Variation in Rates of Post-Mastectomy Radiotherapy Among Women with Early Invasive Breast Cancer in England and Wales: A Population-Based Cohort Study.

AIMS: This study examined whether patterns of post-mastectomy radiotherapy (PMRT) among women with early invasive breast cancer (EIBC) varied within England and Wales and explored the role of different patient factors in explaining any variation. MATERIALS AND METHODS: The study used national cancer data on women aged ≥50 years diagnosed with EIBC (stage I-IIIa) in England and Wales between January 2014 and December 2018 who had a mastectomy within 12 months of diagnosis. A multilevel mixed-effects logistic regression model was used to calculate risk-adjusted rates of PMRT for geographical regions and National Health Service acute care organisations. The study examined the variation in these rates within subgroups of women with different risks of recurrence (low: T1-2N0; intermediate: T3N0/T1-2N1; high: T1-2N2/T3N1-2) and investigated whether the variation was linked to patient case-mix within regions and organisations. RESULTS: Among 26 228 women, use of PMRT increased with greater recurrence risk (low: 15.0%; intermediate: 59.4%; high: 85.1%). In all risk groups, use of PMRT was more common among women who had received chemotherapy and decreased among women aged ≥80 years. There was weak or no evidence of an association between use of PMRT and comorbidity or frailty, for each risk group. In women with an intermediate risk, unadjusted rates of PMRT varied substantially between geographical regions (range 40.3-77.3%), but varied less for the high-risk (range 77.1-91.6%) and low-risk groups (range 4.1-32.9%). Adjusting for patient case-mix reduced the variation in regional and organisational PMRT rates to a small degree. CONCLUSIONS: Rates of PMRT are consistently high across England and Wales among women with high-risk EIBC, but variation exists across regions and organisations for women with intermediate-risk EIBC. Effort is required to reduce unwarranted variation in practice for intermediate-risk EIBC.

The Association Between Survival and Receipt of Post-mastectomy Radiotherapy According to Age at Diagnosis Among Women With Early Invasive Breast Cancer: A Population-Based Cohort Study.

AIMS: Clinical trials of post-mastectomy radiotherapy (PMRT) for early invasive breast cancer (EIBC) have included few older women. This study examined whether the association between overall survival or breast cancer-specific survival (BCSS) and receipt of PMRT for EIBC altered with age. MATERIALS AND METHODS: The study used patient-level linked cancer registration, routine hospital and radiotherapy data for England and Wales. It included 31 243 women aged ≥50 years diagnosed between 2014 and 2018 with low- (T1-2N0), intermediate- (T3N0/T1-2N1) or high-risk (T1-2N2/T3N1-2) EIBC who received a mastectomy within 12 months from diagnosis. Patterns of survival were analysed using a landmark approach. Associations between overall survival/BCSS and PMRT in each risk group were analysed with flexible parametric survival models, which included patient and tumour factors; whether the association between PMRT and overall survival/BCSS varied by age was assessed using interaction terms. RESULTS: Among 4711 women with high-risk EIBC, 86% had PMRT. Five-year overall survival was 70.5% and BCSS was 79.3%. Receipt of PMRT was associated with improved overall survival [adjusted hazard ratio (aHR) 0.75, 95% confidence interval 0.64-0.87] and BCSS (aHR 0.78, 95% confidence interval 0.65-0.95) compared with women who did not have PMRT; associations did not vary by age (overall survival, P-value for interaction term = 0.141; BCSS, P = 0.077). Among 10 814 women with intermediate-risk EIBC, 59% had PMRT; 5-year overall survival was 78.4% and BCSS was 88.0%. No association was found between overall survival (aHR 1.01, 95% confidence interval 0.92-1.11) or BCSS (aHR 1.16, 95% confidence interval 1.01-1.32) and PMRT. There was statistical evidence of a small change in the association with age for overall survival (P = 0.007), although differences in relative survival were minimal, but not for BCSS (P = 0.362). CONCLUSIONS: The association between PMRT and overall survival/BCSS does not appear to be modified by age among women with high- or intermediate-risk EIBC and, thus, treatment recommendations should not be modified on the basis of age alone.

