PB.51: Axillary lymph node ultrasound and fine needle aspiration in preoperative staging of breast cancer: re-audit

Axillary ultrasound and fine needle aspiration (FNA) are used to triage breast cancer patients to appropriate axillary surgery. We present a complete audit cycle. Departmental guidelines were changed to include repeat biopsy in cases with suspicious ultrasound/negative FNA and for patients with inconclusive FNA results between audit periods one and two.

Introduction: Previous research in this centre enabled the introduction of a local protocol of nonbiopsy and discharge of women <30 years old with presumed fibroadenomas (FAs). Four years on, we have audited protocol accuracy, effect on biopsy workload, safety and its potential for influencing UK and European practice. Methods: Women aged <30 attending the breast unit between 1 February 2009 and 31 January 2013 were retrospectively identified. Clinical and imaging results were scored following national guidelines locally adapted to incorporate a nonbiopsy protocol such that presumed FAs scored E2/U2 meeting specific protocol criteria were discharged without core biopsy. In addition, a survey assessing European practice was completed by 31 centres. Results: A total of 1,571 women age <30 were referred to the breast unit. Seven cancers were diagnosed, all aged 25 to 29. In total, 266 presumed FAs E2/U2, meeting nonbiopsy criteria were discharged without biopsy, 84 were aged 25 to 29. Fourteen re-attended with increase in size, none biopsied but five excised due to patient choice. Sixty-six E2/U2, probable FAs were biopsied due to noncompliance with the protocol. Of these, 54 were FAs, seven phyllodes tumours, and one cancer. The protocol resulted in a 78% reduction in biopsy workload in women aged ≥20 and a 72% reduction in women aged 25 to 29. No cancers developed in discharged patients, mean follow up 2.4 years. European survey results demonstrate 29% of respondents routinely sample FAs in women age ≥20, 55% in women age ≥25. Seventy-nine per cent of non-UK respondents follow-up FAs regardless of patient age. Conclusion: With rigorous adherence, our nonbiopsy protocol for presumed FAs in women age <30 appears safe and reduces biopsy/followup workload. Historically, open biopsy was performed to exclude associated malignancy. Controversy currently surrounds the management of LISN, and practice consequently varies between departments. This study is a review of a single centre's 13-year experience of managing LISN with vacuum-assisted biopsy (VAB) in order to assess the safety of this policy. Methods: A retrospective review of the breast screening database, pathology database, high-risk patient database and patients recruited to the Sloane Project was completed. Patients with LISN as the most pertinent diagnosis on VAB, with or without preceding 14-gauge CNB, were identified. Those with pathological results not concordant with imaging were excluded. The outcome of subsequent annual surveillance mammograms was recorded.  Introduction: Anisotropy is the directional dependence of the measurement of a property. As breast tissue structure and some breast diseases (DCIS) are anisotropic in structure, we aimed to establish the frequency, degree and diagnostic value of shear wave elastography anisotropy in solid breast lesions. Methods: Ninety-eight solid breast lesions (31 benign and 67 malignant) were examined in the radial and anti-radial planes, with two mean stiffness measurements (in kPa) being taken in each plane and averaged. The difference between the radial and anti-radial measurements was squared to make all readings positive, and compared with the histological diagnosis. Paired Student t tests and chi-square tests were performed to establish statistical significance of the relationships.
Results: Anisotropy was found in both benign and malignant lesions. However, the stiffness values were not related to the examination plane in either group of lesions (P = 0.2). Anisotropy was greater in malignant lesions than benign lesions (P < 0.0001). Using a malignancy threshold value for the square of the difference in radial and anti-radial stiffness of 200, the sensitivity, specificity and diagnostic accuracy of the presence of this level of anisotropy were 72%, 87% and 77% respectively. Conclusion: Stiffness of solid breast lesions on shear wave elastography is not directly related to the examination plane. Malignant lesions show more anisotropy than benign lesions. Therefore, adding anisotropy to other shear wave parameters has the potential to improve the ability of this modality to differentiate benign from malignant solid breast lesions. Introduction: MRI is widely accepted to be the most sensitive imaging modality for detecting breast cancer, but has relatively low specificity. Often additional enhancing areas are identified on MRI that require further investigation. In this study we evaluated second-look ultrasound following breast MRI and the impact of this on patient management. Methods: A retrospective review was undertaken of all breast MRIs performed between July 2010 and December 2012. Patients who had further evaluation with second-look ultrasound were reviewed. Clinic letters were also reviewed to identify any subsequent change in patient management.

