A.R.M. Wilson

The role of ultrasound in breast cancer screening. A consensus statement by the European Group for breast cancer screening

The members of the European Group for Breast Cancer Screening have considered the use of ultrasound in breast diagnosis and breast cancer screening. After wide consultation and a detailed literature review, the consensus of the Group on the role of ultrasound is as follows: current evidence indicates that ultrasound of the breast is an important adjunct to mammography and clinical examination in the further assessment of both palpable and impalpable breast abnormalities. However, the use of ultrasound in population screening of asymptomatic women is associated with unacceptably high rates of both false positive and false negative outcomes. At present there is little evidence to support the use of ultrasound in population breast cancer screening at any age.

Screen detected ductal carcinoma in situ (DCIS): overdiagnosis or an obligate precursor of invasive disease?

OBJECTIVES:Ductal carcinoma in situ (DCIS) represents 20%–25% of malignancy detected at mammographic screening. This study aims to clarify the value of detecting DCIS at mammographic screening by assessing its biological characteristics and by comparing screen detected DCIS with a series of symptomatic DCIS lesions. METHODS:222 Screen detected and 151 symptomatic cases of pure DCIS were identified. Their histological grade and the prevalence of necrosis were ascertained and compared. RESULTS:Of the screen detected lesions 28 (13%) were low grade, 40 (18%) intermediate grade, and 153 (69%) high grade. Of screen detected lesions 186 (87%) were necrotic and 29 (13%) were not. Of the 151 symptomatic lesions 24 (16%) were low grade, 34 (23%) intermediate grade, and 89 (61%) high grade. Of symptomatic lesions 112 (75%) were necrotic and 36 (24%) were not necrotic. Screen detected DCIS was more often necrotic (p=0.008) than symptomatic DCIS. CONCLUSIONS:As most DCIS detected at screening is high grade and necrotic, aggressive investigation of suspicious microcalcification at mammographic screening is advocated. Given the biological features of screen detected DCIS, the existence of an upper limit for the detection of DCIS by the NHS breast screening programme seems to be inappropriate. 8

The positive predictive value of mammographic signs: A review of 425 non-palpable breast lesions

The sensitivity of mammography in cancer detection needs to be high but is also important to achieve a high diagnostic specificity to avoid the morbidity associated with unnecessary surgical biopsy. We have reviewed the mammographic features of non-palpable breast lesions to identify factors which may improve the specificity of mammographic interpretation and reduce the number of open surgical biopsies for benign lesions. Four hundred and twenty-five surgical biopsies of non-palpable breast lesions were performed following image-guided localization between January 1987 and April 1994. The mammographic features of these lesions were reviewed and correlated with their histology. Two hundred and twenty-five of the excised lesions were malignant and 200 were benign giving a benign to malignant ratio of 0.88:1 and a positive predictive value (PPV) for malignancy of 53%. Pre-operative fine needle aspiration cytology was performed in 359 cases (84%). The PPV for the various mammographic abnormalities following the assessment process ranged from 4% for well defined masses to 94% for spiculate masses. The PPV for all microcalcifications was 45%. For impalpable lesions it is our policy to recommend surgical excision of all spiculate masses, parenchymal deformities and high risk microcalcifications. Ill defined masses are managed according to fine needle aspiration cytology (FNAC) and/or core biopsy results. Masses which are entirely well-defined are regarded as benign and are not recalled for assessment unless they are new or enlarging. Needle core biopsy has been added to our preoperative assessment of mammographically indeterminate microcalcifications with the aim of reducing the number of benign surgical biopsies.

Is Ipsilateral Mammography Worthwhile in Paget's Disease of the Breast?

AIMS To identify the clinical value of pre-operative ipsilateral mammography in patients with Pagets disease of the breast. METHOD The mammograms and histological data of 27 patients with Pagets disease and 60 patients with symptomatic DCIS without Pagets disease were reviewed and compared. RESULTS Forty-four percent of patients with Pagets disease had normal mammograms. Mammography did not discriminate between DCIS and invasive disease, and could not predict DCIS sub-type. DCIS was large cell in 80% of patients with Pagets disease. Given that large cell DCIS in non Pagets patients is normally visible mammographically, the large proportion of Pagets patients with normal mammography is difficult to explain, but could be due to the small size of the lesions. Comparison of the Pagets and non-Pagets groups showed that large cell solid disease was more common, small cell cribriform less common and normal mammography more common in the Pagets group. Given that mastectomy is the treatment of choice, the only clinical value of ipsilateral mammography in our unit would be to allow image guided core biopsy of any detected mammographic abnormalities to determine the presence of invasive disease prior to surgery, thus indicating the need for node sampling pre-operatively rather than as a delayed procedure. This study also confirms that mammography is of little help in deciding if breast conserving surgery is appropriate for individual cases of Pagets disease of the nipple due to the insensitivity of mammography in showing the site of disease.