The world's largest omnivore is a fish.

The evolution of very large body size requires a ubiquitous and abundant source of food. In marine environments, the largest animals such as whale sharks are secondary consumers that filter feed on nekton, which is plentiful, although patchy. Consequently, feeding in coastal environments requires cost-efficient foraging that focuses on oceanographic features that aggregate both nektonic prey and marine debris such as floating macroalgae. Consumption of this algae could present an energetic challenge for these animals, unless some component can be digested. Here, we use a multi-technique approach involving amino acid compound-specific stable isotope analysis (CSIA) and fatty acid analysis to determine the trophic level of whale sharks and to identify likely items in the diet. CSIA analyses showed that the species has a trophic level consistent with omnivory. Fatty acid profiles of whale shark tissues, feces and potential prey items suggest that the floating macroalgae, Sargassum, and its associated epibionts is a significant source of food. Although this overcomes the energetic challenge of consumption of floating algae, this mode of feeding and the need to focus on oceanographic features that aggregate prey also increases the threat to the species posed by pollutants such as plastic.

Change in the Use of Fractionation in Radiotherapy Used for Early Breast Cancer at the Start of the COVID-19 Pandemic: A Population-Based Cohort Study of Older Women in England and Wales.

AIMS: Adjuvant radiotherapy is recommended for most patients with early breast cancer (EBC) receiving breast-conserving surgery and those at moderate/high risk of recurrence treated by mastectomy. During the first wave of COVID-19 in England and Wales, there was rapid dissemination of randomised controlled trial-based evidence showing non-inferiority for five-fraction ultra-hypofractionated radiotherapy (HFRT) regimens compared with standard moderate-HFRT, with guidance recommending the use of five-fraction HFRT for eligible patients. We evaluated the uptake of this recommendation in clinical practice as part of the National Audit of Breast Cancer in Older Patients (NABCOP). MATERIALS AND METHODS: Women aged ≥50 years who underwent surgery for EBC from January 2019 to July 2020 were identified from the Rapid Cancer Registration Dataset for England and from Wales Cancer Network data. Radiotherapy details were from linked national Radiotherapy Datasets. Multivariate mixed-effects logistic regression models were used to assess characteristics influential in the use of ultra-HFRT. RESULTS: Among 35 561 women having surgery for EBC, 71% received postoperative radiotherapy. Receipt of 26 Gy in five fractions (26Gy5F) increased from <1% in February 2020 to 70% in April 2020. Regional variation in the use of 26Gy5F during April to July 2020 was similar by age, ranging from 49 to 87% among women aged ≥70 years. Use of 26Gy5F was characterised by no known nodal involvement, no comorbidities and initial breast-conserving surgery. Of those patients receiving radiotherapy to the breast/chest wall, 85% had 26Gy5F; 23% had 26Gy5F if radiotherapy included regional nodes. Among 5139 women receiving postoperative radiotherapy from April to July 2020, nodal involvement, overall stage, type of surgery, time from diagnosis to start of radiotherapy were independently associated with fractionation choice. CONCLUSIONS: There was a striking increase in the use of 26Gy5F dose fractionation regimens for EBC, among women aged ≥50 years, within a month of guidance published at the start of the COVID-19 pandemic in England and Wales.

Surgical decisions in older women with early breast cancer: patient and disease factors.

