N Sharma

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

AIMnTo assess the clinical impact of a new patient management pathway incorporating vacuum-assisted biopsy for lesions of uncertain malignant potential (B3).nnnMATERIALS AND METHODSnA 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.nnnRESULTSnIn 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.nnnCONCLUSIONnThe new pathway has reduced the number of benign diagnostic surgical biopsies performed and increased the preoperative diagnosis of breast cancer.

Palpable Ductal Carcinoma in Situ: Analysis of Radiological and Histological Features of a Large Series With 5-Year Follow-Up

BACKGROUNDnPalpable pure DCIS is a rare entity that presents differently than screen-detected DCIS. The aim of this study was to evaluate the clinical, radiological, and pathological characteristics and management of pDCIS in a retrospective cohort of patients.nnnPATIENTS AND METHODSnPatients diagnosed with pDCIS from January 1999 to December 2011 were identified from an electronic patient database and were included in this study.nnnRESULTSnDuring this period, 669 cases of DCIS were diagnosed and 62 (9.3%) were pDCIS (mean age, 56.9 ± 15.1 years). The most common finding on ultrasound was mass in 43 patients (75%) and only 18 (33%) cases had calcification on mammography. The lesion was mammographically occult in 20 patients (37%). Ultrasound was more sensitive and delineated the pDCIS in 45 (80%) cases. Mean size of the pDCIS was 36.9 ± 30.4xa0mm and most were high grade (nxa0=xa042; 68%) and associated with comedo necrosis in 36 (59%). Most were oestrogen receptor (ER)-positive (n = 34; 62%), however 21 patients (38%) were ER-negative. Breast conservation was attempted in 30 patients (48%), however, because of involved margins further therapeutic surgery was needed in 10 patients (33%). Axillary surgery (sentinel lymph node biopsy or axillary nodal sampling) was performed in 34 patients (55%) and no lymph node metastasis was identified. During a medial follow-up of 60 months, 1 patient has developed a mastectomy scar recurrence and the rest remain disease-free.nnnCONCLUSIONnPalpable DCIS is often occult on conventional radiological imaging and is generally associated with aggressive pathological features. Hence, careful individualized surgical planning through a multidisciplinary meeting is necessary for their management.

Preoperative sentinel lymph node identification, biopsy and localisation using contrast enhanced ultrasound (CEUS) in patients with breast cancer: a systematic review and meta-analysis

AIMnTo evaluate whether contrast-enhanced ultrasound (CEUS)-guided core biopsy of the sentinel lymph node (SLN) could identify metastatic nodes preoperatively and reduce the number of surgical SLN biopsies in patients with breast cancer and normal axillary B-mode ultrasound; and to establish whether CEUS SLN identification and localisation is a viable alternative to standard lymphatic mapping using isotope and blue dye.nnnMATERIALS AND METHODSnA search of several electronic databases was performed and identified studies were assessed using QUADAS-2 for methodological quality. Pooled estimates of sensitivity and specificity for identification of nodal metastases were calculated.nnnRESULTSnEleven prospective studies and one retrospective study with 1,520 participants were included. The SLN identification and localisation rate for CEUS-guided skin marking was 70-100%, CEUS guided-wire localisation was 89-97%, and CEUS-guided iodine-125 (125I) seed localisation was 60%. Across the four studies that evaluated preoperative CEUS-guided SLN biopsy, pooled sensitivity for identification of nodal metastases was 54% (95% confidence interval [CI]: 47-61) and pooled specificity 100% (95% CI: 99-100).nnnCONCLUSIONnCEUS is a promising technique for preoperative staging of the axilla. CEUS-guided core biopsy has the potential to identify nodal metastases in over half (54%) of patients with normal axillary B-mode ultrasound. CEUS-guided identification and localisation of the SLN may offer a viable alternative to standard lymphatic mapping using isotope and blue dye; however, further prospective studies with larger samples are warranted.

The role of magnetic resonance imaging in preoperative planning for patients undergoing therapeutic mammoplasty.

Background. Assessment of the ratio between tumour volume and breast volume in therapeutic mammoplasty is paramount. Traditionally based on clinical assessment and conventional breast imaging, the role of breast magnetic resonance imaging (MRI) in this context has not been established. Methods. Data was collected from all women undergoing therapeutic mammoplasty (TM) between 2006 and 2011. Each case was discussed at an MDT where MRI was considered to facilitate surgical planning. The contribution of MRI to disease assessment and surgical outcome was then reviewed. Results. 35 women underwent TM, 15 of whom had additional MRI. 33% of patients within the MRI subgroup had abnormalities not seen on either mammography or USS. Of those undergoing MRI, 1/15 patients required completion mastectomy versus 3 patients requiring completion mastectomy and 1 patient requiring further wide local excision (4/20) in the conventional imaging group. No statistical difference was seen between size on MRI and size on mammography versus final histological size, but a general trend for greater correlation between size on MRI and final histological size was seen. Conclusion. MRI should be considered in selected patients undergoing therapeutic mammoplasty. Careful planning can identify those who are most likely to benefit from MRI, potentially reducing the need for further surgery.

