B Dall

New patient pathway using vacuum-assisted biopsy reduces diagnostic surgery for B3 lesions

AIM To assess the clinical impact of a new patient management pathway incorporating vacuum-assisted biopsy for lesions of uncertain malignant potential (B3). MATERIALS AND METHODS A retrospective analysis was undertaken of all B3 lesions on core biopsy in the pathology database from April 2008 to April 2010. Outcome measures assessed included final histological diagnosis, frequency of diagnostic surgical biopsy, and impact on management. RESULTS In the old pathway, there were 95 B3 lesions, of which 14% (13/95) were planned for vacuum-assisted biopsy and 86% (82/95) for surgical biopsy. In the new pathway, there were 94 B3 lesions, of which 68% (64/94) were planned for vacuum-assisted biopsy and 32% (30/94) for surgical biopsy. Following further sampling with vacuum-assisted biopsy, only 13% of patients required diagnostic surgical biopsy and in 25% of cases, a preoperative diagnosis of carcinoma was reached allowing patients to proceed to therapeutic surgery. CONCLUSION The new pathway has reduced the number of benign diagnostic surgical biopsies performed and increased the preoperative diagnosis of breast cancer.

PB.38: In the context of overdiagnosis, does size matter?

The Marmot Review showed that although breast screening saves lives, it is harmful through overdiagnosis - treating cancers that would not otherwise have ever become clinically apparent. Currently, there is no size threshold for recalling screening patients with calcifications. Our aim was to assess whether a minimum size threshold would reduce overdiagnosis.

Breast MRI quality assurance in practice

Breast MRI has been incorporated into the NHSBSP programme and therefore is subject to quality assurance (QA) to NHSBSP standards. The breast screening technical guidelines recommend weekly testing of signal-to-noise ratio (SNR) and suppression effectiveness. We tested a method of implementing these recommendations on a Siemens 1.5T Avanto scanner using phantoms and software supplied as standard.

British Society of Breast Radiology Annual Scientific Meeting 2012

0.73(0.51 to 0.88) 0.73(0.48 to 0.89) US specificity 0.83 (0.68 to 0.92) 0.93 (0.8 to 0.98) US positive predictive value 0.70 (0.48 to 0.86) 0.82 (0.55 to 0.95) There were no statistically significant differences between the two groups.

PB.40. What happens to the ductal carcinoma in situ in HER2-positive cancers treated with neoadjuvant chemotherapy and trastuzumab?

There are few data regarding the effect of neoadjuvant chemotherapy (NACT) and trastuzumab on any ductal carcinoma in situ (DCIS) associated with the HER2-positive invasive carcinoma. HER2-positive breast cancers are more likely to achieve a pathological complete response (defined as absence of invasive tumour in the final excision specimen allowing for the presence of DCIS). We review our data to see what happens to HER2-positive DCIS associated with HER2-positive invasive cancer treated with NACT.

Abstract P2-02-01: Did established clinical practice regarding MRI bias the COMICE trial?

Introduction: The negative COMICE study and reports of inappropriate mastectomies worldwide have served to discredit the use of preoperative MRI for the purpose of aiding conservative breast surgery. We postulate that established clinical practice regarding MRI at the time of the COMICE trial lead to bias in case selection, with more complicated cases being preselected out prior to randomisation. We reviewed the local practice at the time of COMICE. Methods and materials: Retrospective analysis of all cases of Breast MRI performed to assess disease extent pre-operatively during recruitment to COMICE (December 2001 - January 2007) was undertaken. Size on mammogram/ultrasound, MRI and histology was documented. As pre-PAC9s era, the information was obtained from imaging and pathology reports. Where reports did not include distance between lesions in multifocal/multicentric disease, the sum of the lesions was used (taken as immediately adjacent) so as not to overestimate the size. All cases were reviewed blinded to COMICE status. Cases with mammogram/ultrasound size >/ = 40mm were excluded as these were deemed unsuitable for conservative surgery. Results: A total of 318 breast MRI examinations were performed in this interval to assess disease extent pre-operatively of which, 81 were excluded appropriately, for inadequate information (n = 47), size on conventional imaging >/ = 40mm (n = 18), receiving neo-adjuvant treatment (n = 6), non cancer diagnosis (n = 7) and non invasive disease (n = 3). 242 cancers from 237 patients were included comprising 77COMICE and 160NON-COMICE patients. Statistical difference was noted in the types of surgery between the groups, p There was a significant difference in histological size between the 2 groups, mean size in NON-COMICE cases 32mm versus 26mm in the COMICE group (p = 0.009). There was a significant difference in the tumour types between the 2 groups (p Conclusion: Data from this well established MRI unit has demonstrated clinical bias in the COMICE trial with more complicated cases, which benefited from MRI, being pre-selected out prior to randomisation which understated the value of MRI. MRI in appropriately selected patients in conjunction with modern oncoplastic surgical techniques will increase the opportunities for conservative surgery rather than increase mastectomy rates. An aggressive biopsy policy for MRI detected lesions is required to avoid inappropriate mastectomies. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-02-01.

