A survey of current UK practice regarding the biopsy of clinically and radiologically benign breast masses in young women

A survey of current UK practice regarding the biopsy of clinically and radiologically benign breast masses in young women
L.J. Hamilton, E.J. Cornford, A.J. Maxwell
Clinical Radiology 2011 66;8:738-741

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Aim: To determine current practice in the UK of needle sampling of clinically and radiologically benign breast masses in young women.

A questionnaire regarding needle sampling practice in young women with clinically and radiologically benign breast masses was sent to 481 members of the Royal College of Radiologists Breast Group. This included questions on whether a written protocol is in place to allow avoidance of biopsy, and if so, the clinical and radiological criteria used.

Responses were available for analysis from 80 units. Forty-two (53%) units had no written policy in place, whilst 38 (47%) adhered to a written policy. Of those with a policy, an age criterion for safe avoidance of biopsy was present in 36 out of the 38 units (95%). The age limit used ranged from <25 years to <35 years. Twenty-seven (71%) written policies included clinical criteria but only four (10%) policies included a size criterion. Radiological criteria were present in all policies and the majority (74%) adhered to full Stavros criteria. Seven units (18%) used a revised form of the Stavros criteria and three units used their own criteria.
Conclusion

There is little concordance between symptomatic breast clinics regarding the criteria for avoidance of breast biopsy in this young patient group. Given the very low incidence of breast carcinoma in women less than 25 years old it is considered safe and feasible to adopt a standardized protocol across the UK and avoid the often-unnecessary benign biopsies in these patients

Digital infrared thermal imaging (DITI) of breast lesions: sensitivity and specificity of detection of primary breast cancers

Digital infrared thermal imaging (DITI) of breast lesions: sensitivity and specificity of detection of primary breast cancers
M. Kontosa, R. Wilson and I. Fentiman
Clinical Radiology 2011 66;6:536-539

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Thermography had 90 true-negative, 16 false-positive, 15 false-negative and 5 true-positive results. The sensitivity was 25%, specificity 85%, positive predictive value 24%, and negative predictive value 86%.

Despite being non-invasive and painless, because of the low sensitivity for breast cancer, DITI is not indicated for the primary evaluation of symptomatic patients nor should it be used on a routine basis as a screening test for breast cancer.

The diagnosis of non-malignant papillary lesions of the breast: comparison of ultrasound-guided automated gun biopsy and vacuum-assisted removal

The diagnosis of non-malignant papillary lesions of the breast: comparison of ultrasound-guided automated gun biopsy and vacuum-assisted removal
M.J. Kima, S.-I. Kimb, J.H. Youka, H.J. Moona, J.Y. Kwaka, B.-W. Parkb and E.-K. Kim

Clinical Radiology 2011 66;6:530-535

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Out of 271 papillary lesions, 195 (80.0%) were benign, 21 (7.7%) were atypical, and 55 (20.3%) were malignant. There were no false negatives or underestimated atypical papillomas in the VAR group. However, in the ACNB group, the false-negative rate was 7.6% (12 of 157 benign papillomas, 95% CI; 4.4–12.9%, p = 0.039) and the atypical papilloma underestimation rate was 33% (five of 15 atypical papillomas, 95% CI; 15.2–58.3%, p = 0.135). The histological upgrade rates of the diagnosis for papillary breast lesions were 0% for the VAR (0 of 66) group and 10.2% for the ACNB (21 of 206) group before adjusting for the population (p = 0.003).

ACNB was associated with significantly higher false-negative and histological upgrade rates of diagnosis for papillary breast lesions than VAR.

Staging primary breast cancer. Are there tumour pathological features that correlate with a false-negative axillary ultrasound?

Staging primary breast cancer. Are there tumour pathological features that correlate with a false-negative axillary ultrasound?
S. Johnson, S. Brown, G. Portera, J. Steela, K. Paisleya, R. Watkinsa and C. Holgate
Clinical Radiology 2011 66;6:497-499

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Of 155 women with normal ultrasounds, 45 (29%) were node positive at axillary surgery. Breast tumour size was significantly different with the average size smaller in the true-negative group: 21 versus 30 mm (p < 0.02). The histological type varied significantly between the groups, with more lobular carcinomas in the false-negative group [6/110 (5%) versus 6/45 (13%), p < 0.001]. The false-negative group was also more likely to show lymphovascular invasion in the breast [6/110 (5%) versus 14/45 (31%), p < 0.001]. There was no significant difference in tumour grade or ER status.