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.

Human Epidermal Growth Factor 2–positive Breast Cancer with Mammographic Microcalcification: Relationship to Pathologic Complete Response after Neoadjuvant Chemotherapy

Purpose To determine the relationship between the presence or absence of mammographic calcifications in human epidermal growth factor receptor 2 (HER2)-positive breast cancers and pathologic complete response (pCR) to neoadjuvant chemotherapy and to determine other tumor and clinical characteristics that may be predictive of such a response. Materials and Methods A database of all patients with HER2-positive breast cancer who underwent neoadjuvant chemotherapy between 2007 and 2015 was retrospectively reviewed. Patient demographic characteristics, mammographic appearance, molecular subtype of cancer (luminal or nonluminal), radiologic response (based on breast magnetic resonance images), surgery, and pathologic response to treatment were recorded. Inter- and subgroup comparison was performed for presence of mammographic microcalcification and cancer subtype by using Mann-Whitney and χ2 tests and logistic regression. Results A total of 111 patients with a median age of 49 years (interquartile range, 40-57 years) were evaluated. Of these, 64.9% (72 of 111) had mammographic microcalcifications, 63.1% (70 of 111) had luminal B cancer, and 36.9% (41 of 111) had nonluminal HER2-positive cancer. Radiologic response to neoadjuvant chemotherapy was observed in 70.3% (78 of 111) of patients. Surgery was performed in 97.3% (108 of 111) of patients, and 30.6% (34 of 111) of patients underwent breast conservation. pCR was observed in 33.3% (37 of 111) of patients; 16.2% (18 of 111) showed residual ductal carcinoma in situ and 50.5% (56 of 111) had residual invasive disease. The pCR rate was the same (P = .21) in patients with mammographic microcalcification (29.2% [21 of 72]) as in those without calcification (41.0% [16 of 39]). The pCR rate in patients with nonluminal HER2-positive cancers (46.3% [19 of 41]) was higher (P = .01) than in those with luminal B cancers (25.7% [18 of 70]). pCR was associated with nonluminal HER2-positive subtype (odds ratio, 5.4; 95% confidence interval: 1.8, 16.0; P = .01) and complete radiologic response (odds ratio, 20.4; 95% confidence interval: 3.3, 126.6; P = .01). Conclusion Patients with HER2-positive cancer and mammographic microcalcification can achieve pCR after neoadjuvant chemotherapy. Nonluminal HER2-positive subtype and complete radiologic response are predictors of pCR.

The need for triple assessment and predictors for diagnosis of breast cancer in patients <40 years of age

AIMnTo assess the safety of selective use of triple assessment with omission of radiological assessment proposed in patients <40-years old.nnnMATERIALS AND METHODSnData were collected retrospectively for all patients seen in the one-stop breast clinic between January 2014 and August 2015. Demographics, symptoms, diagnostics, and treatment details were recorded. Subgroup and logistic regression analysis was performed to identify predictors for breast cancer.nnnRESULTSnOf the 3,305 patients included, 95.6% (n=3,161) were first-time referrals. 57.6% (n=1,903) had a breast lump, and 4% (n=133) had a high-risk family history; 75.6% (n=2,499) underwent imaging and 16.7% (n=552) underwent a biopsy. The median age was 29 years (interquartile range [IQR]=25-34). Breast cancer was diagnosed in 29 cases (0.88%) and 3.2% (n=105) had surgery. Median referral-to-diagnosis time was 13 days (IQR=9-14) and referral-to-surgery time was 44 days (IQR=34-95). Patients with breast cancer were significantly older (33 versus 28 years, p=0.016). All patients were first-time referrals. Most patients had a breast lump with low suspicion on clinical examination and breast cancer identified on imaging. Time-to-diagnosis (12 versus 14 days, p=0.017) and time-to-surgery (37 versus 67 days, p=0.012) was significantly shorter in the breast cancer group. Comparative older age (odds ratio [OR]=1.08, 95% confidence interval [CI]: 1.01-1.15) and breast lump (OR=11.43,95% CI: 2.72-48.07) were the only significant predictors of cancer on uni/multivariate regression.nnnCONCLUSIONSnTriple assessment is also the best practice for all patients in the younger age group. This cohort should not be treated any differently regarding one-stop clinic infrastructure as the cancers detected were not clinically malignant. Missed cancers in this age group would have significant personal, clinical, and legal consequences.

Prospective study looking at CT staging for metastases in early breast cancer.

Practice is variable nationally with no agreed guidelines for performing CT staging of asymptomatic patients with a new diagnosis of breast cancer. We have devised a new proforma for performing staging CT in asymptomatic women with high-risk early breast cancer. In our unit, 600 cancers are diagnosed/year.

Role of mammographic templates in managing ever increasing workloads

A breast imaging report is a key component of the breast cancer diagnostic process. The report must be clear and concise to avoid ambiguity and confusion. However, substantial variation in the information provided in a breast imaging report is not uncommon to see. We sought to develop a report template containing a summary of all essential information pertinent to the surgeons and the radiologists.

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.