BACKGROUND: Studies reporting lower rates of surgery for older women with early invasive breast cancer have focused on women with oestrogen receptor (ER)-positive tumours. This study examined the factors that influence receipt of breast surgery in older women with ER-positive and ER-negative early invasive breast cancer . METHODS: Women aged 50 years or above with unilateral stage 1-3A early invasive breast cancer diagnosed in 2014-2017 were identified from linked English and Welsh cancer registration and routine hospital data sets. Logistic regression analysis was used to evaluate the influence of tumour and patient factors on receipt of surgery. RESULTS: Among 83 188 women, 86.8 per cent had ER-positive and 13.2 per cent had ER-negative early invasive breast cancer. These proportions were unaffected by age at diagnosis. Compared with women with ER-negative breast cancer, a higher proportion of women with ER-positive breast cancer presented with low risk tumour characteristics: G1 (20.0 versus 1.5 per cent), T1 (60.8 versus 44.2 per cent) and N0 (73.9 versus 68.8 per cent). The proportions of women with any recorded co-morbidity (13.7 versus 14.3 per cent) or degree of frailty (25 versus 25.8 per cent) were similar among women with ER-positive and ER-negative disease respectively. In women with ER-positive early invasive breast cancer aged 70-74, 75-79 and 80 years or above, the rate of no surgery was 5.6, 11.0 and 41.9 per cent respectively. Among women with ER-negative early invasive breast cancer, the corresponding rates were 3.8, 3.7 and 12.3 per cent. The relatively lower rate of surgery for ER-positive breast cancer persisted in women with good fitness. CONCLUSION: The reasons for the observer differences should be further explored to ensure consistency in treatment decisions.

Life-history traits of the leatherjacket Meuschenia scaber, a long-lived monacanthid.

The present study describes the age and growth of the leatherjacket Meuschenia scaber, a common Australasian monacanthid and valued by-catch of the inshore bottom trawl fishery in New Zealand. Age was determined from the sagittal otoliths of 651 individuals collected between July 2014 and March 2016 in the Hauraki Gulf of New Zealand. Otolith sections revealed alternating opaque and translucent zones and edge-type analysis demonstrated that these are deposited annually. Meuschenia scaber displayed rapid initial growth, with both males and females reaching maturity in 1-2 years and 50% of both sexes matured at 1·5 years. Maximum age differed substantially between the sexes, at 9·8 years for males and 17·1 years for females. Growth rate was similar between sexes, although males reached greater mass at age than females in the early part of the lifespan. The length-mass relationship differed significantly between the sexes, with males displaying negative allometric growth and females isometric growth. Female condition was highest in July, declined in August with the onset of spawning and showed a slight peak in January and February, immediately following the spawning season. This study substantially extends the maximum longevity recorded for monacanthids, although males had much shorter lifespans and higher mortality, than females.

Radiotherapy after mastectomy for screen-detected ductal carcinoma in situ.

BACKGROUND: A role for radiotherapy after mastectomy for ductal carcinoma in situ (DCIS) is unclear. Using a prospective audit of DCIS detected through the NHS Breast Screening Programme we sought to determine a rationale for the use of post mastectomy radiotherapy for DCIS. METHODS: Over a nine year period, from 9972 patients with screen-detected DCIS and complete surgical, pathology, radiotherapy and follow up data, 2944 women underwent mastectomy for DCIS of whom 33 (1.1%) received radiotherapy. RESULTS: Use of post mastectomy radiotherapy was significantly associated with a close (<1 mm) pathology margin (χ(2)(1) 95.81; p < 0.00001), DCIS size (χ(2) (3) 16.96; p < 0.001) and the presence of microinvasion (χ(2)(1) 3.92; p < 0.05). At a median follow up 61 months, no woman who received radiotherapy had an ipsilateral further event, and only 1/33 women (3.0%) had a contralateral event. Of the women known not to have had radiotherapy post mastectomy, 45/2894 (1.6%) had an ipsilateral further event and 83 (2.9%) had a contralateral event. CONCLUSION: Recurrence following mastectomy for DCIS is rare. A close (<1 mm) margin, large tumour size and microinvasion, may merit radiotherapy to reduce ipsilateral recurrence.

Bridging the Gap: A Collaborative Approach to Health Information Management and Informatics Education.

BACKGROUND: Health Information Management (HIM) and Health Informatics (HI) were very separate professions when they were first formed. However, with the increasing adoption of electronic health records, the interests of the two fields have become more aligned. OBJECTIVES: To describe the evolution of a joint master's program in health informatics(HI) and health information management (HIM). METHODS: After analyzing workforce needs, and reviewing both CAHIIM accreditation requirements and existing curricular offerings in separate programs in HIM and HI, a joint program was developed. RESULTS: An HI master's program with a core curriculum for all students and tracks in Data Analytics, User Experience and Advanced Practice HIM was developed. A model for a comprehensive examination, based on the CAHIIM competencies, to be administered prior to and after the core curriculum was also developed. CONCLUSIONS: A core and track curriculum that incorporates HIM education as part of the Master of Science of Health Informatics provides a feasible roadmap for the future as HIM and HI become more closely aligned.