The present study has found significant differences in tumour characteristics between women with true-negative and false-negative axillary staging ultrasound in terms of size, primary tumour histological type and presence of lymphovascular invasion. In particular, axillary ultrasound in primary lobular carcinoma may be less accurate and a negative result is more likely to be spurious than with primary ductal carcinomas.

Significance of internal mammary lymph nodes in patients after mastectomy with tissue-expander reconstruction: a case–control study

Significance of internal mammary lymph nodes in patients after mastectomy with tissue-expander reconstruction: a case–control study
R. Kaewlai, S.R. Digumarthy, B.L. Smith, A.D. Corben, W.G. Austen Jr., J.-A.O. Shepard, A. Sharma
Clinical Radiology 65 (2010) 453–459
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IMNs are common on imaging after mastectomy and tissue-expander placement. The IMNs decreased or remained stable on follow-up imaging and may represent reactive nodes

Ultrasound of the axilla: where to look for the sentinel lymph node

Ultrasound of the axilla: where to look for the sentinel lymph node
P. Britton, P. Moyle, J.R. Benson, A. Goud, R. Sinnatamby, S. Barter, M. Gaskarth, E. Provenzano, M. Wallis
Clinical Radiology 2010 65:373–376

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Of 121 patients who underwent axillary ultrasound and CB no malignancy was identified in 73, all of whom subsequently underwent SLNB. Histological evidence of CB in the SLN was identified in 47 (64%) patients. The position of all the lymph nodes identified on ultrasound and the 47 patients whose SLNs were identified were drawn on composite diagrams of the axilla.

Of the 36 nodes identified as sentinel whose position relative to other nodes could be determined, 29 (81%) represented the lowest node identified in the axilla, four (11%) were the second lowest, and three (8%) were the third lowest node. None of the four patients whose CB was from the fourth lowest node had the CB site identified at subsequent SLNB

Ultrasound of the axilla should be carried out in a systematic fashion focusing on level I nodes paying particular attention to the lowest one or two lymph nodes

Image-guided breast biopsy: state-of-the-art

Image-guided breast biopsy: state-of-the-art
E.A.M. O'Flynn, A.R.M. Wilson, M.J. Michell
Clin Rad 65;4:259-270

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Review of breast biopsy by the King's team

Criteria for the safe avoidance of needle sampling in young women with solid breast masses

Criteria for the safe avoidance of needle sampling in young women with solid breast masses
A.J. Maxwell, J.M. Pearson
Clinical Radiology 2010 65;3:218-222

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Nine women with breast cancer, seven with phyllodes, and six with papillomas were found.

No delayed diagnoses in those who had ultrasound would have been made if the following criteria had been applied to avoid needle sampling:

• age less than 25 years
• no known risk factors for breast malignancy
• mass not rapidly enlarging
• smooth discrete mobile mass on clinical examination, or lesion impalpable
• well-defined homogeneously isoechoic or mildly hypoechoic solid mass
• less than 3 cm in greatest dimension
• ovoid shape, aligned parallel to the skin surface
• smooth or gently lobulated contour (two or three lobulations only; no microlobulation
• thin echogenic pseudocapsule
• no calcification
• no acoustic shadowing

Needle sampling could have been safely avoided in approximately two-thirds of the women reviewed below the age of 25 with a solid breast mass

Screening for breast cancer post reduction mammoplasty

Screening for breast cancer post reduction mammoplasty
T.M. Muir, J. Tresham, L. Fritschi, E. Wylie
Clinical Radiology 2010 65;3:198-205

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Postoperative breast changes following reduction mammoplasty do not significantly hinder analysis of the screening mammogram

Lesion size is a major determinant of the mammographic features of ductal carcinoma in situ: findings from the Sloane project

Lesion size is a major determinant of the mammographic features of ductal carcinoma in situ: findings from the Sloane project
A. Evans, K. Clements, A. Maxwell, H. Bishop, A. Hanby, G. Lawrence, S.E. Pinder
Clinical Radiology 2010 65;3:181-184

