The requirements of a specialist Breast Centre.

INTRODUCTION: In recognition of the advances and evidence based changes in clinical practice that have occurred in recent years and taking into account the knowledge and experience accumulated through the voluntary breast unit certification programme, Eusoma has produced this up-dated and revised guidelines on the requirements of a Specialist Breast Centre (BC). METHODS: The content of these guidelines is based on evidence from the recent relevant peer reviewed literature and the consensus of a multidisciplinary team of European experts. The guidelines define the requirements for each breast service and for the specialists who work in specialist Breast Centres. RESULTS: The guidelines identify the minimum requirements needed to set up a BC, these being an integrated Breast Centre, dealing with a sufficient number of cases to allow effective working and continuing expertise, dedicated specialists working with a multidisciplinary approach, providing all services throughout the patients pathway and data collection and audit. It is essential that the BC also guarantees the continuity of care for patients with advanced (metastatic) disease offering treatments according to multidisciplinary competencies and a high quality palliative care service. The BC must ensure that comprehensive support and expertise may be needed, not only through the core BC team, but also ensure that all other medical and paramedical expertise that may be necessary depending on the individual case are freely available, referring the patient to the specific care provider depending on the problem. CONCLUSIONS: Applying minimum requirements and quality indicators is essential to improve organisation, performance and outcome in breast care. Efficacy and compliance have to be constantly monitored to evaluate the quality of patient care and to allow appropriate corrective actions leading to improvements in patient care.

Image-guided breast biopsy: state-of-the-art.

Percutaneous image-guided breast biopsy is widely practised to evaluate predominantly non-palpable breast lesions. There has been steady development in percutaneous biopsy techniques. Fine-needle aspiration cytology was the original method of sampling, followed in the early 1990s by large core needle biopsy. The accuracy of both has been improved by ultrasound and stereotactic guidance. Larger bore vacuum-assisted biopsy devices became available in the late 1990s and are now commonplace in most breast units. We review the different types of breast biopsy devices currently available together with various localization techniques used, focusing on their advantages, limitations and current controversial clinical management issues.

Vacuum-assisted excision of breast lesions of uncertain malignant potential (B3) - an alternative to surgery in selected cases.

To assess whether vacuum-assisted excision (VAE) is a safe alternative to surgery in the treatment of breast lesions of uncertain malignant potential (B3) in which no atypia is present on needle core biopsy (NCB). Forty two VAE procedures were performed for B3 lesions. Twenty four (57%) were papillary lesions. Eighteen (43%) were radial scars. Two patients (4.7%) were upgraded to carcinoma at VAE. Two patients with papillary lesions went on to develop cancer in the same breast (at 24 and 41 months post VAE). No cancer developed in the radial scar group. Eight patients (19%) had surgery - four for carcinoma, two for radial scars missed at VAE excision and two for symptomatic papillomatosis. Follow-up mammography after VAE of radial scars often showed residual distortion. VAE can be a safe alternative to surgery in the treatment of B3 lesions without atypia, providing thorough multidisciplinary discussion has taken place.

The pathological and radiological features of screen-detected breast cancers diagnosed following arbitration of discordant double reading opinions.

AIM: To compare the mammographic background pattern, the mammographic and the pathological features of screen-detected cancers diagnosed following arbitration of discordant double reading opinions with screen-detected cancers diagnosed following concordant double reading. METHODS: Between April 2002 and December 2003, 249 patients were diagnosed with screen-detected malignancies following concordant double reading. In the same period 38 patients were diagnosed with screen-detected malignancies after their mammograms had undergone arbitration prior to recall. Mammograms of both groups of patients were reviewed retrospectively and the mammographic features documented. Histological data for both groups were also compared. RESULTS: Cancers detected following arbitration were more likely to manifest as parenchymal distortions (44 versus 8%, p<0.001) and less likely to manifest as spiculate masses (19 versus 42%, p=0.014). Arbitration cancers were less likely to be detected in fatty breasts (4 versus 29%, p=0.01). Arbitration cancers were smaller (p=0.045). Lobular cancers were commoner in the arbitration group, although this was of borderline significance (19 versus 8%, p=0.057) There was no significant difference in patient age, tumour grade or lymph node stage between the two groups. CONCLUSION: Cancers detected following arbitration are smaller and more likely to manifest as a parenchymal distortion compared with cancers detected by both readers. Arbitration cancers have broadly similar prognostic features to cancers detected by concordant double reading. It is estimated that approximately 11% more cancers are detected as a result of double reading with arbitration compared with single reading alone, after taking into consideration second reader bias.

The use of a short-acting benzodiazepine to reduce the risk of syncopal episodes during upright stereotactic breast biopsy.

The use of sublingual lorazepam provides a safe and effective means of reducing the risk of syncopal episodes during upright stereotactic breast biopsy. Sublingual lorazepam, 2-4mg, was received by 19 women undergoing a total of 20 stereotactic procedures. Of 14 women who had previously fainted during upright stereotactic biopsy, 13 had a successful repeat biopsy following administration of sublingual lorazepam. All 4 women who received lorazepam for significant anxiety had successful biopsies. Stereotactic guided wire localization also was performed in 2 cases.