P O S T E R P R E S E N T A T I O N S
Results: A total of 261 breast MRI scans were performed over this time period. Fifty-two (19.9%) had a second-look ultrasound performed; 24 for mass-like lesions and 28 for nonmass-like lesions identified on MRI. In total, 18/24 (75%) mass-like lesions had a corresponding ultrasound abnormality, and 12/28 (42.8%) nonmass-like lesions had a corresponding ultrasound abnormality. Thirty biopsies were performed (57.6%) and of these nine (17.3%) were malignant. Malignant lesions were equally distributed between mass-like and nonmass-like lesions. In total, 7/9 malignant lesions were scored U4 or U5, demonstrating features suspicious of malignancy. Management was altered in all nine cases. Conclusion: MR-directed second-look ultrasound is a valuable tool in diagnostic work-up. Mass-like lesions on MR are more likely to have an ultrasound correlate. Most malignant lesions had clearly malignant features on ultrasound.
found negative nodes. Nodes found to be positive on FNA had axillary clearance rather than sentinel node biopsy, confirmed on surgical histology in all 10. Of the 14 patients who did not have an FNA on second look, only one was found to be positive on later histology. Two of the 15 had FNA on second look, and given a negative result, did ultimately have positive nodes on sentinel node biopsy. Conclusion: MRI and second-look ultrasound/FNA correctly identified 10 (5.9%) more patients with involved nodes than initial staging. Twentynine (17.1%) other patients had additional axillary ultrasound including FNA in 15 (8.8%) without a change in axillary management. Introduction: The aim was to evaluate whether breast magnetic resonance imaging (MRI) following mid-cycle chemotherapy was influencing the neoadjuvant chemotherapy (NAC) regimen. Method: Thirty-two patients with breast malignancy receiving NAC were included in this retrospective study. Baseline and mid-cycle MRI were performed. NAC regimen and breast MRI reports were obtained from an online database. Tumour response was assessed by calculating percentage of volume reduction between interval scans. The response was categorised arbitrarily as good, moderate and poor with >50%, 20 to 50% and <20% reduction in tumour volumes respectively. Results: Nine patients had second tumours detected on the baseline MRI. The index tumours (n = 32) had showed good response in 23 (71.9%), moderate response in four (12.5%) and poor response in five (15.6%) on their mid-chemotherapy MRI. The five poor responders had good response in either the axillary node or in the second tumour. The second tumours (n = 9) showed good response in six (66.7%), moderate in two (22.2%) and poor in one (11.1%). No changes were made to chemotherapy regimen based on the MRI findings and these percentage tumour volume reductions. Conclusion: Our study shows that the percentage reduction in the tumour volumes demonstrated by the interval MRI scans are an important determinant of response to NAC. It is possible to obtain similar information from newer 4D sonography, which is cheaper and quicker to perform than MRI, and is better tolerated. In our practice, assessment at the midchemotherapy point is now undertaken with clinical assessment and ultrasound, which have provided adequate information regarding tumour responses to chemotherapy. Introduction: Lobular carcinoma presents a diagnostic challenge. Imaging and clinical findings are usually subtle. In the current climate it imposes extra strain on our resources. Our aim was to assess contribution of MRI in the preoperative local staging of lobular and mixed lobular/ductal carcinoma and to evaluate whether we can select cases for preoperative MRI based on mammographic appearance. Methods: A retrospective review of data provided by the local breast cancer database was performed. Patients with confirmed lobular or mixed lobular/ductal carcinomas that had MRI staging during a 5-year period were identified. Imaging and histopathology reports were reviewed. A total of 381 cancers were diagnosed in the study period. Ninety-one patients had breast MRI. Four cases were excluded as no final histology was available. Eightyseven patients (mean age 58) with 89 involved breasts constituted our study population. Results: Breakdown of mammographic lesions was as follows: PD, 39 (43.8%); masses, 20 (22.4%); ASD, 18 (20.2%); lymphoedema, one (1.1%); calcifications, two (2.2%); occult/subtle, nine (10.1%). MRI had a positive contribution in 27/83 cases (32.5%), did not add any further information in 49/83 cases (59%) and a negative contribution in only 7/83 cases (8.4%). MRI notably identified greater disease extent, multifocal and contralateral disease. MRI was most useful in assessing disease extent when lobular carcinoma presented as PD or mammographically occult and was of least benefit when presenting as a mass lesion. Conclusion: MRI had no advantage over conventional imaging in the majority of lobular and mixed lobular/ductal cancers presenting as a focal mass lesion. Its application could be tailored more specifically to assess nonmass lesions. Introduction: As the specificity is relatively low, histological confirmation of incidental breast lesions at 3T is needed if the treatment plan has to change. MRI-guided biopsy is needed as a proportion of these lesions will not been seen on conventional imaging. Methods: Forty-nine out of 240 patients undergoing DCE-MRI studies performed between 1 July 2011 and 20 July 2013 warranted second-look US (20% of patients). Fifteen of the 49 patients underwent MRI-guided biopsy predominantly as second-look US was negative. Diagnostic imaging and biopsy were performed on GE 3T using a dedicated breast coil, grid method, CADstream software and Vacora vacuum-assisted biopsy device with a 10G needle obtaining between 10 and 22 cores. Results: Fourteen of the 15 patients had technical success (in one patient the biopsy had to be performed twice due to unsatisfactory sampling, and repeat biopsy yielded B5b). Seven nonmass M3 lesions yielded a 43% malignancy rate (B4 = 1 and B5a = 2). Two of five M4 lesions were masses yielding B5a with overall malignancy yield in this category of 40%. One of the two M5 masses was B5b with a cancer yield in this category of 50%. Overall malignancy yield was 43%. Conclusion: As far as we know we are the only unit in the UK to perform MRI-guided breast biopsy at 3T and our results are in accordance with published literature (cancer yield between 24 and 40%). This preliminary work has shown that MRI biopsy at 3T is feasible using a hand-held multiple-insertion vacuum-assisted device.