Pain referents used to respond to the pain catastrophizing scale.

BACKGROUND: Pain catastrophizing has emerged as a highly important construct in pain research. The Pain Catastrophizing Scale (PCS) is a widely used self-report measure used to determine a person's level of pain catastrophizing, assumed to be associated with an ongoing, recalled or anticipated pain experience. In practice, instructions for self-reporting catastrophizing typically do not provide a specific pain referent, even when assessing patients with chronic pain. Researchers have noted that it is not known what type of pain participants are referring to when responding to a catastrophizing questionnaire. METHOD: In the current study, 182 presumably healthy undergraduate students completed the PCS followed by a query regarding the pain referent used to complete the scale. In addition, they were asked if they have ever experienced chronic pain and to list their worst pain experience. RESULTS: The most commonly used primary referents included pain due to acute injury (26.4%), headache (18.0%) and general physical pain (11.5%). The type of primary referent and the number of referents did not influence the catastrophizing scores. However, the catastrophizing scores were influenced by the context of the primary pain referent, i.e., whether the primary pain referent was non-chronic worst pain, both chronic and worst pain, chronic pain or unrelated to either chronic or worst pain. Notably, a larger than expected proportion of participants reported having experienced chronic pain (44.5%; n = 81). CONCLUSION: The examination of pain referents while responding to a catastrophizing measure would add to our understanding of a person's pain experience and related catastrophic cognitions.

Variations in the management of the axilla in screen-detected ductal carcinoma in situ: evidence from the UK NHS breast screening programme audit of screen detected DCIS.

The diagnosis and surgical management of screen-detected Ductal Carcinoma In Situ (DCIS) remains controversial including a range of axillary approaches and consequent morbidity. This study examined the management of the axilla in all patients with DCIS presenting through the United Kingdom National Health Service Breast Screening Programme (UK NHS BSP). Retrospective analysis of the UK NHS BSP identified 26,696 women initially diagnosed with DCIS over the 8 years 1 April 2003-31 March 2011. The final breast pathology of these women was upgraded to invasive ductal cancer in 5564 (20.8%) women or micro-invasive cancer in 1031 (3.9%) women. At first operation, 5290 (26.3%) of the 20,094 women who had a final post-operative diagnosis of DCIS only underwent axillary surgery (72.4% at the time of mastectomy, 23.8% breast conservation surgery, 3.8% axillary surgery alone). Performance of axillary surgery reflected increasing tumour size, micro-invasion or increasing nuclear grade for the final diagnosis of DCIS. More extensive nodal surgery was performed in those undergoing mastectomy; 10.8% of women had more than 8 nodes removed. Overall, 12.0% of women with invasive cancer, 1.7% with micro-invasion, and 0.2% with DCIS alone, were ultimately node positive. Improved pre-operative sampling of DCIS, axillary assessment by ultrasound with needle biopsy for suspected metastases, risk stratification for sentinel node biopsy (for high grade or extensive DCIS) and avoiding axillary clearance for a pre-operative diagnosis of DCIS alone should reduce unnecessary axillary surgery. Standards using such criteria for axillary surgery in screen-detected DCIS should be integrated into the NHS BSP.

Enhanced visual responses in the superior colliculus in an animal model of attention-deficit hyperactivity disorder and their suppression by D-amphetamine.