Breast imaging findings in women with BRCA1- and BRCA2-associated breast carcinoma.

AIM: To document the breast imaging findings of women with BRCA1 and BRCA2-associated breast carcinoma. MATERIALS AND METHODS: Family history clinic records identified 18 BRCA1 and 10 BRCA2 cases who collectively were diagnosed with 27 invasive breast carcinomas and four ductal carcinoma in situ (DCIS) lesions. All underwent pre-operative imaging (29 mammogram and 22 ultrasound examinations). All invasive BRCA-associated breast carcinoma cases were compared with age-matched cases of sporadic breast carcinoma. RESULTS: Within the BRCA cases the age range was 26-62 years, mean 36 years. Two mammograms were normal and 27 (93%) abnormal. The most common mammographic features were defined mass (63%) and microcalcifications (37%). Thirty-four percent of women had a dense mammographic pattern, 59% mixed and 7% fatty. Ultrasound was performed in 22 patients and in 21 (95%) indicated a mass. This was classified as benign in 24%, indeterminate in 29% and malignant in 48%. Mammograms of BRCA1-associated carcinomas more frequently showed a defined mass compared with BRCA2-associated carcinomas, 72 versus 36% (73% control group) whilst mammograms of BRCA2-associated carcinomas more frequently showed microcalcification, 73 versus 12% (8% control group; p < 0.001). Thirty-six percent of the BRCA2-associated carcinomas were pure DCIS while none of the BRCA1 associated carcinomas were pure DCIS (p = 0.004). Of those patients undergoing regular mammographic screening, 100% of BRCA2-associated carcinomas were detected compared with 75% of BRCA1-associated carcinomas. CONCLUSION: These data suggest that the imaging findings of BRCA1 and BRCA2-associated carcinomas differ from each other and from age-matched cases of sporadic breast carcinoma.

Woman feels breast lump--surgeon cannot: the role of ultrasound in arbitration.

The role of ultrasound scanning (USS) in patients complaining of a breast lump where the clinical examination (CE) is normal is not clearly defined. To determine this in greater detail, all patients complaining of a breast lump underwent CE. Where no lump could be found, but was still reported by the patient, an USS was performed. All lesions underwent biopsy and/or aspiration, as well as mammography in suspicious cases or those over 40 years of age. This cohort represented 5% of all referrals in the study period. Four hundred and twenty women were prospectively studied in this way. Median follow up is 3.4 years (range 2.5-4.2 years). Twenty two had solid lumps (of which 3 were cancers) and 48 had cysts. Nineteen patients re-presented with symptoms in the same breast (median time = 12 months (range 4.5-20 months), all of which were imaged on USS: 15 cysts and 4 further cancers (3 in the same quadrant as the original lump, one contralateral) were identified. Women with symptomatic breast lumps and a normal CE can be considered a reliable indication that cancer is very unlikely to be present (negative predictive value = 0.98). Ultrasound may be a suitable complimentary investigation, which will relieve symptoms in those with cysts and can detect small clinically--and sometimes mammographically--occult breast cancers.

Cosmesis and satisfaction after breast-conserving surgery correlates with the percentage of breast volume excised.

BACKGROUND: The cosmetic outcome after breast-conserving surgery correlates with psychosocial adjustment. Previous studies have shown that, among other factors, cosmesis is dependent on breast size and weight of the wide local excision specimen. This study assessed cosmetic outcome relative to a combination of these factors-the estimated percentage of breast volume excised (EPBVE). METHODS: The study group consisted of 151 women who had undergone breast-conserving surgery. All had previously completed a patient satisfaction questionnaire and an independent panel had assessed cosmetic outcome. Their mammograms were reviewed and breast volume was estimated. A validation series showed cone volume on the oblique mammogram to predict true breast weight most accurately (r = 0.93). RESULTS: Both subjective cosmetic assessment and patient satisfaction correlated strongly with EPBVE. Overall, when the EPBVE was below 10 per cent, 83.5 per cent of patients were very satisfied with their appearance and only 3.1 per cent were not satisfied, compared with 37.0 and 16.7 per cent respectively if the EPBVE was more than 10 per cent. However, tumour location in the breast was also an important factor; cosmetic outcome was worse for medial tumours. CONCLUSION: The percentage of breast volume excised was an important determinant of cosmesis and patient satisfaction after breast-conserving surgery. Calculating the EPBVE before surgery may help select women in whom breast reshaping or volume replacement should be considered.

Radioisotope for occult lesion localisation (ROLL) of the breast does not require extra radiation protection procedures.