P6
PB.06: Preliminary results in the performance comparison between the size ratio and colour scoring breast ultrasound elastographic techniques LCH Leong * , THL Moey, LSJ Sim Singapore General Hospital, Singapore Breast Cancer Research 2013, 15(Suppl 1):P6 Introduction: There are a few breast ultrasound elastographic techniques that can help with distinguishing malignant breast lesions from benign ones. Two of the better known ones are the size ratio and colour scoring methods. The aim of this study is to prospectively compare the diagnostic performance of these two elastographic techniques. Methods: Female patients referred to the radiology department for imageguided breast biopsy were prospectively evaluated with ultrasound elastography prior to biopsy following informed consent. The two elastographic methods were assessed on each breast lesion separately by different radiologists. A size ratio of ≥1.1 was taken to be malignant and <1.1 was benign. Colour scores of 1 to 3 were taken as benign and colour scores of 4 to 5 were considered malignant. Histological diagnosis was used as the gold standard. The sensitivity and specificity of both techniques were compared using the Fisher's exact test. Results: Sixty-five breast lesions in 63 women were evaluated at the interim stage of the study. There were 21 malignant and 44 benign breast lesions. The sensitivity and specificity of the size ratio technique were 100% (21/21) and 81.8% (36/44). The sensitivity and specificity of the colour scoring method were 57.1% (12/21, P = 0.001) and 86.4% (38/44, P = 0.772).

Conclusion:
The preliminary results indicate that the size ratio elastographic technique is more sensitive and accurate than the colour scoring method. A larger study is ongoing.

P7
PB.07: Why are some fibroadenomas stiff using shear wave elastography? M Elseedawy 3* , P Whelehan 1,2,3 , S Vinnicombe 1,2,3 , K Thomson 1,2,3 , A Evans 1,2,3 1 Dundee Cancer Centre, Dundee, UK; 2 Ninewells Hospital, Dundee, UK; 3 University of Dundee, UK Breast Cancer Research 2013, 15(Suppl 1):P7 Introduction: Shear wave elastography (SWE) is a promising modality for differentiating benign from malignant breast masses. A proportion of fibroadenomas are stiff (mean stiffness >50 kPa), resulting in false positive SWE findings. The aim of this study was to identify which features of fibroadenomas are associated with false positive SWE findings. Methods: A total of 151 patients with histologically confirmed fibroadenomata were identified from a prospective database, from a single breast unit. The following features were assessed by a single observer who was unaware of the SWE findings: Patient age, greyscale ultrasound lesion diameter (<15 mm or ≥15 mm), distance from the lesion to skin, composition of surrounding tissue (fatty, mixed or dense) and source of referral (screening or symptomatic). Statistical analysis was carried out using the chi-square test. Results: A statistically significant association was found between greyscale ultrasound lesion size and lesional stiffness. Twenty-nine of 70 (41%) lesions ≥15 mm were stiff, versus 10 of 81 (12%) <15 mm, P = 0.001. Patient age, distance from the lesion to skin, makeup of surrounding tissue and source were not significantly associated with stiffness. Conclusion: Fibroadenomas giving false positive SWE results tend to be larger in size than these that do not. More compression of adjacent normal tissue is assumed to be the cause of our findings. As previous studies have shown that large cancers tend to be stiffer than smaller cancers, it may be appropriate to vary the quantitative cutoff value used for benign/malignant differentiation in SWE according to lesion size. Introduction: Digital mammography has increased the number of technical recall (TR) appointments due to blurred images. Within a regional breast screening unit, 177/29,314 women (0.6%) were recalled in an analogue 12-month period compared with 639/30,102 (2.12%) with digital. Current NHSBSP TR standard = 3%, target = 2% [1]. A retrospective audit to assess breath-hold technique TR data aimed to: measure and record data for the TR's pre and post breath hold; compare these results with NHSBSP standards; and make recommendations for future practice based on these results. Methods: Datasets gathered information that included mammographic view, radiographer, side of blur, compressed breast thickness, force and location. The data for the pre breath hold sample (8,467) and post breath hold sample (9,072) were compared. A retrospective questionnaire of mammographers' perceptions demonstrated the technique was easy and rarely added additional time. Results: Pre breath hold there were 104/8,467 recalls for blurring, and post breath hold there were 