Attention-deficit hyperactivity disorder (ADHD) is a prevalent neurodevelopmental disorder characterized by overactivity, impulsiveness and attentional problems, including an increase in distractibility. A structure that is intimately linked with distractibility is the superior colliculus (SC), a midbrain sensory structure which plays a particular role in the production of eye and head movements. Although others have proposed the involvement of such diverse elements as the frontal cortex and forebrain noradrenaline in ADHD, given the role of the colliculus in distractibility and the increased distractibility in ADHD, we have proposed that distractibility in ADHD arises due to collicular sensory hyper-responsiveness. To further investigate this possibility, we recorded the extracellular activity (multi-unit (MUA) and local field potential (LFP)) in the superficial visual layers of the SC in an animal model of ADHD, the New Zealand genetically hypertensive (GH) rat, in response to wholefield light flashes. The MUA and LFP peak amplitude and summed activity within a one-second time window post-stimulus were both significantly greater in GH rats than in Wistar controls, across the full range of stimulus intensities. Given that baseline firing rate did not differ between the strains, this suggests that the signal-to-noise ratio is elevated in GH animals. D-Amphetamine reduced the peak amplitude and summed activity of the multi-unit response in Wistar animals. It also reduced the peak amplitude and summed activity of the multi-unit response in GH animals, at higher doses bringing it down to levels that were equivalent to those of Wistar animals at baseline. The present results provide convergent evidence that a collicular dysfunction (sensory hyper-responsiveness) is present in ADHD, and that it may underlie the enhanced distractibility. In addition, D-amphetamine - a widely used treatment in ADHD - may have one of its loci of therapeutic action at the level of the colliculus.

Modelled evaluation of multi-component meningococcal vaccine (Bexsero®) for the prevention of invasive meningococcal disease in infants and adolescents in the UK.

Neisseria meningitidis is the main cause of bacterial meningitis and sepsis in the UK, and can potentially be lethal or cause long-term sequelae. Bexsero® (4CMenB) is a new multi-component vaccine approved by the European Commission for use in individuals aged ⩾2 months. A theoretical transmission model was constructed to assess the long-term effectiveness of Bexsero compared to standard care. The model was populated with UK-specific demographic data and calibrated to ensure that the transmission dynamics of meningococcal disease in the UK were adequately simulated. The model showed the best strategy to be a routine vaccination programme at ages 2, 3, 4, 12 months and 14 years combined with a 5-year catch-up programme in toddlers aged 12-24 months and adolescents aged 15-18 years. This would lead to a 94% reduction in meningococcal cases or 150 000 cases and 15 000 deaths over a 100-year time-frame.

The effect of DCIS grade on rate, type and time to recurrence after 15 years of follow-up of screen-detected DCIS.

BACKGROUND: The incidence of ductal carcinoma in situ (DCIS) rose rapidly when the NHS Breast Screening Programme (NHSBSP) started in 1988. Some authorities consider that this represents both over-diagnosis and over-treatment. We report long-term follow-up of DCIS diagnosed in the first 10 years (April 1988 to March 1999) of the West Midlands NHSBSP. METHODS: 840 noninvasive breast cancers were recorded on the national breast screening computer system. Following exclusions, and thorough case note and pathology review, 700 DCIS cases were identified for follow-up. RESULTS: After a median follow-up of 183 (range 133 to 259) months, 102 (14.6%) first local recurrences were identified, 49 (48%) were invasive. Median time to first noninvasive recurrence was 15 months, and 60 months for invasive recurrence. Median time to invasive recurrence was 76 months from initially high-grade DCIS, and 131 months from low/intermediate grade DCIS. For the seven women, presenting with metastasis as their first event, the median time was 82 (range 15 to 188) months. The cumulative proportion developing recurrence at 180 months was twice as high as at 60 months. INTERPRETATION: Short-term follow-up of patients diagnosed with DCIS will miss significant numbers of events, especially invasive local recurrences.

Incidence and prevalence of epilepsy among older U.S. Medicare beneficiaries.

