British Society of Breast Radiology Annual Scientific Meeting 2018

A retrospective multi-reader study using images from the 152 participants with cancer and 148 normal/benign participants was conducted. Two readers examined each case under each of three reading conditions: FFDM, DBT, DBT+FFDM. No reader read the same case twice; each read the same proportion of cases under each condition, in randomised order. Cancer sensitivity was calculated using a Monte Carlo simulation to extract subsets of cases to estimate the variance in sensitivity as well as calculate confidence intervals.

Results: Across all ages, 1095 invasive cancers were diagnosed in the study period; 413 screen-detected, 679 symptomatic. There were 183 deaths (all causes); 82 in the screen-detected group, 101 in the symptomatic group; mean follow-up was 4.8yrs. Amongst women with symptomatic breast cancer the proportion of deaths due to breast cancer vs other causes significantly decreased with age (95.5% in <50yrs, 63.9% in 50-69yrs, 48.6% 70-79, 17.5% >80yrs; p<0.00001). In the study period, 5003 women aged >70yrs attended breast-screening, 184 (3.7%) were recalled to assessment, over half had an invasive procedure. Cancer detection rate was 13.5/1000 (25% DCIS).

Our model predicts that almost all invasive and high-risk DCIS will be detected with recall rates below 7% (needle biopsy rate 3%) at prevalent screen and below 4% (needle biopsy 1.5%) at incident screens.

The performance of all breast screening personnel is recorded in the Breast Screening Information System (BSIS) which holds all national screening reader QA results for England. These individuals also take part annually in the PERFORMS self-assessment scheme where they report a series of challenging breast screening cases and their data are recorded and fed back to them to help their improve real life screening performance. Previously, a regional study showed strong correlation between real-life data and PERFORMS data for cancer detection rate. The relationship between these two sets of data were investigated nationally to determine how PERFORMS data relate to actual screening performance. Some 582 screeners consented to take part. Data were acquired from BSIS concerning their performance over a three-year period. Comparative data for each individual were also obtained from the PERFORMS database over the same time period and the relationship between the two sets of measures were examined. Some 533 participants’ data were successfully matched, validated and therefore included in this study. A Kendall's tau-b correlation was run to determine the relationship between the PPV values calculated from real-life data (cancer detected/ total recalls) over the past three years and the PERFORMS average PPV values over the same period. There was a strong, positive correlation between them, which was statistically significant (τb = .141, p <.01) confirming that PERFORMS data accurately reflect real life screening performance. Therefore PERFORMS scheme can be used to give an early indication of any individual having difficulties and helped appropriately to improve.

Papilloma is the most common intraductal mass lesion of the breast and includes solitary intraductal papilloma, multiple papillomas (MP), papillomatosis, and juvenile papillomatosis. MP occur in approximately 10% of cases of intraductal papilloma. They can present in a number of ways including pain, lump and (serosanguineous) nipple discharge, or may be incidental. Imaging features vary and core biopsy and sometimes an additional vacuum biopsy is required, for definitive diagnosis.

MP compared to solitary lesions, tend to occur in younger patients, are less frequent, they are often bilateral, associated with nipple discharge and usually they are located at the periphery of the breast.

They carry an increased risk of malignancy and their management could be challenging. International Guidelines are not clear with regards to follow up or treatment. Some Breast societies, suggest annual follow up, as they are high-risk lesions, but it is not quite clear what imaging modalities (mammograms, US, MRI and combinations) should be used. Treatment options include both radiological and surgical excision of the lesions as well as surgical duct excision. However, when the lesions are innumerous, the only definitive treatment option is mastectomy but this option is considered aggressive and there is a controversy between doctors and centers.

The aim of our study is to present imaging features (mammograms, US, MRI) of multiple papillomatosis, and flag the diagnostic and therapeutic dilemmas, through a series of cases from our department and discuss scenarios of multiple papillomatosis, with or without atypia or DCIS in the prophylactic mastectomy.

There is a well recognised staffing crisis in breast radiology. Our experience is that providing good core training means that trainees are more likely to choose breast as a subspecialty. We distributed a survey to all trainees in the Mersey Training Programme to establish how much exposure they had had to breast radiology and at what stage. We also asked whether this had influenced their choice of subspecialty.

Following on from this we collaborated with breast radiologists from elsewhere in the North Western Deanery School of Radiology to draw up a comprehensive, practical guide to core breast training. This is divided into knowledge and skills and provides guidance on essential and desirable competencies.

Once approved at School board level this will be rolled out across the deanery and our hope is that it will ensure that all trainees in our region gain comprehensive, standardised breast radiology experience at ST2/3 level. This will allow them to make an informed decision regarding their future career options.

We will present the results of the survey as well as the main points from our core breast training document.

Commercially available breast ultrasound phantoms are expensive and are known to degrade with repeated use. A homemade cheaper alternative is necessary in order to facilitate interventional training within a departmental setting. In the past, chicken breasts were used in order to replicate breast tissue, however, infection control concerns now prevent raw meat from being used for this purpose.

Jethwa et al have previously presented an informative poster with a recipe for a breast phantom and replication of the phantom was attempted using the recipe described. Technical difficulties arose and modifications to the original recipe were made to enable reproducible breast phantoms to be made.

Teaching Points:

We present a series of cases demonstrating the use of CESM in various settings such as neoadjuvant assessment of tumour size, lobular breast cancer and as a problem solving tool in dense breasts. We also highlight the pitfalls of artefact posed by the presence of marker coils and case of reduced sensitivity for detecting additional sites of disease in multifocal cancer as has previously been described in the literature.

