Outcomes of male patients attending the symptomatic breast unit: adherence to local and national imaging guidelines and effectiveness of clinical examination and imaging in detecting male breast cancer.

AIM: To review outcomes of male patients attending the breast unit, evaluate effectiveness of imaging and examination in detecting breast cancer and review adherence to guidelines for male breast imaging. MATERIALS AND METHODS: A retrospective review was undertaken of male patients attending Cambridge Breast Unit from 1 January 2015 to 31 December 2019. Patient electronic records and imaging were reviewed to establish demographics, clinical findings, imaging, biopsy, and pathology outcomes. RESULTS: Of 1,362 male patients attending the breast unit, 1,028 (75%) had imaging performed. Biopsy was performed in 41 men (3%), with 14 cancers diagnosed (1%). Clinical examination showed 42.7% sensitivity, 99.6% specificity, 54.6% positive predictive value (PPV) and 99.4% negative predictive value (NPV) for detection of cancer. Mammogram demonstrated 84.6% sensitivity, 99.4% specificity, 69.8% PPV, and 99.8% NPV for detection of malignancy. Ultrasound demonstrated 78.6% sensitivity, 98.9% specificity, 73.3% PPV and 99.2% NPV for detection of cancer. Forty-one percent of patients <40 years and 51% < 50 years were imaged, who according to local and Royal College of Radiologists (RCR) guidelines did not require imaging based on age and clinical score. CONCLUSION: Male patients account for a small proportion of referrals to the breast unit but generate significant workload. Imaging protocols, incorporating clinical score and age cut-off at 40 years remains robust for detecting malignancy. Clinician awareness of the imaging protocol, and close liaison with radiologists is essential to minimise additional radiology workload.

MRI-guided breast biopsy: a review of technique, indications, and radiological-pathological correlations.

Breast magnetic resonance imaging (MRI) is the technique of choice in detection, local staging, and monitoring of breast cancer; however, breast MRI results in the detection of more indeterminate/suspicious lesions that need to be histopathologically proven to guide patient management than any other breast imaging method. If such abnormalities are not detectable in any of the conventional imaging tools (mammography (MMG) or ultrasound) then an MRI-guided biopsy needs to be performed to obtain a diagnosis. Breast MRI-guided biopsy is a time-consuming and complex procedure that requires specific equipment and experienced, well-trained staff. This review article explores and illustrates the indications, the currently available technologies, and the technique of breast MRI-guided biopsy, and explains the importance of careful imaging review and selection of cases. We correlate the radiological-pathological findings and highlight the impact on patient management in a multidisciplinary setting.

Does preoperative axillary staging lead to overtreatment of women with screen-detected breast cancer?

AIM: To determine the impact of preoperative axillary ultrasound staging in a screen-detected breast cancer population. MATERIALS AND METHODS: Ultrasound and needle biopsy staging results alongside reference standard sentinel lymph node biopsy and axillary lymph node dissection were extracted retrospectively from the unit's computer records between 1 April 2008 and 31 March 2015. Axillary staging was compared with final histopathology and treatment. RESULTS: Of the 215,661 screening examinations performed, 780 invasive cancers were diagnosed, which had preoperative axillary staging data, of which 162 (20.7%) were node positive. Thirty-six (4.6%) had a heavy nodal burden (three or more nodes). Ninety (11.5%) had an abnormal axillary ultrasound and axillary biopsy of which 54 were positive for cancer (33.3% of the node positive cases) and triaged to axillary lymph node dissection avoiding a sentinel lymph node biopsy. Of these 22 (40.7%) had neoadjuvant treatment, and 32 (59.3%) proceeded directly to axillary lymph node dissection. The sensitivity of axillary ultrasound and biopsy to detect women with a heavy nodal burden (three or more nodes) was 41.7% (15 of 36); however, 17 (53%) of the 32 women with a positive axillary biopsy had a low burden of axillary disease (two or fewer positive nodes) at axillary lymph node dissection, the mean number of nodes obtained was 14.6. CONCLUSION: Significant numbers of women are being potentially overtreated or denied entry into positive sentinel node: adjuvant therapy only versus adjuvant therapy and clearance or axillary radiotherapy (POSNOC) because of routine preoperative axillary staging.

Microbubble detection and ultrasound-guided vacuum-assisted biopsy of axillary lymph nodes in patients with breast cancer.

AIMS: To assess the feasibility of undertaking microbubble-guided vacuum-assisted biopsy (VAB) of the sentinel lymph node (SLN) and determine its sensitivity in detecting metastases. Patient experience and the impact of VAB on subsequent axillary surgery were also evaluated. MATERIALS AND METHODS: Patients with a normal axillary ultrasound or benign core biopsy planned for surgical SLN biopsy were recruited. Part 1 of the study was used to establish the technique of ultrasound microbubble contrast to detect the SLN. In Part 2 microbubble detection of the SLN was followed by 13 G VAB. All patients subsequently had surgical histological correlation. RESULTS: One hundred and thirty-nine patients were recruited: 36 to Part 1 and 103 to Part 2. Of the 100 patients in Part 2 included for analysis, 82 (82%) underwent successful biopsy. Sensitivity for detecting metastases was 58.8% (95% confidence interval: 32.9%, 81.6%). The procedure was generally well tolerated; however, VAB interfered adversely with subsequent surgical SLN biopsy with surgeons reporting moderate or severe interference in 48% of patients and an additional 8.3% with complete failure of SLNB. CONCLUSION: It is possible to perform VAB of microbubble-detected SLNs. Although the sensitivity for detecting metastases was reasonable, the adverse effect on subsequent surgery was significant.

New horizons in breast imaging.

The imaging of breast cancer has undergone significant progression in recent years. A multimodality approach is often required, with ongoing developments in mammography, ultrasound, magnetic resonance and nuclear medicine all contributing to breast cancer imaging. Here we review the literature to assess how advances in well-established technologies, such as mammography, have brought added benefits both in terms of diagnostic and practical benefits, as well as allowing the application of derived technologies, such as tomosynthesis and contrast-enhanced mammography. We consider how these newer technologies may fit into clinical practice, both in terms of general population screening as well as use as problem solving tools in specific patient groups, and where the limitations for these may lie. We aim to highlight some of the promising advances in imaging that are still in earlier stages, such as magnetic resonance elastography, as well as reviewing techniques that are already becoming incorporated into clinical practice.