An audit of mammographic screen detected lesions of uncertain malignant potential (B3) diagnosed on initial image guided needle biopsy: how has our practice changed over 10 years?

AIM: To review all cases of B3 lesion diagnosed at initial image-guided needle biopsy over two 5-year cohorts to identify upgrade rates to malignancy and the effect of changing guidance on the management of such lesions. MATERIALS AND METHODS: Data was collected retrospectively. Mammographic features, biopsy type and management were recorded for each lesion. Upgrade rates for each B3 histological category were quantified. Statistical analysis was performed using SPSS. RESULTS: There were 224 cases in 2005-2010 and 240 cases in 2010-2015. Mammographically 211 lesions were microcalcifications, 182 masses, 65 distortions and six asymmetric densities with no difference in the mammographic features in the two cohorts. Two hundred and eight 14 G core biopsies and 256 initial vacuum-assisted biopsies were performed. There was a statistically significant reduction in benign surgical biopsies and an increase in second-line vacuum biopsy/excision in the latter cohort, with no significant change in the upgrade rate. There was an overall 6% upgrade to invasive malignancy and 13% upgrade to ductal carcinoma in situ (DCIS). The upgrade rates for the following histological categories were atypical intraductal epithelial proliferation (AIDEP) 33.2% (21/63); classical (not pleomorphic) in situ lobular neoplasia (ISLN) 18.2% (6/33); flat epithelial hyperplasia (FEA) 21.7% (20/92); papilloma with atypia 53.8% (7/13), without atypia 12.1% (8/66); and radial scar/complex sclerosing lesion with atypia 16.7% (2/12), and without atypia 7.9% (6/76). CONCLUSION: Upgrade rates remain high for some histological categories even with first-line use of vacuum biopsy. Management of borderline lesions should be considered carefully in a multidisciplinary meeting. In many cases, the need for diagnostic surgical excision has been replaced by image-guided vacuum sampling.

Can digital breast tomosynthesis accurately predict whether circumscribed masses are benign or malignant in a screening population?

AIM: To evaluate whether digital breast tomosynthesis (DBT) can predict if circumscribed masses are benign or malignant by assessing margin sharpness. MATERIALS AND METHODS: Circumscribed masses were evaluated on co-registered two-dimensional digital mammography (2DDM) and DBT. Lesions were categorised as follows: category 1=visible sharp border 0-25% of the total margin; category 2 = 26-50% category 3= 51-75%, and category 4=76-100%. Changes in category between 2DDM and DBT were analysed; if the category was lower on DBT the change was negative, if higher the change was positive. RESULTS: Of 759 lesions, 121 masses classified as circumscribed on DBT were included; 25 were malignant and 96 benign. Of the benign lesions, 8/96 were within category 3 or 4 on 2DDM compared with 48/96 benign lesions within category 3 or 4 on DBT (Fisher's exact test p<0.000527). Forty-eight of 51 (94.1%) lesions categorised as 3 or 4 on DBT were benign and 65/67 (97.01%) of the positive category change group were benign. Lesions in category 1 on DBT had 45.4% chance of being malignant (20/44) compared with 22.72% (20/88) on 2DDM (chi-squared test p<0.001). Sixty-five of 67 (97.01%) lesions in the positive category change group were benign and 23/54 (42.6%) lesions with either no or negative category change were malignant. CONCLUSION: The present study demonstrates 97% accuracy in predicting circumscribed lesions as benign when using positive category change and 94% accuracy when >50% of the margin is sharply defined on DBT.

The accuracy of digital breast tomosynthesis compared with coned compression magnification mammography in the assessment of abnormalities found on mammography.

AIM: To compare the diagnostic accuracy of the digital breast tomosynthesis (DBT) with coned compression magnification mammography (CCMM). MATERIALS AND METHODS: The study design included two reading sessions completed by seven experienced radiologists. In the first session, all readers read bilateral standard two-view mammograms and a CCMM view of the lesion before giving a combined score for assessment. In the second session, readers read bilateral standard two-view mammograms plus one-view DBT. The two reading sessions of the experiment were separated by at least 2 weeks to reduce the chance of reader memory of the images read in the previous session from influencing the performance in the subsequent session. RESULTS: Three hundred and fifty-four lesions were assessed and receiver-operative characteristic (ROC) analysis was used to evaluate the difference between the two modes. For standard two-view mammography plus CCMM, the area under the curve (AUC) was 0.87 [95% confidence interval (CI): 0.83-0.91] and for standard two-view mammography plus DBT the AUC was 0.93 (95% CI: 0.91-0.95). The difference between the AUCs was 0.06 with p-value of 0.0014. CONCLUSION: Two-view mammography with one-view DBT showed significantly improved accuracy compared to two-view mammography and CCMM in the assessment of mammographic abnormalities. These results show that DBT can be used effectively in the further evaluation of mammographic abnormalities found at screening and in symptomatic diagnostic practice.

Carbon nanotubes on a spider silk scaffold.

