Should breast screening programmes limit their detection of ductal carcinoma in situ?

OBJECTIVE: Previous research has shown that the detection of ductal carcinoma in situ (DCIS) aids the detection of small invasive cancers at mammographic screening. A correlation may therefore exist between a screening unit's DCIS detection rate and their small invasive cancer detection rate. We have therefore investigated the effect of DCIS detection rate on the detection of small (<15 mm) invasive cancers in the 95 units of the U.K. NHS Breast Screening Programme (NHSBSP). MATERIALS AND METHODS: DCIS detection rates were examined against large (> or =15 mm) and small (<15 mm) invasive cancer detection rates in women aged 50-64 years at prevalent and incident screens over a 3-year period. RESULTS: After adjusting for background incidence, screening units with the highest DCIS detection of > or =1.3/1000 detected over 20% more small invasive cancers than units with DCIS detection rates within the NHSBSP guidelines of 0.5-1/1000 (P<0.001). Sixty percent of units had DCIS detection rates above the guidelines. There was no correlation between DCIS detection and > or =15 mm invasive cancer detection. The results suggest that over the range of DCIS rates studied, that for every two extra DCIS cancers detected, an additional small invasive cancer (<15 mm) is detected that may otherwise not have been. The results therefore provide supporting evidence that the detection of DCIS aids the detection of small invasive cancers. CONCLUSION: Units with DCIS detection above the NHSBSP guidelines have significantly better small invasive cancer detection rates. The existence of an upper limit for DCIS detection within the NHSBSP may be preventing the detection of small invasive cancers, because units are not recalling some small clusters of calcification in order to keep DCIS detection rates down. The upper limit may therefore be inappropriate.     

Is breast MRI ever useful in a mammographic screening programme?

OBJECTIVE: To establish the diagnostic impact of breast magnetic resonance imaging (MRI), on the management of cases in our mammographic screening programme. METHODS AND MATERIALS: We analysed the cases examined from July 1997 to December 2000 during which time 44,000 population screening mammograms and 85 MRI studies were undertaken on women identified by computer overlap. The studies were reviewed to find the reason for the MRI study and its diagnostic impact. RESULTS: Of 83 studies analysed, 31 were for recurrence of tumour, 33 in newly diagnosed cancer, 22 to assess extent, 11 to monitor primary chemotherapy. In a small diagnostic subset of 19 cases MRI was used to find or characterize a lesion. The 11 cases in which MRI results caused a measurable beneficial change in management were from the query recurrence and diagnostic groups. In 52 cases from all groups, MR increased diagnostic confidence. In 11 cases MRI results were indeterminate, and in six of these stimulated more studies. CONCLUSION: MRI is an expensive investigation and its use must be justified. There is a limited, but valuable role for breast MRI in selected cases from screening assessment. Misinterpretation of enhancing lesions may generate additional procedures. Diagnostic impact was greatest for the detection of tumour recurrence.     

Does computer-aided detection assist in the early detection of breast cancer?

PURPOSE: To evaluate whether breast cancers detected at screening are visible in previous mammograms, and to assess the performance of a computer-aided detection (CAD) system in detecting lesions in preoperative and previous mammograms. MATERIAL AND METHODS: Initial screening detected 67 women with 69 surgically verified breast cancers (Group A). An experienced screening radiologist retrospectively analyzed previous mammograms for visible lesions (Group B), noting in particular their size and morphology. Preoperative and previous mammograms were analyzed with CAD; a relatively inexperienced resident also analyzed previous mammograms. The performances of CAD and resident were then compared. RESULTS: Of the 69 lesions identified, 36 were visible in previous mammograms. Of these 36 "missed" lesions, 14 were under 10 mm in diameter and 29 were mass lesions. The sensitivity of CAD was 81% in Group A and 64% in Group B. Small mass lesions were harder for CAD to detect. The specificity of CAD was 3% in Group A and 9% in Group B. Together, CAD and the resident found more "missed" lesions than separately. CONCLUSION: Of the 69 breast cancers, 36 were visible in previous mammograms. CAD's sensitivity in detecting cancer lesions ranged from 64% to 81%, while specificity ranged from 9% to as low as 3%. CAD may be helpful if the radiologist is less subspecialized in mammography.     

