Audit of eliminating biopsy for presumed fibroadenomas with benign ultrasound greyscale and shear-wave elastography findings in women aged 25-39 years.

AIM: To assess the safety of a policy of not biopsying presumed fibroadenomas with benign ultrasound and shear-wave elastography findings in women aged 25-39 years. MATERIALS AND METHODS: Patients aged 25-39 years were included after attending a one-stop clinic before 01/05/2019 where clinical and ultrasound greyscale findings suggested a benign mass and shear-wave elastography showed a mean stiffness of <50 kPa. Such patients were reassured and discharged without biopsy or follow-up. The archived ultrasound images were reviewed subsequently by a second radiologist who could recall patients for biopsy if he deemed the imaging findings to be not definitively benign. Local and national electronic records were reviewed to identify whether these patients later re-presented with breast problems. RESULTS: Seventy-six women with a mean age of 33 years were included. The minimum follow-up was 12 months and the mean follow-up was 2 years. Three (4%) of patients were recalled after review of the ultrasound images by a second radiologist. Five (7%) patients re-presented with the same lump. Three (4%) patients re-presented with a different benign problem. Two patients presented with breast cancer in the ipsilateral breast but at a different location from the assessed benign lesion. CONCLUSION: Early audit results of a policy of not biopsying or following up clinically benign masses with benign ultrasound greyscale appearances and shear wave stiffness <50 kPa in women aged 25-39 years suggest that this approach may be safe and acceptable.

Associations between the ultrasound features of invasive breast cancer and breast cancer specific survival.

AIM: To assess whether ultrasound features of breast cancer are associated with breast cancer specific survival (BCSS). MATERIALS AND METHODS: Within a single breast service, data was collected prospectively (April 2010-April 2012) from 319 consecutive women (mean age 63 years) with 335 ultrasound-visible invasive breast cancers. Ultrasound features were evaluated retrospectively from the recorded images according to the Breast Imaging Reporting and Data System (BI-RADS) lexicon by a radiologist blinded to outcomes. Survival and cause of death were ascertained from local and national sources. Kaplan-Meier survival curves were generated, and statistical significance tested using the log-rank test. RESULTS: Mean follow-up in those alive was 80.9 months. Thirty breast cancer deaths and 45 non-breast cancer deaths occurred. Five-year BCSS in the presence of distal acoustic enhancement was 76% compared to 88%, 96%, and 100% for those with distal shadowing, no distal effect or combined effect respectively (p<0.0002). Patients with sonographic skin involvement had 73% 5-year BCSS compared to 92% for no skin involvement (p<0.0001). Focal oedema was associated with 56% 5-year BCSS compared to 89% for those without (p=0.0002). A significant association was demonstrated between ultrasound tumour size and BCSS (p<0.0001). At multivariate analysis, skin changes, distal enhancement, and focal oedema maintained prognostic significance. CONCLUSION: Distal enhancement, focal oedema, and skin involvement have strong associations with breast cancer death. These factors could be taken into account, along with lesion size and other commonly used preoperative prognostic features, when considering management of women with breast cancer.

Preoperative Red Cell Distribution Width and 30-day mortality in older patients undergoing non-cardiac surgery: a retrospective cohort observational study.

Increased red cell distribution width (RDW) is associated with poorer outcomes in various patient populations. We investigated the association between preoperative RDW and anaemia on 30-day postoperative mortality among elderly patients undergoing non-cardiac surgery. Medical records of 24,579 patients aged 65 and older who underwent surgery under anaesthesia between 1 January 2012 and 31 October 2016 were retrospectively analysed. Patients who died within 30 days had higher median RDW (15.0%) than those who were alive (13.4%). Based on multivariate logistic regression, in our cohort of elderly patients undergoing non-cardiac surgery, moderate/severe preoperative anaemia (aOR 1.61, p = 0.04) and high preoperative RDW levels in the 3rd quartile (>13.4% and ≤14.3%) and 4th quartile (>14.3%) were significantly associated with increased odds of 30-day mortality - (aOR 2.12, p = 0.02) and (aOR 2.85, p = 0.001) respectively, after adjusting for the effects of transfusion, surgical severity, priority of surgery, and comorbidities. Patients with high RDW, defined as >15.7% (90th centile), and preoperative anaemia have higher odds of 30-day mortality compared to patients with anaemia and normal RDW. Thus, preoperative RDW independently increases risk of 30-day postoperative mortality, and future risk stratification strategies should include RDW as a factor.

Value of shear-wave elastography in the diagnosis of symptomatic invasive lobular breast cancer.