Pure mucinous breast cancer-mammographic and ultrasound findings

UNLABELLED Aim to describe the mammographic and ultrasonographic features of pure mucinous breast cancer. PATIENTS AND METHODS The mammographic features of 15 patients and ultrasonographic features of seven patients with pure mucinous breast cancer were reviewed retrospectively by three experienced breast radiologists. RESULTS The commonest mammographic appearance was of a poorly defined (86%) lobulated (71%) mass which could contain calcification (14%). A well defined mass (14%) and suspicious calcifications without a mass (7%) were also seen. Ultrasound showed a mass lesion in all seven cases which was either hypoechoic (86%) or mixed echogenicity (14%); 86% had a heterogeneous internal echo pattern; 71% showed distal enhancement while none showed distal attenuation. CONCLUSION The imaging features of pure mucinous cancer are different from more common types of breast carcinoma. It is possible to misinterpret the appearances of this slow growing tumour as a benign lesion due to rarity of speculation on mammography and distal attenuation on ultrasonography. Most cases do, however, show other features suggesting malignancy.

Radiological Features of Papillary Carcinoma of the Breast

Seventeen patients with papillary carcinoma of the breast were analysed with respect to the radiological findings by three experienced breast radiologists. The most frequent mammographic appearance of papillary tumours was of an ill-defined (70%) and lobulated (60%) mass and at ultrasound as a well-defined (76%), inhomogeneous (62%) and hypoechoic (92%) lesion. Histopathological subtypes of encysted papillary carcinoma, encysted papillary carcinoma with an invasive focus and invasive papillary carcinomas could not be predicted from the radiological features, although invasive tumours tended to be larger at presentation than the other subtypes.

Early experience in breast cancer screening: emphasis on development of protocols for triple assessment

Abstract The early experience of the Nottingham Breast Screening Service participating in the prevalent round of the UK National Health Service Breast Screening Programme is presented. Over a 3-year-period management protocols have been developed and refined. These protocols are based on the principle of multidisciplinary triple assessment, including imaging, clinical evaluation and fine needle aspiration cytology (FNAC). Throughout this period screening performance indicators well within the national guidelines were achieved. In addition, recall for assessment rates fell from 12% to 3.4%, the benign-to-malignant biopsy ratio falling from 1:1 to 0.3:1, while the cancer detection rate of 7 per 1000 women screened was maintained. A progressive increase in diagnostic specificity was achieved while retaining cancer detection sensitivity. Overall, 60% of carcinomas were diagnosed by FNAC. Using the Nottingham Prognostic Index, 47% of cancers were in the good prognostic group, previously shown to correlate with a 10 year survival of 83%. These results are encouraging and suggest that a significant mortality benefit can be predicted for screen detected breast cancers. The adoption of a multidisciplinary triple assessment increases the specificity of the screening test without compromising sensitivity.

Correlations between the mammographic features of screen detected invasive breast cancer and pathological prognostic factors

Abstract The success of any mammographic breast screening programme depends on the detection of carcinomas with overall good prognostic features. Knowledge of mammographic correlates of prognostic features would therefore be of interest. The screening mammograms of 212 patients with prevalent round screen detected invasive cancer were assessed by two radiologists without knowledge of tumour pathological prognostic indicators. The mammographic findings were then correlated with the following prognostic indicators: tumour grade, lymph node stage, and vascular invasion status. The following radiological appearances showed significant correlation with histological grade: spiculate mass with low histological grade ( P = 0.006), and ill-defined mass ( P = 0.02), calcification suggestive of comedo DCIS ( P = 0.001) and all calcification ( P = 0.03) with high histological grade. No correlations were found between lymph node stage and mammographic features. A significant correlation was found between asymmetric density and the presence of vascular invasion ( P = 0.026). Tumours presenting as poorly defined masses and asymmetric densities tend to be large and tumours presenting as architectural distortion small at mammographic detection. Significant correlations exist between tumour grade and mammographic appearances of screen detected breast cancer. No correlations exist between mammographic appearance and lymph node stage.

Mammographic sensitivity in women under 50 years presenting symptomatically with breast cancer

Abstract The sensitivity of mammography with respect to age in women with symptomatic palpable invasive breast cancers has been assessed. The mammogram reports of 257 women less than 50 years old were compared with those of 143 women between 50 and 70 years old. The reports were classified as malignant, indeterminate, or normal/benign. Mammography demonstrated a lesion classified as suspicious of malignancy in 83 % of women over-50 compared to 65 % of those under 50 (p =

Mammography in the pre-operative assessment and post-operative surveillance of patients treated by excision and radiotherapy for primary breast cancer.

To evaluate the place of mammography in the selection of patients for excision and radiotherapy for primary breast cancer a detailed analysis of pre-operative mammograms was performed in (i) a study group of 37 patients who developed local recurrence; (ii) a matched control group with a median local recurrence free survival of 57 months. There were significantly more multifocal tumours in the study group. Tumours were significantly larger (P = 0.02) and closer to the nipple (P = 0.008) in the study group compared to the control group. Regular follow-up mammograms were available in 26 of the study group. Twenty-one patients had mammographic evidence of either residual or recurrent tumour. We conclude that pre-operative mammography is essential in the selection of patients for excision and radiotherapy. Following treatment, mammography is useful in detecting residual or recurrent disease.