31/9,072. The results demonstrate recalls measured against the NHSBSP targets, and TRs dropped from 3.21% (above recommended practice) to 2.08% (in line with standard/almost target recommendations). This is a 69.1% reduction. Fisher's exact test and Pearson's chi-squared with Yates' continuity both produced P < 2.2 × 10 -16 . Both were therefore statistically significant for blur. Conclusion: The breath hold technique has reduced the number of TRs for blur. Therefore, it is recommended that this technique should be adopted across the entire NHSBSP. Introduction: Adequate compression of the breast during mammography is essential both for ensuring high-quality images and for accurate assessment of breast density using automated volumetric breast density software. Here we explore the relationship between breast density and imaging parameters. Method: We identified a set of 210 women undergoing routine screening mammography by the same experienced radiographer using the same mammography unit. Breast density data (breast volume, fibroglandular tissue volume) were obtained using Volpara™ 1.4.0 and imaging parameters (compression force, breast thickness and dose) were extracted from the DICOM headers. Statistical analysis using Spearman's rank-order coefficient was used to examine any existing relationships.
Results: There were significant positive correlations (P < 0.01) between both breast volume and gland volume with compressed breast thickness, X-ray dose and compression force (P < 0.05). Volumetric breast density was negatively correlated with compression force in the CC view (P < 0.01) and thickness in all views (P < 0.01), and breast volume had a significant positive correlation with gland volume (P < 0.01). Conclusion: Our results show that large, dense breasts had greater thicknesses, higher X-ray doses and required a greater compression force during mammography. There was insufficient evidence to determine whether higher compression forces in larger breasts were due to increased glandular content. The negative correlations with volumetric breast density expressed as the percentage of the breast volume occupied by dense fibroglandular tissue can be explained by the fact that the positive correlations with breast volume were stronger than those with gland volume. Introduction: Breast density is a well-established risk factor for breast cancer, with assessment of percentage density via a visual analogue scale (VAS) a practical method of measurement strongly associated with risk. We present a method to adjust for inter-observer differences in VAS density estimates and examine the effect of adjustment on the classification of women at high risk of developing breast cancer.

P11
Methods: A two-stage method is used to make estimates by different observers comparable. Results from all observers are transformed onto the same distribution, then differences in case mix are accounted for. We applied our approach to 13 experienced readers assessing 13,694 screening mammograms from a large clinical study where women are categorised as high risk if they have a 5 to 8% 10-year risk computed by a validated risk model and their breast density is in the top decile of the study population.
Breast Cancer Research 2013, Volume 15 Suppl 1 http://breast-cancer-research.com/supplements/15/S1 Results: A total of 1,125 women were assessed as having a 10-year risk of 5 to 8%. Initially 126 of these were also high density, therefore classified as high risk, rising to 147 after density adjustment. After adjustment, 35 women were reclassified from nonhigh to high risk (3.5% of those initially nonhigh risk) and 14 women were reclassified from high to nonhigh risk (11.1% of those initially high risk). Conclusion: Adjusting VAS estimates of breast density for inter-observer variation substantially affected which women were classified as high risk of developing breast cancer. If VAS assessment of density is to be used in risk assessment to inform screening strategies, adjustment must be considered. Results: Twenty-three women were recalled for soft tissue lesions (six malignancies) and 13 for calcifications (one malignancy). Fifty analogue/ digital single-view mammogram pairs were obtained, 11 included histologically malignant abnormalities. Breast density scores were lower on digital than analogue (P < 0.001). There was no significant difference in the descriptions of calcifications. More inconsequential soft tissue features were described on analogue. Soft tissue features tended to be scored as less conspicuous on analogue than digital images. There was no significant difference in the description of 5/6 soft tissue cancers, but one cancer was seen by five readers on analogue, and only two on digital mammogram. See Table 1.

