The effect of the addition of tomosynthesis to digital mammography on reader recall rate and reader confidence in the UK prevalent screening round.

AIM: To compare reader recall rate and confidence associated with recall decisions for digital mammography (DM) alone with DM plus digital breast tomosynthesis (DBT) in the prevalent screening round. MATERIALS AND METHODS: Following regional ethics committee approval and written informed consent from all participating women, DM and DBT were obtained. DM followed by the combination of DM plus DBT were reviewed retrospectively by one of nine radiologists, for 880 women aged between 46 and 53. Differences in recall rates and reader confidence were assessed using the McNemar test and sign test, respectively. Subgroup analyses were performed for conventional prevalent round (aged 50-53 years) and age extension trial (aged 46-49 years) groups, as well as low breast density (BI-RADS A and B) and high breast density (BI-RADS C and D) groups. RESULTS: The recall rate using DM alone was 17.4% (95% confidence interval [CI] 15, 20). The recall rate using DM and DBT was 11.4% (95% CI: 9.5 to 13.8). There was a relative reduction of 35% (p=0.0001). There were reductions in both the conventional prevalent round (31.1% reduction, p=0.004) and age extension subgroups (37% reduction, p=0.0007). There were also reductions in both the low density group (37.2% reduction, p=0.0007) and the high density group (31.1% reduction, p=0.003). The median confidence rating with the recall decision was 7/10 using DM and 8/10 using the combination of DM and DBT (p=0.0001). CONCLUSION: The addition of DBT to DM in the prevalent screening round was found to reduce the reader recall rate, with a modest associated increase in reader confidence.

Carcinoma of the breast wire localisation post nuclear medicine sentinel lymph node imaging. Are radiologists receiving a significant dose?

OBJECTIVE: To assess the radiation dose received by the radiologist when performing wire localisation for axillary radio-isotope sentinel node imaging-guided biopsy in patients with impalpable breast cancers treated with breast-preserving excision. When wire placement follows radio-isotope sentinel node imaging (RSNI) the radiologist is exposed to a radiation risk that has never been previously assessed. METHODS: Radiation doses to radiologists performing ultrasound-guided localisation following nuclear medicine sentinel node imaging were measured for procedures on the day of surgery (20 MBq) and also on the day before surgery (40 MBq). These measurements were compared with theoretically calculated doses. RESULTS: Twelve patients showed comparable results between measurements and estimated doses. The mean measured dose was 1.8 muSv (estimated 1.8 muSv) for same-day and 4.8 muSv (estimated 3.4 muSv) for next-day surgery cases. At worst, radiologists who perform 36 wire localisations per year immediately following RSNI receive a radiation dose of 0.17 mSv. CONCLUSIONS: This study highlights the need to inform radiologists of the relative risk when performing pre-surgical localisation after RSNI. This risk should be justified locally in accordance with the total dose received by the localising radiologist. Particular consideration should be given to pregnant staff and the possibility of performing wire localisations before radio-isotope injection.

Colorectal breast metastases presenting with atypical imaging features.

Breast metastases from non-breast primaries are rare in female patients and exceedingly rare in male patients, with only a handful of cases described. Lymphoma, metastatic melanoma and bronchial carcinoma are the primary sites for the majority of breast metastases. Breast metastases from colorectal carcinoma have been described previously in only a small number of cases in the literature. Here, we report a further two patients with biopsy-proven colorectal carcinoma metastases to both breasts, who demonstrate contrasting unusual and atypical imaging features that have not been reported previously. In one case, the imaging appearances mimic a multifocal primary breast carcinoma. Metastatic disease in the breast is a marker for disseminated metastatic spread, with a correspondingly poor prognosis. Therefore, we review the imaging features that differentiate metastatic breast disease from multifocal breast primaries, which are important to recognize because the management options for these patients differ greatly.

The impact of image guided needle biopsy on the outcome of mammographically detected indeterminate microcalcification.

A study was carried out to examine the impact of development in image guided needle biopsy on the outcome of mammographically detected indeterminate microcalcification. Between 01.04.1991 and 31.03.2001, the South East London Breast Screening Programme detected 392 cases of indeterminate microcalcificaton. Histological diagnosis was obtained using open biopsy, fine needle aspiration cytology (FNAC), 18/14 G wide bore needle core biopsy (WBNCB) and 11 G vacuum assisted core biopsy (VACB). The study period group was divided into two. Group A (between 01.04.1991 and 31.03.1996) and group B (between 01.04.1996 and 31.03.2001). There was a significant reduction in the benign open biopsy rate in group B compared to group A (25% vs. 51%) (P=0.0001). Of the malignant cases, there is a higher percentage of ductal carcinoma in situ (DCIS) in group B compared to group A (77% vs. 62%). In conclusion, the implementation of more effective methods of image guided biopsy has led to a 50% reduction in benign open biopsies for indeterminate microcalcification and to an increase in the detection of DCIS.

15. Image-guided breast biopsy.

The introduction of mammographic screening has led to an increased number of impalpable in situ and invasive breast cancers. Image-guided percutaneous biopsy in these patients has advantages over surgical biopsy, primarily cost savings and reducing the number of operations required for definitive treatment. Image-guided breast biopsy is also useful in palpable lesions. Image-guided biopsy should be used in conjunction with full clinical and imaging work-up as part of the triple assessment protocol. Techniques available include fine needle aspiration, automated needle-gun core and vacuum assisted large core biopsy. Lesions visible on ultrasound are preferentially biopsied using ultrasound guidance, while those seen only mammographically are biopsied using stereotactic guidance. Major complications are rare following image-guided biopsy. In most cases further management can be decided based on the biopsy result. If there is discordance between clinical and imaging features and the biopsy result, image-guided percutaneous biopsy should be repeated or surgical biopsy may be required.

MR imaging of the skin and nipple of the breast: differentiation between tumour recurrence and post-treatment change.

Contrast-enhanced MR imaging of the breast has been found to be valuable in the assessment of local recurrence of previously treated breast cancer. We looked specifically at the appearances of the skin and nipple of the treated breast in order to describe the appearances of post-treatment change and recurrence in this region. Thirty-nine women treated for breast cancer had MR imaging of one or both breasts reviewed retrospectively with particular attention to the nipple and skin. The skin and chest wall were assessed for patients with mastectomies. All available histology of the skin and/or nipple, obtained following MR imaging, was reviewed. In patients who did not undergo surgery following MR imaging, clinical follow-up was obtained. Six of 39 cases had nodular enhancing areas seen on MR imaging, which correlated with histology demonstrating tumour recurrence within the skin and/or nipple. Of the remaining 33 patients, changes of linear or diffuse enhancement were seen in the skin and/or nipple of 15 patients. These changes were shown to be benign post-treatment changes at surgery/biopsy in 4 cases or by clinical follow-up in the remainder. In this article we demonstrate differing patterns of contrast enhancement within the skin and nipple in recurrent breast carcinoma vs. post-treatment changes. This suggests that contrast-enhanced MR imaging of the breast may be a useful tool in differentiating tumour recurrence from post-treatment changes within the skin and nipple.

An unusual case of intrapulmonary granulocytic sarcoma presenting as interstitial pneumonitis following allogeneic bone marrow transplantation for acute myeloid leukaemia and responding to donor lymphocyte infusion.

We report a 45-year-old female with AML who underwent a T cell-depleted sibling allograft and relapsed a year later with extramedullary disease involving the lung parenchyma and presenting with the clinical and radiological features of interstitial pneumonitis. The patient was treated with donor lymphocyte infusion (DLI) resulting in complete resolution of the radiological signs. The unusual presentation and the management options are discussed.