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Lesion size has a strong influence on the radiological features of calcific DCIS; small, high-grade lesions often show no casting calcifications, whereas casting calcifications are seen in nearly half of large, low-grade lesions. As small clusters of punctate or granular calcifications may represent high-grade DCIS, an aggressive clinical approach to the diagnosis of such lesions is recommended as the adequate treatment of high-grade DCIS will prevent the occurrence of potentially life-threatening high-grade invasive disease

Diagnosis of breast cancer at dynamic MRI in patients with breast augmentation by paraffin or silicone injection

Diagnosis of breast cancer at dynamic MRI in patients with breast augmentation by paraffin or silicone injection
J.H. Youk, E.J. Son, E.-K. Kim, J.-A. Kim, M.J. Kim, J.Y. Kwak, S.M. Lee
Clinical Radiology
Volume 64, Issue 12, December 2009, Pages 1175-1180

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In patients with breasts injected with foreign material, MRI was used to successfully diagnose malignant breast lesions and could be the diagnostic method of choice. Analysis of the morphological and kinetic features at MRI in conjunction with clinical findings is essential.

(Ed..) If the patient has been injected with Silicone rather than paraffin oil, then add silicone suppression sequence to the fat suppression series to distinguish between foci of silicone and

Can breast MRI computer-aided detection (CAD) improve radiologist accuracy for lesions detected at MRI screening and recommended for biopsy in a high-

Can breast MRI computer-aided detection (CAD) improve radiologist accuracy for lesions detected at MRI screening and recommended for biopsy in a high-risk population?
T. Arazi-Kleinman, P.A. Causer, R.A. Jong, K. Hill, E. Warner
Clinical Radiology Volume 64, Issue 12, December 2009, Pages 1166-1174

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The breast MRI CAD system used could not improve the radiologists' accuracy for distinguishing all malignant from benign lesions, due to the poor sensitivity for DCIS detection

Pseudoangiomatous stromal hyperplasia: a study of the mammographic and sonographic features

Pseudoangiomatous stromal hyperplasia: a study of the mammographic and sonographic features
L. Celliers, D.D. Wong, A. Bourke
Clinical Radiology 65 (2010) 145–149

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Although there are emerging patterns associated with PASH on imaging, the features are not sufficiently specific to allow for a prospective diagnosis. Histological confirmation, preferably with core biopsy, should always be considered

(Ed:)
From a BIRADS point of view, on ultrasound these most commonly present as a circumscribed oval solid mass, and therefore benign appearances. The mammographic features are usually more suspicious and therefore more likely to prompt biopsy

Will MRI screening deliver the expected survival advantage in BRCA 1 carriers?

Will MRI screening deliver the expected survival advantage in BRCA 1 carriers?
L.J. Hamilton, A.J. Evans, E.J. Cornford, E.A. Rakha, I.O. Ellis, W.D. Foulkes
Clinical Radiology (2009) 64, 1045-1047

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Magnetic resonance imaging (MRI) screening for breast cancer has greater sensitivity than conventional mammographic screening.1,2 Digital mammography gives maximum sensitivity in younger women with denser breasts.3 Combining MRI with digital mammography is likely to give maximum sensitivity. This additional sensitivity offered by MRI has the potential to identify breast cancer at an earlier stage, when the tumours are smaller in size and are not associated with metastases to regional lymph nodes

It is of vital importance that actual mortality data on a cohort of MRI-screened BRCA1 carriers without prior breast cancer are published to en- able an informed decision on the benefits of MRI screening in this group. Until such mortality data are available, the predicted benefits must remain just that - predictions. We urge caution until such time as prospective survival data are available

Ultrasound-guided vacuum-assisted excision of breast papillomas: review of 6-years experience

Ultrasound-guided vacuum-assisted excision of breast papillomas: review of 6-years experience
A.J. Maxwell
Clinical Radiology (2009) 64, 801-806

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The findings suggests that vacuum-assisted removal is a satisfactory alternative to surgery for the majority of patients, but that particular attention should be paid to ensuring complete lesion removal in view of the relatively high recurrence rate in this series

The Royal College of Radiologists Breast Group breast imaging classification

The Royal College of Radiologists Breast Group breast imaging classification
A.J. Maxwell, N.T. Ridley, G. Rubin, M.G. Wallis, F.J. Gilbert, M.J. Michell

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Standardisation of the classification of breast imaging reports will improve communication between the referrer and the radiologist and avoid ambiguity, which may otherwise lead to mismanagement of patients. Following wide consultation, the Royal College of Radiologists Breast Group has produced a scoring system for the classification of breast imaging. This will facilitate audit and the development of nationally agreed standards for the investigation of women with breast disease.