P13
Conclusion: This study showed that readers reported breasts as less dense and identified fewer distracting soft tissue lesions on digital mammography but there was no difference in the reporting of calcifications. One of six cancers was under-reported on digital mammography. Introduction: Digital breast tomosynthesis (DBT) increases the sensitivity and specificity of detecting invasive breast carcinoma. Integration into screening raises questions. Should we perform two-view full-field digital mammography (FFDM) and two-view DBT or two-view FFDM and singleview DBT at every screening? DBT is shown to offer greatest benefit in the assessment of a soft tissue lesion. We routinely use two-view DBT in combination mode for all patients recalled from screening for a soft tissue abnormality. The aim of our study is to assess the need for two-view DBT in the detection of breast cancer. Background: The purpose of the study was to determine the intensity of pain experienced by women undergoing mammography examination through investigation of biological, psychological and technical factors that influence any pain felt during the examination. Methods: Sixty-four women presenting for diagnostic and screening mammography were examined. Pain experience data were collected at three discrete time-points during mammography using both a visual analogue and Likert scales. Results: Pain due to compression was rated by 96.6% of women. The pain/discomfort averaged between mild (42%) to moderate (49%) in the craniocaudal (CC) projection and between mild (22%), moderate (61%) to very severe pain (13.5%) in the mediolateral oblique (MLO) projection. Correlation identified significant associated factors for pain: women's age (P = 0.001), menstruation (P = 0.042), menopausal status (P = 0.002) and marital status (P = 0.000). A unique aspect was the investigation of the sources of pain in each projection. Pain experienced during breast compression mainly arises from compression pressing on the middle of the breast and chest wall in the CC and from the compression pressing on the sternum, middle and underside of the breast and the axilla in the MLO.
Conclusion: This study supports other published work that women experience pain during breast compression within mammography and that the radiographer plays a major role in the women's experience of pain. Introduction: Breast density is an important risk factor for breast cancer. Assessment of density at screening could help identify women at increased risk of cancer, who may benefit from screening with shorter intervals or different modalities. Visual analogue scale (VAS) assessment of percentage density by observers is straightforward to implement and strongly associated with cancer risk. However, using VAS assessment for stratification would require reproducibility between observers. We examine agreement between observers assessing VAS density. Methods: The VAS breast density of 120 screening cases with full-field digital mammograms was independently assessed by 12 experienced mammographic readers. The agreement between the readers was assessed using Bland-Altman limits of agreement and the concordance correlation coefficient (CCC Introduction: High breast density, where there is a relatively large proportion of fibroglandular tissue in the breast, is associated with increased risk of developing cancer. There are several methods of assessing breast density from mammograms, and as these sometimes disagree about whether density is high (or low), we have investigated potential causes of disagreement.
Methods: A set of 6,422 mammograms with density assessed visually by two readers using Visual Analogue Scales, and volumetric breast density measured using Quantra™ and Volpara™ was obtained from the PROCAS (Predicting Risk Of Cancer At Screening) database. Cases were ranked from the highest to lowest density by each method. For each pair of methods the 20 cases with the largest discrepancy in rank, and the 20 with the smallest, were selected. Image features were recorded and compared.
Results: The two volumetric methods were more likely to disagree when calcification was present and the inframammary fold was poorly positioned. When comparing Quantra™ to visual assessment, there were more skin folds and a higher compressed breast thickness in the discrepant cases. Comparing Volpara™ with visual assessment, there were more suboptimal inframammary folds and higher compression forces in the discrepant group. Conclusion: Although visual and volumetric methods are unlikely to produce similar density estimates, those ranked highly by one method should correspond to the high-density cases identified by another. Our study indicates the need for further investigation, as lack of ground truth means that in cases of disagreement it is not possible to tell which method produced better density estimates. Introduction: The purpose was to determine the effectiveness of a silicon cushion in providing pain relief during mammography when used to cover sharp edges on the image receptor and/or compression paddle. The impact of the silicon pad(s) on image quality and radiation dose was assessed.
Methods: The transparent silicon pad was randomly assigned to the right/ left breast of the patient; the other breast was imaged as normal. The pad (s) was strategically placed on the mammography machine using three methods. Pain experience data were collected at three discrete time-points during mammography using a visual analogue and Likert scales. Radiologist image evaluators were blinded to pad assignment for image quality evaluation. Radiation dose to the breast was compared with the pad and without.