OBJECTIVE: To determine the prevalence and incidence of epilepsy among U.S. Medicare beneficiaries aged 65 years old and over, and to compare rates across demographic groups. METHODS: We performed a retrospective analysis of Medicare administrative claims for 2001-2005, defining prevalent cases as persons with ≥1 claim with diagnosis code 345.xx (epilepsy) or 2 or more with diagnosis code 780.3x (convulsion) ≥1 month apart, and incident cases as prevalent cases with 2 years immediately before diagnosis without such claims. Prevalence and incidence rates were calculated for the years 2003-2005 using denominators estimated from a 5% random sample of Medicare beneficiaries. Results were correlated with gender, age, and race. RESULTS: We identified 282,661 per year on average during 2001-2005 (a total of 704,243 unique cases overall), and 62,182 incident cases per year on average during 2003-2005. Average annual prevalence and incidence rates were 10.8/1,000 and 2.4/1,000. Overall, rates were higher for black beneficiaries (prevalence 18.7/1,000, incidence 4.1/1,000), and lower for Asians (5.5/1,000, 1.6/1,000) and Native Americans (7.7/1,000, 1.1/1,000) than for white beneficiaries (10.2/1,000, 2.3/1,000). Incidence rates were slightly higher for women than for men, and increased with age for all gender and race groups. CONCLUSIONS: Epilepsy is a significant public health problem among Medicare beneficiaries. Efforts are necessary to target groups at higher risk, such as minorities or the very old, and to provide the care necessary to reduce the negative effects of epilepsy on quality of life.

Participatory action research and photovoice in a psychiatric nursing/clubhouse collaboration exploring recovery narrative.

The Clubhouse of Winnipeg (a community psychosocial rehabilitation centre) collaborated with a psychiatric nursing assistant professor on a participatory action research (PAR) project exploring the concept of recovery using a using a research method called photovoice. The collaborative project -Our Photos Our Voices- demonstrates how PAR and photovoice are well suited for collaborative research in mental health which honours principles underlying consumer empowerment and recovery. The foundation of empowerment is the power to act on one's behalf; PAR and photovoice support the full participation of concerned individuals in all aspects of research with the ultimate goal of action to solve problems or to meet goals identified by those individuals. Empowerment is also the ability to lay claim to one's own truth. At the core of the recovery model is the principle that recovery is defined by the individual and based on individual determinations of meaningful goals and a meaningful life. The Our Photos Our Voices project uses PAR and photovoice to effectively access, explore, document and share personal, local knowledge about recovery grounded in the personal experience of the Clubhouse researchers.

Reproductive biology of an odacine labrid, Odax pullus.

The sexual ontogeny of butterfish Odax pullus was examined in the Hauraki Gulf of New Zealand through histological analysis of gonad material, size and age information and seasonal patterns of sexual maturation. The patterns of gonad development and schedules of male recruitment were established and sexual ontogeny of O. pullus was diagnosed as monandric protogyny, with all males developing from mature females after female-to-male sex reversal. All individuals underwent an immature female phase before maturing as functional females at 228·7-264·8 mm fork length (L(F) ) and at 1·1-1·5 years of age, and there was no evidence of a juvenile bisexual phase. Degenerating mature oogenic elements were found in the gonad lumen of individuals with developing spermatogenic tissue, providing histological evidence for functional protogyny. Sex change was estimated to occur at 359-379 mm L(F) and 2-3 years of age. The diagnosis of monandric protogyny for O. pullus coincided with the pattern of sexual ontogeny seen in the majority of labrids, particularly those of the same clade (tribe Hypsigenyini) and contrasted with that seen in a number of other temperate labrids. This study suggests that the protogynous mode of sexual development in O. pullus is likely to be lineage-specific, i.e. associated with the phylogeny of labrid sexual development, and is not constrained by environmental effects on the evolution of sex change in temperate regions.

Swim stress increases hippocampal Zif268 expression in the spontaneously hypertensive rat.

The spontaneously hypertensive rat (SHR), which is used as an animal model of ADHD, displays numerous behavioural differences on learning and memory tasks. This study characterises differences in neural Zif268 expression in male SHR, Wistar Kyoto (WKY) and Sprague-Dawley (SD) rats after a 10-min forced swim. Swim stress increased Zif268 expression in the hippocampus of SHR only. In addition, SHR had increased expression in the prefrontal cortex, dorsal striatum and decreased expression in the nucleus accumbens shell in comparison to WKY and SD; and increased expression in the amygdala compared to SD. These findings: (i) support previous research indicating that SHR have altered neurobiological response to stressors, (ii) extends the characterisation of multiple memory systems in SHR to include differences in Zif268 expression in brain regions underlying their altered behaviour and (iii) supports previous findings that SHR may have a specific deficit within the shell of the nucleus accumbens.