AIM OF STUDY: Dosimetry data from patients and hospital personnel involved in the use of radioisotope for occult lesion localisation (ROLL) of the breast were collected to determine the need for extra radiation protection procedures. METHODS: Sixty-three patients have been enrolled to date into a randomised trial evaluating ROLL. Two megabecquerels of (99m)Tc- MAA in a syringe was mixed with X-ray contrast medium; this was injected directly into the lesion under image guidance. A gamma-detecting probe (Neo-Probe) was used to locate the area of radioactivity. Radiation doses to all staff groups were estimated using time and motion studies and dose rate measurements at a range of distances during each stage of ROLL. RESULTS: The finger dose [FD](+/-95% CI) was considered to be the critical variable for surgeons and radiologists. Surgeon FD=9.3+/-3.3 microSv, Radiologist FD=0.5+/-0.13 microSv. Whole body doses [WBD](+/-95% CI) were estimated for other staff groups. Nurse WBD=0.4+/-0.4 microSv, porter WBD: nil, contamination and waste: nil. CONCLUSIONS: In the case of a surgeon performing 100 procedures per annum, a FD dose of approximately 1 mSv is received, well within the annual dose limit of 150 mSv. Annual WBD to assisting staff may reach 0.04 mSv, compared to an annual limit of 6 mSv. These low doses and the lack of contamination of radioactive waste indicate that no additional radiation protection measures are required.

Diagnosis of axillary nodal metastases by ultrasound-guided core biopsy in primary operable breast cancer.

The purpose of this study was to examine the use of ultrasound (US)-guided core biopsy of axillary nodes in patients with operable breast cancer. The ipsilateral axillae of 187 patients with suspected primary operable breast cancer were scanned. Nodes were classified based on their shape and cortical morphology. Abnormal nodes underwent US-guided core biopsy/fine needle aspiration (FNA), and the results correlated with subsequent axillary surgery. The nodes were identified on US in 103 of 166 axillae of patients with confirmed invasive carcinoma. In total, 54 (52%) met the criteria for biopsy: 48 core biopsies (26 malignant, 20 benign node, two normal) and six FNA were performed. On subsequent definitive histological examination, 64 of 166 (39%) had axillary metastases. Of the 64 patients with involved nodes at surgery, preoperative US identified nodes in 46 patients (72%), of which 35 (55%) met the criteria for biopsy and 27 (42%) of these were diagnosed preoperatively by US-guided biopsy. In conclusion, US can identify abnormal nodes in patients presenting with primary operable breast cancer. In all, 65% of these nodes are malignant and this can often be confirmed with US-guided core biopsy.

Radiology review of the UKCCCR Breast Screening Frequency Trial: potential improvements in sensitivity and lead time of radiological signs.

AIM: To review all previous mammograms of breast cancer cases diagnosed during a randomized trial comparing 3 yearly to annual mammographic screening with a view to identifying and quantifying cases that might potentially have been diagnosed earlier. METHODS: Mammograms of 602 breast cancer cases (399 screen-detected and 203 interval cases) were reviewed in chronological order and suspicious radiological features noted for each mammogram, up to and including the diagnostic mammogram. RESULTS: Of the 602 cases, 79 (13%) had features at diagnosis that were visible on previous mammograms, suggesting a sensitivity of interpretation of 87%. A similar proportion of screen-detected (14%) and interval cancers (11%) had signs at diagnosis that were visible on previous mammograms. The potential for improvement was particularly noted for asymmetric density (sensitivity = 77%, average time visible before diagnosis 14 months) and parenchymal deformity/stellate lesion (sensitivity = 81%, average time visible before diagnosis 12 months). CONCLUSION: The highest sensitivity was observed for comedo-type microcalcifications (sensitivity = 97%, average time visible before diagnosis 5 months). By improvements in sensitivity to asymmetric density and parenchymal deformity/stellate lesion, 4% of tumours could have their time of diagnosis advanced substantially.

Is the presence of mammographic comedo calcification really a prognostic factor for small screen-detected invasive breast cancers?

AIM: It has been suggested that the use of traditional prognostic factors such as histological grade and lymph node stage are not reliable predictors of outcome for small (<15 mm diameter) screen-detected breast cancers. It has also been suggested that the presence of mammographic comedo (casting) microcalcifications may be an important prognostic factor. We have determined prognostic factors for small screen-detected cancers in a univariate and multivariate fashion. MATERIALS AND METHODS: Histological grade, lymph node stage, invasive tumour size and vascular invasion status was obtained on 161 consecutive patients with primary invasive breast cancer <15 mm diameter, detected by screening. The Nottingham Prognostic Index was calculated for each patient. The mammograms were assessed for the presence of microcalcifications, these being classified as either comedo or non-comedo. Survival data was also obtained. RESULTS: Overall survival in this group of patients was excellent with only 12 patients (7.5%) dying from their breast cancer (mean follow-up 7.5 years). Univariate analysis showed a significant association between lymph stage and outcome (chi(2)=9.68, P=0.008). No significant association was demonstrated between the presence of comedo calcification and survival. Multivariate analysis confirmed lymph node stage as the only independent prognostic factor for these small screen-detected breast cancers (chi(2)=7.18, P=0.007). There were significant associations between the presence of comedo calcification on the screening mammogram and high histological grade and small tumour size. CONCLUSION: Although the overall outcome for small screen-detected breast cancers (<15 mm diameter) is excellent, the presence of lymph node metastases is associated with a significant reduction in long-term survival. The presence of mammographic comedo calcification is not an independent prognostic factor, but is closely related to histological grade.