Early diagnosis of ovarian carcinoma: is a solution in sight?

Ovarian cancer is the most lethal of the gynecologic malignancies. Because ovarian cancer symptoms are subtle and nonspecific, the diagnosis is often delayed until the disease is well advanced. Overall 5-year survival is a rather dismal 50% but can be improved to greater than 90% if the disease is confined to the ovary at the time of diagnosis (generally in fewer than 25% of patients). Effective screening tools are currently not available. Owing to the rather low incidence of the disease in the general population, potential screening tests must provide very high specificity to avoid unnecessary interventions in false-positive cases. This article reviews currently available serum biomarkers and imaging tests for the early detection of ovarian cancer and provides an outlook on the potential improvements in these noninvasive diagnostic tools that may lead to successful implementation in a screening program. Supplemental material: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.11090563/-/DC1.     

Lobular carcinoma in situ on core biopsy-what is the clinical significance?

AIM: To retrospectively review the surgical histological findings in all cases where lobular carcinoma in situ(LCIS) was identified on percutaneous core biopsy (CB) performed as part of the Cambridge and Huntingdon breast screening programme.MATERIALS AND METHODS: We retrospectively reviewed all the core biopsies performed in our department for screen detected abnormalities over a 5-year period between 1 April 1994 and 31 March 1999. All patients where LCIS was identified on CB were reviewed. As the significance of LCIS on CB was unclear all went on to surgical excision. We reviewed the clinical and imaging findings, biopsy technique and subsequent surgical histology of each patient.RESULTS: During the study period 60 769 women were invited for screening, of whom 47 975 attended (attendance rate = 79%). Of these, 2330 (4.9%) were recalled for assessment and 749 (1.6%) underwent CB. A malignant diagnosis was obtained in 311 (42%), 211 invasive and 100 in situ lesions. LCIS was identified on CB in 13 (2%). LCIS was the only lesion identified in seven cases. All seven cases subsequently underwent surgical excision. Surgical histology revealed a single case of LCIS and invasive lobular carcinoma. There were two cases of LCIS and DCIS one with a probable focus of invasive ductal carcinoma. In one case LCIS was identified in association with a radial scar. In three of the seven cases LCIS was the only abnormality on both CB and surgical biopsy.CONCLUSION: Our series shows that isolated LCIS on CB following mammographic screening is an infrequent finding, and it may be associated with either an invasive cancer or DCIS. It is therefore advisable that when LCIS is identified on CB, surgical excision of the mammographic abnormality should be performed. Decisions on management should be undertaken in a multidisciplinary setting taking into account clinical and imaging findings.     

Is it possible to refine the indication for sentinel node biopsy in high-risk ductal carcinoma in situ?

BACKGROUND: The indication for sentinel node biopsy (SNB) has not been fully established yet for patients with ductal carcinoma in situ (DCIS). AIM: To relate the conversion rate to invasive carcinoma with sentinel node positivity in high risk DCIS, and to refine the clinical presentation analysis in order to better select patients for SNB. For this purpose, a risk score was devised. METHODS: From 1998 to 2005, 151 high-risk DCIS patients from six clinical centres were included in a prospective sentinel node database. The conversion rate to invasive carcinoma was 39%. Ten of 142 (7%) successful SNBs showed a positive sentinel node (eight micrometastatic). The sentinel node was positive in 1% of pure DCIS, in 5.5% of DCIS with micro-invasion, and in 19.5% of invasive carcinoma. RESULTS: Both clinical presentation and corresponding risk score were closely related to conversion to invasive carcinoma. The association of risk score and sentinel node positivity approached but did not reach statistical significance (P=0.06); therefore a subset of further selected higher risk patients could not be defined. CONCLUSION: The relevance of SNB positivity cannot be overlooked in high-risk DCIS patients, however, because SNB is not free from morbidity and cost, more studies are needed to refine its final indication.     