Abstract P2-01-08: Imaging overview of metaplastic carcinomas of the breast; a study of 46 cases

Background: Metaplastic breast cancer (MBC) is a rare form of breast cancer affecting <1% of breast cancer patients. Previous studies report that the size of MBC is greater than conventional invasive ductal carcinoma at presentation. This may reflect the rapid growth rate of MBC or the difficulty in diagnosis. Imaging characteristics of MBC are not well described but the few published reports suggest that MBC often mimics benign lesions on imaging. The aim of this study therefore is to review the clinical presentation, baseline imaging features, surgical management and final surgical pathology of MBC in a large UK breast cancer unit. Methods: All female patients diagnosed with MBC during the time period Jan 2005-2012 were identified from the pathology database at Leeds University Teaching Hospitals Trust. Pathology reports were reviewed and data on MBC type (following the WHO classification), size, grade, nodal and molecular marker status was extracted. Mammography, Ultrasound (USS), CT and MRI features were recorded. Follow-up was complete until May 2013. Results : 46 patients were identified with a median age of 61yrs and a 5yr survival of 32.6% (median 50 months). Of the 46 cases, 33 presented symptomatically (71.7%), 37 (80.4%) showed a mass on mammography of which 28 (75.7%) was ill defined, 4 (10.8%) well defined and 5 (13.5%) spiculated. All 46 cases had a mass on USS. The imaging score was Bi-rads (Breast Imaging-Reporting and Data System) 5 in 23 cases, Birads 4c in 17 cases and 4a,b in 6 cases. Thirteen patients had MRI. This was performed either to determine disease extent or for neoadjuvant chemotherapy monitoring. All but one of the tumours was seen as a solid mass with some central necrosis the other was seen as an area of nodular enhancement. Nine cases had a staging CT scan for metastatic disease which was negative in all cases.The average size was 28mm (range 11-75mm), 8 (17.3%) were histological grade 3, 5 (10.9%) cases had involved lymph nodes and 28 (60.8%) cases were triple receptor negative. Only 2 cases were HER2 positive. Conclusion : In this series metaplastic cancers were symptomatic in >70%, tended to be large at the time of presentation and only 11% of cases had nodal involvement which is consistent with previous reports. Review of our radiology revealed that all modalities used (mammogram, USS and MRI) reliably showed characteristics suggestive of malignancy. Features suggestive of malignancy include spiculated or irregular ill defined masses on mammography or ultrasound and on MRI large irregular masses with central necrosis and rim enhancement following contrast. These are characteristic or suggestive of malignancy which is contrary to many previous studies of MBC that suggest MBC is difficult to pick up on imaging and commonly exhibits benign features. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-01-08.

Indications for marker clip in the setting of neoadjuvant/neoendocrine therapy

We are aware that the use of neoadjuvant therapy (NACT) and neoendocrine therapy (NAET) is steadily increasing and more patients are being referred for marker clip placement. This is our experience of the indications for marker clip placement in a large cancer unit using both NACT and NAET for treatment of breast cancers.

Should general practitioner access to breast imaging and 2WW co-exist?

The Leeds breast service treats over 500 breast cancers a year. The general practitioners (GPs) have always had access via the one-stop breast clinic or direct access to the imaging department. Any positive imaging findings are actioned within imaging and the patients are referred to the clinic for results. The GP is informed. With the introduction of 2WW it is appropriate to re-audit this practise.

How can the prevalent round recall rate be reduced

The prevalent round recall rate is higher than the incident recall rate. Implementation of age extension will lead to two prevalent rounds and with this increased clinical and financial pressure on screening units. Any processes that help reduce the recall rate will be of benefit to screening units.