Understanding the compatibility between spider silk and conducting materials is essential to advance the use of spider silk in electronic applications. Spider silk is tough, but becomes soft when exposed to water. Here we report a strong affinity of amine-functionalised multi-walled carbon nanotubes for spider silk, with coating assisted by a water and mechanical shear method. The nanotubes adhere uniformly and bond to the silk fibre surface to produce tough, custom-shaped, flexible and electrically conducting fibres after drying and contraction. The conductivity of coated silk fibres is reversibly sensitive to strain and humidity, leading to proof-of-concept sensor and actuator demonstrations.

A comparison of the accuracy of film-screen mammography, full-field digital mammography, and digital breast tomosynthesis.

AIM: To measure the change in diagnostic accuracy of conventional film-screen mammography and full-field digital mammography (FFDM) with the addition of digital breast tomosynthesis (DBT) in women recalled for assessment following routine screening. MATERIALS AND METHODS: Ethics approval for the study was granted. Women recalled for assessment following routine screening with screen-film mammography were invited to participate. Participants underwent bilateral, two-view FFDM and two-view DBT. Readers scored each lesion separately for probability of malignancy on screen-film mammography, FFDM, and then DBT. The scores were compared with the presence or absence of malignancy based on the final histopathology outcome. RESULTS: Seven hundred and thirty-eight women participated (93.2% recruitment rate). Following assessment 204 (26.8%) were diagnosed as malignant (147 invasive and 57 in-situ tumours), 286 (37.68%) as benign, and 269 (35.4%) as normal. The diagnostic accuracy was evaluated by using receiving operating characteristic (ROC) and measurement of area under the curve (AUC). The AUC values demonstrated a significant (p = 0.0001) improvement in the diagnostic accuracy with the addition of DBT combined with FFDM and film-screen mammography (AUC = 0.9671) when compared to FFDM plus film-screen mammography (AUC = 0.8949) and film-screen mammography alone (AUC = 0.7882). The effect was significantly greater for soft-tissue lesions [AUC was 0.9905 with the addition of DBT and AUC was 0.9201 for FFDM with film-screen mammography combined (p = 0.0001)] compared to microcalcification [with the addition of DBT (AUC = 0.7920) and for FFDM with film-screen mammography combined (AUC = 0.7843; p = 0.3182)]. CONCLUSION: The addition of DBT increases the accuracy of mammography compared to FFDM and film-screen mammography combined and film-screen mammography alone in the assessment of screen-detected soft-tissue mammographic abnormalities.

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.

AIM: To determine whether the extent of microcalcification and ductal carcinoma in situ (DCIS) grade can be used to accurately predict the presence and size of invasive cancer in cases of malignant microcalcification. MATERIALS AND METHODS: Over a 10-year period, 402 cases of malignant microcalcification from an NHS screening programme were analysed. For each case, measurement of mammographic microcalcification extent, DCIS grade, and the presence and size of invasive carcinoma from the excised surgical specimen were recorded. RESULTS: The final histological diagnosis was DCIS only in 71% (284/402) and DCIS with a focus of invasive disease in 29% (118/402). The risk of invasive disease increased with increasing size of microcalcification from 20% (27/136) for cluster size less than 11mm, to 45% (18/40) for cluster size more than 60mm. The risk of invasive disease also increased with increasing histological grade of DCIS from 13% (4/31) with low-grade DCIS to 36% (86/239) with high-grade DCIS. There were significant associations with the presence of invasive disease for cluster size (p=0.0001) and DCIS grade (p=0.003), and when using univariate analysis with simple [cluster size (p=0.01) and grade (p=0.01)] and multiple [cluster size (p=0.02) and grade (p=0.02)] logistic regression, respectively. The Hosmer-Lemeshow goodness-of-fit test suggests that the multiple logistic regression model has a good fit (p=0.99). CONCLUSION: The multidisciplinary team can use these data in individual cases to estimate the risk of invasive cancer and decide whether to carry out an axillary staging procedure.

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.

Status of health in India and its future prospects.

PIP: This overview of health programs and conditions in India reveals that health is related to economic development antipoverty measures, food production and distribution, drinking water supply, sanitation, housing, environmental protection, and education. There are urgent requirements for effective intersectorial coordination. Unprecedented growth of 1 million a year has resulted in slums and shanties--a place of epidemics; urbanization has contributed to environmental pollution impacting on health, and water pollution to water-born diseases. Health services are still insufficient to meet the needs. Sanitation practices contribute to cholera, dysentery, diarrhea, enteric fevers, and malaria. Indian Systems of Medicine and Homeopathy must be active in preventive and health care. Accomplishments include in 1987/8 a decline in leprosy cases attributed to the existence of leprosy control units. 40 AIDS Surveillance Units are actively treating and screening. The Naval Goitre Control Programme's goal is replacement of iodized salt for edible salt by 1992, thereby reducing mental retardation and low birth weight babies. The Family Welfare Programme, targets a New Production Rate of Unity before 2000. A National Technology Mission on immunization and the Universal Immunization Programme plans to be operational in all districts by 1990. Oral rehydration therapy programs dispense free packets to fill the needs of 1 million children under 5 who suffer from diarrhea 3 times a year with 3 million facing death. The Primary Health Care Programme provides iron and folic acid to women with nutritional anemia and Vitamin A to children. Health service developments have been increased.^ieng