields results that are very close to actual values and it is a simple, pain-free, and rapid method. The most common objection to using the Grossman-Roudner device in breast volume measurement is the difficulty in performing measurements over 425 mL with the original three-disc set. We tried to overcome this problem by preparing two custom discs with diameters of 24 cm and 28 cm for volumes of 700 mL and 1500 mL, respectively, similar to the additional disc for 600 mL described by Caruso et al.13
However, the high-volume breast (over 500 mL) is still a problem for the accuracy of the Grossman-Roudner device.
We also suggest that the anthropometric method, and the mammographic method when appropriate, should be used in addition to the routine Grossman-Roudner device procedure. We maintain that this triple measurement method may provide interesting and valuable information, especially for research clinics.
The accuracy of the Grossman-Roudner device for measurement in cases of macromastia and in rigid breasts, such as those with capsular contracture, postirradiation breast thickening has been reported to be poorer.11
Removing those cases from this study resulted in a satisfactory level of accuracy. In conclusion, we suggest that further prospective studies using specimen volume as a control group should be conducted to compare several methods. In this way, we can determine an ideal method of breast volume measurement that becomes a part of routine breast examination.