Non-operative diagnosis—effect on repeat-operation rates in the UK breast screening programme

Non-operative diagnosis rates in the UK breast screening programme have improved dramatically from 48.8% in 1994/95 (only nine units achieved the then minimum standard of 70%) to 94% in 2005/06 (only seven units failed to achieve the target of 90%). Preoperative and operative history of all 120,550 women diagnosed with screen-detected breast cancer in the UK between April 1994 and March 2006 was derived from different national databases. In 2005/06, 2,790 (17.8%) of the 15,688 women having surgery needed two or more operations. In 2001/02 (non-operative diagnosis rate 87%), the re-operation rate was 23.8% (2,377 of 9,969). Extrapolation backwards to 1994/95 (non-operative diagnosis rate 48.8%) suggests a re-operation rate of 62%. Analysis over the 4 years from April 2002 (n = 34,198) demonstrates that 4,089 (12%) women with a correct non-operative diagnosis of invasive disease required additional surgery compared to 1,166 (48%) of women who were under-staged (diagnosed as non-invasive based on core biopsy, but actually suffering from invasive disease). Failure to achieve a non-operative diagnosis of invasive disease (n = 1,542) or non-invasive disease (n = 2,247) resulted in re-operation rates of 65 and 43% respectively. Given the impact of not having a diagnosis pre-operatively, or of under-staging invasive carcinoma, it seems timely to introduce more sophisticated standards.     

Does dynamic post contrast MRI of the breast have a role in screening of high risk patients?

Purpose

The aim of this work is to assess the role of dynamic post contrast MRI of the breast as an adjunct to mammography in screening high risk women especially those with dense breast parenchyma.

Patients and methods

A prospective study of 70 high risk cases of breast cancer who are examined by mammography and MRM to evaluate the results.

Results

MRM proved higher sensitivity, specificity, positive and negative predictive values.

Conclusion

MRM proved to be of high importance in diagnosis and management of breast cancer.     

How reliable is modern breast imaging in differentiating benign from malignant breast lesions in the symptomatic population?

AIM: To assess the ability of mammography and ultrasound individually and in combination to predict whether a breast abnormality is benign or malignant in patients with symptomatic breast disease. MATERIALS AND METHODS: Patients included were those in whom histological confirmation of the abnormality following surgical excision was available. Mammographic and ultrasound appearances were prospectively classified using a four-point scale (1 = no significant lesion, 2 = benign lesion, 3 = possibly malignant, 4 = probably malignant). RESULTS: Histological confirmation following surgical excision was available in 559 patients, of which 303 were benign and 256 were malignant. The imaging classification was correlated with histology in these 559 lesions. In predicting final histology, the sensitivity and specificity of mammography alone were 78.9 and 82.7%, respectively, of ultrasound alone were 88.9 and 77.9%, respectively, and of mammography and ultrasound in combination were 94.2 and 67.9%, respectively. Only one patient had both a mammogram and ultrasound reported as normal (category 1 for both tests) in whom subsequent histology revealed a carcinoma (0.4% of all carcinomas). CONCLUSION: We found that the extensive use of ultrasound increases the cancer detection rate in this selected population by 14%.     

Is the appearance of microcalcifications on mammography useful in predicting histological grade of malignancy in ductal cancer in situ?