Results: Quantitatively, no significant reduction (P > 0.05) was observed in the pain experienced due to the silicon pad in either mammographic projection. Qualitatively, there was a trend for pain reduction with the silicon pad. No statistically significant degradation in image quality was assessed in either projection except due to the pad design. There were, however, significant increases in the radiation dose (P < 0.00) for both projections due to the slight increase in the compressed breast thickness due to pad thickness. Conclusion: The silicon breast cushion requires significant design changes before commercial use for pain reduction intervention in mammography.
The study did, however, emphasise that the radiographer plays an important role in the women's experience and communication by the radiographer helps in qualitatively reducing the women's experience of pain during the examination. Introduction: Radiography of the excised specimen post localisation determines whether the target lesion has been removed [1]. The surgical specimen is oriented and if a margin appears suspicious on imaging, further The differences between all of the arms for calcification clusters were statistically significant (P < 0.05). No significant differences were found for noncalcification lesions. The percentage of correctly marked lesions that were classified as recalled lesions dropped from 58% to 39% (calcifications) and from 72% to 62% (non-calcifications) between Arms 1 and 3. Conclusion: Detector type has a significant impact on the detection and recall of calcification clusters but not noncalcification cancers. Introduction: The study investigated the accuracy of two-view full-field digital (2D) mammograms (FFDM) by comparing its performance with twoview digital breast tomosynthesis (3D) plus FFDM combination in a symptomatic setting.
Methods: A multi-case multi-reader study was conducted involving four imagers of varying experience. A total of 109 lesions from 103 patients who attended symptomatic breast clinics during a 7-month period between March 2012 and September 2012 were retrospectively read. All patients who had subtle signs on 2D images were retrospectively double read in a free response study and the findings recorded. The performance quality of the methods was evaluated using receiver operating characteristic (ROC) curves. Reader agreement (k values) was calculated and the area under curve (AUC) was compared between 2D imaging and 2D+3D imaging, regarding both readers and cases as random events.
Results: There was more inter-reader agreement between the two readers with 2D+3D combination (k = 0.391) compared with 2D images alone (k = 0.153). In total, 85.19% of M3 mammograms on 2D imaging were changed to 11.01% M3 and 77.06% M2 on combination of FFDM and DBT. There was more correlation between the mammographic scores and the final result for combination mode compared with 2D images alone (P = 0.0001). ROC analysis revealed the AUC for the combination (0.898) was significantly greater than 2D mammograms alone (0.734; P = 0.009). Conclusion: DBT increases diagnostic sensitivity in a symptomatic setting and reduces the number of M3 mammograms, when used as an adjuvant to 2D images. Thus DBT has the potential of increasing work-flow efficiency in a symptomatic setting by reducing benign biopsies. Introduction: The purpose was to determine the frequency of recurrent/ residual papillomas in women who had previously undergone vacuumassisted excision biopsy (VAB) of benign papillomas without atypia and to identify factors that may be associated with recurrence. Methods: Women who had undergone VAB of papillomas and had subsequent breast imaging were identified from hospital records. Papilloma size, VAB device used and number of cores was recorded and subsequent imaging reviewed. Possible associations between the likelihood of recurrent/ residual papilloma and patient age, lesion size and excised volume to papilloma volume ratio were analysed using Mann-Whitney U tests.

P25
Results: Thirty-four women had subsequent imaging available. Median follow-up was 1,052 days. Twelve women (35%) had evidence of a mass at the excision site, with a median time to identification of recurrent/residual papilloma of 1,369 days. In three of the six cases that underwent ultrasound the recurrence was larger than the original lesion. Three recurrences were removed at open surgical biopsy and one by further VAB. None of the 34 women were diagnosed with atypia or malignancy during follow up. No significant association was found between the risk of recurrence and the age of the patient, the size of the initial lesion or the ratio of the volume of tissue removed to the lesion volume. Conclusion: Recurrent/residual papillomas are common but most do not require further intervention. No definite risk factors were identified. VAB remains the excision method of choice for most benign papillomas without atypia. Introduction: While a <2% benign biopsy rate is widely regarded as the gold standard in the screening population, there is no such guidance for biopsy in symptomatic patients. When symptomatic patients present with a lump visible on ultrasound, the decision to biopsy is down to the individual radiologist. There is currently no gold standard for the benign: malignant biopsy ratio.
Methods: A prospective list of all symptomatic clinic biopsies was compiled over 18 months from January 2012 to May 2013. Imager and histological outcome of each biopsy (B1 to B5) were recorded. Cancer detection rate for each operator per 1,000 symptomatic cases was also calculated. Axillary biopsies were excluded. Results: Six anonymised operator biopsy results were recorded. There is a wide variation with our centre of B2:B5 ratios without significant variation in the cancer detection rate between operators.