AIM: To investigate the contribution of shear-wave elastography (SWE) in diagnosing invasive lobular breast cancer (ILC) in symptomatic patients. MATERIALS AND METHODS: A retrospective case-controlled study of 52 patients with ILC and 52 patients with invasive ductal cancer (IDC), matched for age and tumour size, was performed. Breast density and mammographic and greyscale ultrasound features were graded using Breast Imaging-Reporting and Data System (BI-RADS) classification by two radiologists, blinded to SWE and pathology findings. Forty-four benign lesions were also included. The sensitivity of SWE was assessed, using a cut-off value of 50 kPa for mean elasticity. Statistical significance was evaluated using Chi-square and Chi-square for trend tests. RESULTS: Mean age for both ILC and IDC groups was 67 years. Mean size for ILC was 44 mm and IDC was 37 mm. The sensitivity for detection of ILC and IDC for mammography, greyscale ultrasound, and SWE were 79% versus 87%, 87% versus 98%, 94% versus 100%, respectively. SWE had significantly higher sensitivities than mammography for the detection of both ILC and IDC (p = 0.012 and p = 0.001, respectively). SWE was not significantly more sensitive than greyscale ultrasound for the detection of either tumour type. Four (8%) lobular cancers were benign/normal at both mammography and greyscale ultrasound, but suspicious on SWE. The incremental gain in sensitivity by using SWE in ILC was statistically significant compared to IDC (p = 0.01). CONCLUSION: SWE can diagnose lobular cancers that have benign/normal findings on conventional imaging as suspicious.

Upgrade of ductal carcinoma in situ on core biopsies to invasive disease at final surgery: a retrospective review across the Scottish Breast Screening Programme.

AIM: To identify factors affecting upgrade rates from B5a (non-invasive) preoperative core biopsies to invasive disease at surgery and ways to improve screening performance. MATERIAL AND METHODS: This was a retrospective analysis of 1252 cases of B5a biopsies across all six Scottish Breast Screening Programmes (BSPs), ranging between 2004 and 2012. Final surgical histopathology was correlated with radiological and biopsy factors. Data were analysed using basic Microsoft Excel and standard Chi-squared test used for evaluating statistical significance. RESULTS: B5a upgrade rates for the units ranged from 19.2% to 29.2%, with an average of 23.6%. Mean sizes of invasive tumours were small (3-11 mm). The upgrade rate was significantly higher for cases where the main mammographic abnormality was mass, distortion, or asymmetry, compared with micro-calcification alone (33.2% versus 21.7%, p = 0.0004). The upgrade rate was significantly lower with the use of large-volume vacuum-assisted biopsy (VAB) devices than 14 G core needles (19.9% versus 26%, p = 0.013); in stereotactic than ultrasound-guided biopsies (21.2% versus 36.1%, p < 0.001). Heterogeneity of data from different centres limited evaluation of other potential factors. CONCLUSION: Upgrade rates are lower for cases with micro-calcification as the sole mammographic feature with the use of VAB devices. Nevertheless, there is variation in practice across Scottish BSPs, including first-line biopsy technique and/or device; and it is of interest that a few centres maintain low upgrade rates despite not using VAB routinely for biopsy of micro-calcification.

The use of imaging in patients post breast reconstruction.

AIM: To evaluate the usefulness of mammographic surveillance for asymptomatic patients and as a problem-solving tool in symptomatic patients with reconstructed breasts. MATERIALS AND METHODS: The imaging records over 4 years identified 227 patients with a history of breast reconstruction post-mastectomy due to cancer. Clinical and imaging records were reviewed to evaluate the use of imaging in the follow-up management of these patients. RESULTS: Records showed that 116 (51%) of the patients identified underwent surveillance mammography of the reconstructed breast, in which one recurrent cancer was detected in an autologous tissue flap reconstruction (0.86% detection rate of non-palpable recurrent cancer), with a recall rate of 4%. One other patient had interval recurrence diagnosed following presentation with pain. Mammography of the contralateral breast only was performed in 111 patients. Fifty-four patients (24%) presented on 78 occasions with symptoms relating to the breast reconstructions, most commonly lump or swelling. Half of these patient episodes subsequently found no significant abnormality, and a further 29% had fat necrosis revealed on imaging. Four recurrent cancers were diagnosed. CONCLUSION: There is insufficient evidence for recommending routine surveillance mammography for non-palpable recurrent cancer in the reconstructed breasts. Ultrasound and mammography are useful imaging techniques in the assessment of reconstructed breasts in the symptomatic setting. Fat necrosis is the most common benign finding on mammograms of reconstructed breasts, both in the surveillance and symptomatic groups.