This five-point system is as follows:

1. normal
2. benign findings
3. indeterminate/probably benign findings
4. findings suspicious of malignancy
5. findings highly suspicious of malignancy

It is recommended that this be used in the reporting of all breast imaging examinations in the UK

NB (Ed) : There are no definitions or lexicon associated with this classification, which renders it less than it could have been, and allows significant variability in reporting, particularly category 2 and 3 findings. These are important differences with the BIRADS classification which will hinder the comparison of data between the US/Europe and the UK

Mammographically non-calcified ductal carcinoma in situ: sonographic features with pathological correlation in 35 patients

Mammographically non-calcified ductal carcinoma in situ: sonographic features with pathological correlation in 35 patients
B. Mesurolle, M. El-Khoury, K. Khetani, N. Abdullah, L. Joseph, E. Kao
Clinical Radiology 64( 6) 2009: 628-636

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Ultrasonographically detected radiographically non-calcified DCIS commonly displays an irregular shape, microlobulated margins, and complex echotexture, giving a “pseudomicrocystic” appearance. Microlobulated margins and “pseudomicrocystic” echotexture seem to be associated with a cancerization of the lobules

Risk–benefit analysis of preoperative breast MRI in patients with primary breast cancer

Risk–benefit analysis of preoperative breast MRI in patients with primary breast cancer
K.C. Siegmann, A. Baur, U. Vogel, B. Kraemer, M. Hahn, C.D. Claussen
Clinical Radiology 2009 64(4): 403-413

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119 patients undergoing pre-operative MRI of the breasts. The findings changed management in 48 patients (40.3%). The change in clinical management and patient benefit were independent of BD and TT (p > 0.05).
The percentage of additional biopsies of benign lesions was 10.1%

NB No difference in outcome between tumour types (rather unexpected)

Patient satisfaction and efficacy of vacuum-assisted excision biopsy of fibroadenomas

Patient satisfaction and efficacy of vacuum-assisted excision biopsy of fibroadenomas
P. Thurley, A. Evans, L. Hamilton, J. James, R. Wilson
Clinical Radiology (2009) 64; 4:381-385

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VAB excision is well-tolerated, safe, and popular with a high initial success rate for fibroadenomas. Bruising and pain are common the week after the procedure

Prediction of the presence of invasive disease from the measurement of extent of malignant microcalcification on mammography and DCIS

Prediction of the presence of invasive disease from the measurement of extent of malignant microcalcification on mammography and ductal carcinoma in situ grade at core biopsy
E.A.M. O'Flynn, J.C. Morel, J. Gonzalez, N. Dutt, D. Evans, R. Wasan, M.J. Michell
Clinical Radiology 64, Issue 2, February 2009, Pages 178-183

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Risk of invasion associated positively with -

increased cluster size

Cluster size DCIS (mm)	Total cases	Invasive cases	Non-invasive cases
<11	136	27 (20%)	109 (81%)
11–30	131	40 (31%)	91 (69%)
31–60	95	33 (35%)	62 (65%)
>60	40	18 (45%)	22 (55%)
Total	402	118 (29%)	284 (71%)

Increasing DCIS Grade

DCIS grade	All cases	Invasive cases	Non-invasive cases
Low	31	4 (13%)	27 (87%)
Intermediate	103	26 (25%)	77 (75%)
High	239	86 (36%)	153 (64%)
Unclassified	3	1 (33%)	2 (67%)
Unknown	26	1 (4%)	25 (96%)
Total	402	118 (29%)	284 (71%)

Allows risk of invasion to be objectively estimated pre-operatively, and therefore an informed decision made about whether SLNB should be performed at the same time as definitive surgery