Conclusion: This study demonstrates considerable variation in biopsy threshold within one unit. There is no correlation of biopsy rate and cancer detection in this dataset, meaning that potentially there are many unnecessary biopsies performed. This study has stimulated discussion in our unit, and is a useful and simple audit to perform to investigate biopsy threshold. If performed by a number of units nationally, it may be possible to assess the range for these parameters and to suggest a normal range. There was no reduction in our B3 rate (12 and 13 cases respectively) although VAB had higher sensitivity with better correlation between biopsy diagnosis and surgical histology (77% compared with 42%). Four of 12 (25%) B3 lesions diagnosed following 14G CNB were upgraded to DCIS following surgical excision compared with no cases following VAB. Preoperative invasive malignancy diagnostic rates were unchanged, 15% of cases were upgraded in both groups. Conclusion: VAB has not reduced our B3 rate but has increased the accuracy of our preoperative diagnosis of non-invasive cancer supporting current theories that patients who have undergone vacuum-assisted biopsy may not require surgical diagnostic excision. However, we recognise the number of cases is low and further cases will be analysed and presented. Introduction: Increasing evidence supports vacuum-assisted biopsy (VAB) instead of surgical excision for the management of lesions of uncertain malignant potential (B3). This followed reports of up to 34% upgrade to malignancy on excision. In January 2012, regional guidance was adopted to clarify the options for managing such lesions. In our department, we have used similar local guidelines since 2011. We report our analysis of the management of B3 lesions before and after the introduction of VAB Introduction: There are currently no available guidelines regarding the double reporting of patients discharged from the assessment clinic back to the screening programme. Methods: A retrospective audit of patients who were referred for arbitration following discordant double reporting of patients discharged from the assessment clinic was performed. This was performed over a 2-year period from May 2011 to May 2013. The available imaging was reviewed. The outcome of arbitration was documented. The morphology of the lesion, whether a second assessment was required and outcome of the second assessment were also recorded.

P31
Results: A total of 4,445 patients were assessed in our breast unit. All patients discharged back to the screening programme following assessment were double reported at the end of the clinic. Thirteen (0.29%) patients were referred for arbitration. The morphology of the lesions was as follows: asymmetric density (n = 8), microcalcification (n = 4) and distortion (n = 1). Following arbitration, nine patients were discharged back to the screening programme. The remaining four patients underwent a second assessment. All patients who underwent a second assessment had a biopsy performed. Three of these patients were discharged following a benign biopsy result. The remaining patient was diagnosed with a grade I invasive ductal carcinoma. Conclusion: The number of patients requiring a second assessment is very small (0.09%), limiting the psychological impact on our patients. Asymmetric densities are the most common abnormality resulting in referral for arbitration. Double reporting of assessment clinic patients discharged back to the screening programme is now standard practice in our unit. Introduction: Ultrasound has long been used in the symptomatic service, not only to distinguish cystic from solid masses but also to help in the differentiation of benign from malignant lesions. The ability to correlate a benign ultrasound mass with a mammographic mass eliminates the need for further intervention. We evaluate the need for stereotactic biopsy in screen-detected, nonpalpable lesions without calcification, which have either benign or normal sonographic findings. Methods: Patients who had stereotactic biopsy for mammographic lesions from January 2011 to January 2013 were retrospectively identified from our screening database. Clinical examination and ultrasound findings, presence of calcification and pathological diagnosis were recorded. Final imaging opinion was also recorded from the pathology request forms. Results: Of 4,339 patients recalled for assessment, 1,860 had a biopsy (853 stereotactic and 1,007 ultrasound guided). Stereotactic biopsies were for microcalcification (n = 748) and for 105 impalpable, noncalcified densities with normal (n = 73) or benign (n = 32) ultrasound findings. Malignancy was detected in eight (8%) noncalcified lesions and 169 (23%) microcalcifications (P < 0.0002, Fischer exact test). Simple cysts were detected in 28/32 (88%) of cases with benign ultrasound findings. Suspicion of malignancy was mentioned in 38/105 (36%) final imaging opinions. Asymmetry (n = 4) and distortion (n = 2) were the commonest lesion features associated with a positive biopsy result. Conclusion: Stereotactic biopsy for screen-detected mammographic densities with normal or benign ultrasound findings has a low yield of malignancy. Careful analysis of mammographic findings, ultrasound correlation and further multidisciplinary discussion could help reduce unnecessary biopsies. Introduction: 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.