Lesion size is a major determinant of the mammographic features of ductal carcinoma in situ: findings from the Sloane project.

AIM: To assess the radiological features of calcific ductal carcinoma in situ (DCIS) in a large, multicentre dataset according to grade and size, and to investigate the possibility that DCIS has different mammographic features when small. MATERIALS AND METHODS: The dataset consisted of all Sloane Project DCIS cases where calcification was present mammographically and histological grade and size were available. The radiology data form classifies calcific DCIS as casting/linear, granular/irregular, or punctate. The pathology dataset includes cytonuclear grade and microscopic tumour size. Correlations were sought between the radiological findings and DCIS grade and size. The significance of differences was assessed using the chi-square test and chi-square test for trend. RESULTS: One thousand, seven hundred and eighty-three cases were included in the study. Of these, 1128, 485, and 170 had high, intermediate, and low-grade DCIS, respectively. Casting calcification was more frequently seen the higher the grade of DCIS, occurring in 58% of high grade, 38% of intermediate grade, and 26% of low-grade cases, respectively (p<0.001). Casting calcification was also increasingly common with increasing lesion size, irrespective of the histological grade (p<0.001). Thus casting calcifications in small (<10mm) high-grade DCIS lesions were seen with a similar frequency (50%) to those in moderate-sized (21-30 mm) intermediate-grade lesions (48%), and to those in large (>30 mm) low-grade lesions (46%). CONCLUSION: Lesion size has a strong influence on the radiological features of calcific DCIS; small, high-grade lesions often show no casting calcifications, whereas casting calcifications are seen in nearly half of large, low-grade lesions. As small clusters of punctate or granular calcifications may represent high-grade DCIS, an aggressive clinical approach to the diagnosis of such lesions is recommended as the adequate treatment of high-grade DCIS will prevent the occurrence of potentially life-threatening high-grade invasive disease.

Radiological and pathological size estimations of pure ductal carcinoma in situ of the breast, specimen handling and the influence on the success of breast conservation surgery: a review of 2564 cases from the Sloane Project.

BACKGROUND: The Sloane Project, an audit of UK screen-detected non-invasive carcinomas and atypical hyperplasias of the breast, has accrued over 5000 cases in 5 years; with paired radiological and pathological data for 2564 ductal carcinoma in situ (DCIS) cases at the point of this analysis. We have compared the radiological estimate of DCIS size with the pathological estimate of DCIS size. We have correlated these sizes with histological grade, specimen-handling methods, particularly the use of specimen slice radiographs, and the success or failure of breast-conserving surgery (BCS). METHODS: The Sloane Project database was interrogated to extract information on all patients diagnosed with DCIS with complete radiological and pathological data on the size of DCIS, nuclear grade, specimen handling (with particular reference to specimen radiographs) and whether primary BCS was successful or whether the patient required further conservation surgery or a mastectomy. RESULTS: Of 2564 patients in the study, 2013 (79%) had attempted BCS and 1430 (71%) had a successful single operation. Of the 583 BCS patients who required further surgery, 65% had successful conservation and 97% of them after a single further operation. In successful one-operation BCS patients, there was a close agreement between radiological and pathological DCIS size with radiology tending to marginally overestimate the disease extent. In multiple-operation BCS, radiology underestimated DCIS size in 59% of cases. The agreement between pathological and radiological size of DCIS was poor in mastectomies but was improved by specimen slice radiography, suggesting specimen-handling techniques as a cause. CONCLUSION: In 30% of patients undergoing BCS for DCIS, preoperative imaging underestimates the extent of disease resulting in a requirement for further surgery. This has implications for the further improvement of preoperative imaging and non-operative diagnosis of DCIS so that second operations are reduced to a minimum.