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 In many cases, the need for diagnostic surgical excision has been replaced by image-guided vacuum sampling.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.

Secretory otitis media and mastoid air cell development.

Controversy continues over the factors involved in the development of the mastoid air cell system (MACS). This study examines the effect of persistent secretory otitis media with effusion (SOME) on the development of the MACS. Thirty-one children, aged 4, were drawn from a cohort of cleft palate children in a multi-centre, prospective otological study set up in 1984. The initial presence of SOME was assessed by otoscopy, tympanometry and bilateral myringotomy, performed under the same anaesthetic as surgical repair of the cleft lip or palate. Only one ear in each child was ventilated with a tube and the other, the control ear, was assessed by regular follow-up otoscopy and tympanometry. The persistence of SOME after palate repair in over 70% of the non-ventilated ears in 4 years olds and the presence of a contralateral ventilated middle ear provides the perfect model for assessing the effect of SOME on MACS development. Plain, lateral mastoid X-rays were assessed by planimetry to give a well accepted measurement of mastoid pneumatization. Nine children were excluded from analysis as they did not meet the strict criteria of one persistently ventilated middle ear and one with persistent SOME. 22 children (44 ears) were available for analysis, 9 children were tubed at 3 months and 13 were tubed at 12 to 16 months. In 19 of the 22 ears the mastoid air cell system was larger on the tubed side.(ABSTRACT TRUNCATED AT 250 WORDS)

What can be done to improve the results in colorectal cancer?

It is seldom even under the best of circumstances that more than half the patients suffering from colorectal cancer are cured by conventional surgical management, and the results are often much worse. Attempts to improve this state of affairs have followed 4 main directions, which are here critically examined: 1. earlier (presymptomatic) diagnosis; 2. more radical surgery; 3. adjuvant radio- and chemotherapy; and 4. more meticulous follow-up using CEA monitoring and occasional "second-look" operations.

Current trends in the treatment of colorectal cancer.

In recent years interest in the management of bowel cancer has focussed mainly on two main considerations:- A The prospect of improving the overall curability by:- The achievement of much earlier presymptomatic diagnosis with the aid of Hemoccult screening of sections of the population at risk; The deployment of more radical techniques of operation, especially in regard to rectal cancer; The supplementation of surgical excision with adjuvant radiotherapy and chemotherapy; The development of a more meticulous regime of follow-up after operation, using CEA monitoring and occasional "second look" operations to deal with recurrence. B The greater use of sphincter-saving types of excision for growths of the middle and lower parts of the rectum. To this end several new techniques of rectal resection have become popular--especially the downward extrusion of low anterior resection with the aid of the circular stapler. In addition, for small very favourable low growths local excision or local destruction by diathermy fulguration or contact irradiation have been employed. The rationale and success of these two forms of endeavour are examined.

Judging the quality of life after surgical operations.

In gauging the achievements of surgical treatment it is important to try to measure the quality of functional result vouchsafed to the patient and his capacity for work and recreation. Because the impairments of function that may occur after different operations very considerably, an operation-specific assessment for each type of procedure is essential.

Sphincter-saving excision for cancers of the middle and lower parts of the rectum.

Currently four methods of sphincter-saving excision are in vogue for carcinomas of the middle and lower rectum--low anterior resection with or without the aid of the circular stapler, abdomino-sacral (or abdomino-transphincteric) resection, abdomino-anal resection with endocavitary sutured colorectal or colo-anal anastomosis, and local excision (or destruction by diathermy or contact irradiation). The relative advantages and--as far as is known--the results of these different methods are examined with special reference to anterior resection using the circular stapler, which is now by far the most popular choice.

Extended low anterior resection with stapled colorectal or coloanal anastomosis.

The use of extended low anterior resection with the aid of the circular stapler for carcinomas of the middle third or upper part of the lower third of the rectum is discussed and salient technical points are emphasized. A collective survey of the results of the operation for such growths has led to the following conclusions: The immediate mortality and morbidity are not excessive. In most cases, even with anastomoses as low as 3.5-4.5 cm from the anal verge, anorectal function eventually reaches a satisfactory state, though there may be quite troublesome diarrhoea and possibly some incontinence during the initial 3-6 months after operation. Adequate data regarding 5-year survival are still lacking, but the high incidence of local recurrence in some reports is perplexing and disappointing and demands continued close attention.

Current use of sphincter-saving excision in the radical treatment of rectal cancer.

The author examines the recent increased use of sphincter-saving forms of excision to treat carcinomas of the middle third and upper part of the lower third of the rectum. This trend has been due chiefly to technical innovations--especially the introduction of the circular stapler, which has extended the downward reach of low anterior resection--and the willingness to accept a distal margin of clearance in resections of 2.0 to 2.5 cm instead of 4 to 5 cm. Published data show that these innovations are associated with a low operative mortality and that satisfactory anorectal function can be retained. Insufficient length of follow-up, however, has made it impossible so far to calculate valid long-term survival rates and the high incidence of local recurrence in some reports has been disturbing.