Methods: We conducted a retrospective review of 375 screening patients with microcalcifications over 24 months. We assessed all patients with pure calcifications ≤10 mm documenting core biopsy, final histology and treatment.
Results: Sixty-one cases of microcalcifications ≤10 mm: eight benign, 40 in situ cancers and 13 invasive cancers. This group was subcategorised into calcifications: 0 ≤5 mm (24 patients) and 5 ≤10 mm (37 patients). In the 0 ≤5 mm group, there were 16 in situ (low-grade, one; intermediate grade, seven; high grade, eight) and two invasive cancers (G2 ductals ER/PR + Her2node-negative). In the 5 ≤10 mm group, there were 24 in situ (low-grade, three; intermediate grade, 12; high grade, nine) and 11 invasive cancers (four G1ER + Her2node-negative, six G2ER + Her2 -, one triple-negative). One of these six cases was node-positive (micrometastasis) and one G3ERPR + Her2node-negative. All underwent wide local excision, and all but one patient with invasive carcinoma received radiotherapy. invite uptake in women aged 47 to 49. Screening appointments were reduced from 6 to 5 minutes. Mammographers working patterns -but not overall hours -were changed. An extra workstation was purchased for additional film reading by existing personnel. All assessment clinics became fully booked sessions (recall rate 9.4%). Biopsies were largely undertaken in existing capacity but provision was increased when needed by altering staff working patterns. Women requiring MDT discussion led to a marginal increase in MDT length. All biopsy results were delivered by breast care nurses -the extra work load required an additional session (4 hours) to fulfil the demand. All screening targets were met. Conclusion: Full lower end age extension has undoubtedly increased our screening work load. However, by reducing the screening appointment time, altering working patterns and purchasing a single extra workstation, the impact to the service has been minimised. Potential difficulties do arise in the event of sickness or leave. Introduction: The aim of National Health Services Breast Screening Programme (NHSBSP) is to reduce morbidity and mortality related to breast cancer. The success of NHSBSP depends upon a high proportion of women attending for their 3-yearly screening mammograms. The national target for screening attendance is 80% and the minimum standard is 70%. For 2010 and 2011, an overall national screening uptake for women aged 50 to 70 was 73.4%. The overall uptake rate for our screening service is recorded as the fifth lowest in achieving minimum uptake targets. The purpose of this review was to analyse the factors associated with poor uptake in some of our screening regions and assess the effectiveness of the methods used to maximise attendance in these regions.
Methods: The source of our data collection was west Midlands Cancer Intelligence Unit and NHSBSP database. We analysed the trends in screening uptake from 2007 to 2013. Results: Social deprivation, population size, ethnicity, availability and access, and education and awareness are some of the most significant factors that affect uptake. Interventions were devised to target these factors. The initiatives used were simple such as patient letters, promotional posters and multi-lingual leaflets, DNA flyers, telephonic reminders and most importantly collaborative work with GP surgeries. The results were encouraging and we managed to increase the prevalent uptake by 7.87% in our lowest uptake region. Introduction: In our Trust we classify axillary ultrasound findings as LN1 to LN5, performing fine needle aspiration cytology (FNAC) on LN3 to LN5, where LN3 represents diffuse cortical thickening (DCT) of greater than 2 mm. The resulting FNAC triages patients to either sentinel lymph node biopsy or axillary node dissection. The aim is that patients will undergo only one axillary surgical procedure. There is variation in the literature and between breast units in the DCT threshold for performing FNA, and unnecessary FNAs should be avoided. Does the resulting cytology and surgical histology validate our 2 mm threshold; or can the threshold be safely increased to 2.3 mm or 3 mm as used by some centres? Methods: The MDT records and images for all our invasive breast cancer patients classified axillary LN3 and operated upon in 2012 were reviewed. The positive predictive value (PPV) was calculated for ranges of DCT for a post-test probability of a C5 result at FNA, and then for the yield of 2+ positive nodes at surgery. Results: A total of 112 female patients were LN3 and underwent FNA in 2012. The PPV for a C5 result in DCT in ranges 2.0 to 2.29, 2.30 to 2.99 and ≥3.0 was 9.1% (1/11), 11.3% (6/53) and 14.6% (7/48) respectively. The PPV for a yield of 2+ malignant nodes was 9.1% (1/11), 9.4% (5/53) and 4.2% (2/48) respectively. Conclusion: These findings have validated our use of the 2 mm threshold for FNAC. Increasing the threshold would result in a significant number of women requiring a second axillary surgical procedure as current treatment guidelines stand.