It has been proposed that the grade of malignancy of ductal carcinoma in situ (DCIS) of the breast can be estimated by the morphology of microcalcifications found on mammography. We correlated microcalcifications and histopathology in a retrospective blinded review. We reviewed all patients who underwent excisional breast biopsy over a 5 1/2-year period. Mammograms and pathology slides of all patients (n = 49) with DCIS of the breast were included in a blinded retrospective analysis. Mammographic microcalcifications were divided into four categories, "linear branching", "coarse granular", "fine granular" or "no microcalcification". Independently, pathology specimens were assigned to poorly, intermediately and well differentiated categories according to the consensus classification of DCIS introduced by the European Organisation for the Research and Treatment of Cancer. Two patients had no microcalcifications. 25 (53%) of the remaining 47 patients had "linear branching" microcalcifications, 10 (21%) had "coarse granular" and 12 (25.5%) had "fine granular" microcalcifications. 19 patients (40%) had poorly differentiated, 23 (49%) intermediately differentiated and 5 (11%) well differentiated subtypes of DCIS. 14 (56%) of the 25 patients with "linear branching" microcalcifications had poorly differentiated DCIS, 10 (40%) had intermediately differentiated and 1 (4%) had well differentiated DCIS. 3 (30%) of 10 patients with "coarse granular" microcalcifications had poorly differentiated DCIS, 5 (50%) had intermediately differentiated and 2 (20%) had well differentiated DCIS. 2 (17%) of 12 patients with "fine granular" microcalcifications had poorly differentiated DCIS, 8 (67%) had intermediately differentiated and 2 (17%) had well differentiated DCIS. These findings were not statistically significant. In conclusion, "linear branching" microcalcifications tended to be associated with higher pathological grading. However, correlation was poor and there was considerable overlap between categories. Histological type of DCIS cannot be predicted prospectively on mammographic appearances.     

Does the degree of background enhancement in breast MRI affect the detection and staging of breast cancer?

Objective  

The purpose of this study was to assess the influence of background enhancement on the detection and staging of breast cancer using MRI as an adjunct to mammography or ultrasound.     

How 'hot' is the pathologically positive sentinel lymph node in breast cancer patients?

When many lymph nodes are found by using lymphoscintigraphic techniques performed to detect the sentinel lymph nodes (SLNs) in breast cancer, it is usual to find that the 'hottest' SLN is not always the node that is pathologically positive (pN+). Various criteria have been proposed to define which radioactive lymph nodes should be removed. In order to determine the frequency with which the hottest SLN 'fails' to be pN+, and to determine which criteria best define the radioactive lymph node to be removed, we reviewed and analysed our cases in which more than one SLN was detected and where there was also at least one pN+ node. From a series of 181 patients, 40 were selected. In 11 of these 40 cases (27.5%), the hottest SLN was not pN+. Radioactivity levels in the pN+SLN of these 11 patients ranged from 2% to 94% of the activity of the hottest SLN. Twenty-one patients (52.5%) showed only micrometastatic (pN1a) disease in one or more SLNs. In four of these patients (19%) the pN1a SLN was not the hottest node. Two of the patients had radioactivity levels in the pN+SLN which were more than 50% of that of the hottest SLN. In another two of these patients (9.5%), radioactivity levels were lower than 50% of that of the hottest node (respectively, 38% and 2%). However, in these two last cases, the first and hottest SLN removed surgically was found, by the pathologist, to consist of six nodes. Macrometastases (dimensions greater than 2 mm) were found in 19 patients. In 12 of these patients, the hottest SLN was macrometastatic although macrometastases and/or micrometastases were found in other 'cooler' SLNs in four of them. In another seven of these patients (36.8%), macrometastases were found in SLNs with radioactive levels lower than 51% of that of the hottest node. One patient (with three SLNs) out of the 40 (2.5%) had one SLN pN+ with less than 10% of that of the hottest. In fact, it contained only one micrometastasis and its activity was equal to 2%. Upon pathological examination, however, the hottest lymph 'node' was found to consist of six nodes. It is concluded that, with four intra-mammary and peritumoural injections of 99mTc labelled nanosized colloids of Human Serum Albumin (Nanocoll R: Sorin: 74 MBq and 0.05 mg per injection) performed 18-24 h before using a gamma probe to detect the SLNs, the hottest SLN was not the pathologically positive node in 27.5% of patients in our series. By using the activity in the hottest SLN as the reference point, and 10% of this activity as the lower threshold for removing active SLNs, the sensitivity of the technique is 97.5%.