Aetiology is unclear with genetic and endocrine factors and trauma considered as possible causes. Treatment consists of wide local excision with adequate safety margins. Post-surgical recurrence rates upto 29% have been reported in some studies. Younger age, larger tumour size and positive margin status are factors associated with increased risk of recurrence.

Age at diagnosis ranged from 27 to 81 years, with a mean of 50.2 years.

8 cases presented with a symptomatic lump. 1 was recalled from screening. 1 had a mass noted on follow up mammograms after previous contralateral mastectomy for cancer.

On mammograms, 5 lesions were ill-defined and spiculate, mimicking malignancy. 2 lesions were not visible on mammogram. 3 patients did not have mammograms at diagnosis.

On Ultrasound, 4 cases demonstrated irregular hypoechoic masses mimicking malignancy, 2 demonstrated subtle distortion with surrounding hyperechogenicity and 1 demonstrated a well-defined lesion. 1 patient had a normal US. The remaining 2 did not have US.

All lesions were excised surgically. 1 patient is known to have had local recurrence so far.

Learning Objectives:

Currently there are multiple indications for CESM in breast imaging with a role in both accurate diagnosis and as a problem solving tool; indications that had previously been reserved for breast MRI.

We present a comprehensive series of CESM cases from the past four years in the Belfast Trust. We will depict the imaging features which aid accurate diagnosis and impact on patient management.

We will specifically illustrate cases which highlight the use of CESM for:

A training package was developed comprising of:

How this was implemented: 2 x radiographers undertook the training over a 6 month period. Assessment on a test set of 20 cases. 6 months post assessment, trainees complete course evaluation questionnaire

For the assessment of 20 cases: appearances noted, free text report written and conclusion. The assessment was evaluated independently by 2 x consultant radiographers with consensus meeting for evaluation of results.

They have a greater awareness of the importance of good technical quality imaging and engaged better with the reporting consultant radiographers/radiologists to ensure that mammographic abnormalities (real and compsoite) were appropriately worked up.

On completion certificates have been issued which can be used as evidence of CPD.

Primary angiosarcoma of the breast is a very rare neoplasia, which unlike secondary angiosarcoma is not associated with previous radiation exposure. It accounts for less than 0.05% of all malignant tumours of the breast, however it is highly aggressive and carries a worse prognosis than mammary carcinomas.

Radiologically, angiosarcoma poses a significant challenge for diagnosis as there are no pathognomonic features seen on conventional imaging (ultrasound or mammography), and in fact findings can be very bland or even occult. Breast MRI is considered the most sensitive imaging modality. Pathology can also be non-specific, and therefore a close relationship between radiology and pathology is needed in order to optimise the diagnostic pathway of these patients.

Through the presentation of two cases, with similar histopathology, the difficulties in diagnosis with conventional imaging and pathology appearance will be discussed. Given the rarity and challenges of this condition, it is of high importance that suspected cases of primary angiosarcoma are appropriately referred to a specialist tertiary centre for optimal management.

A solid multi-disciplinary team approach is essential in the successful management of such cases.

Targeted axillary node dissection is a technique used in larger centre’s internationally and is increasingly being used in centre’s in the UK. In post neo-adjuvant cases, it offers women less debilitating surgery and decreased morbidity.

Within our centre, Iodine-125 seed localisation is established as the standard localization technique for breast lesions. The ARSAC license has now been extended to allow seed localization of abnormal axillary nodes.

The aim of this poster is to outline how our procedures had to be adapted to include iodine-125 seed localisation of axillary nodes, including shoulder x-rays to demonstrate that the seed is in place. Post neo-adjuvant chemotherapy, the imaging appearances of the targeted node will have altered and identifying the marker clip may be difficult. Using examples, a discussion of the challenges faced in targeting nodes, in particular post neo-adjuvant chemotherapy will be included.

Pseudocirrhosis is an uncommon but significant complication observed in patients who have undergone systemic chemotherapy for breast carcinoma metastatic to the liver. Despite being a rare finding, it is a cause of morbidity in breast cancer patients and therefore it is important to improve awareness and understanding amongst breast radiologists to aid in appropriate and timely management.

Pseudocirrhosis is a process by which the liver progressively develops a morphological pattern that mimics classical cirrhosis and can cause significant difficulties in interpreting disease progression, stability and also response to chemotherapy. The appearances can be similar in all three scenarios on certain imaging modalities.

Radiologically it has similar appearances to macronodular cirrhosis, however pseudocirrhosis demonstrates a distinct pathophysiology. Pathogenesis is thought to be multifactorial although primarily related to the chemotherapy treatment of breast cancer. Multi modality techniques including ultrasound, CT, MRI and PET-CT will be used to demonstrate imaging characteristics, which include changes in hepatic contour, capsular retraction and complications from portal hypertension.

Working in a liver transplant unit we have had significant input into the imaging management of these patients from our hepatobilary radiology colleagues.

We will review these findings using radiological illustrations and discuss how to assess disease extent and progression with a guide to ongoing management.

We present a series of breast findings incidentally detected in patients undergoing cross sectional imaging for other pathologies. 30 patients presented to the symptomatic clinic for investigation of a lesion reported incidentally on predominantly CT or PET. Correlation with the cross- sectional image was essential for correct lesion correlation; evaluating the size of lesion, the nipple to lesion distance and ability to interpret the cross sectional image and plan where to target the ultrasound aided correct assessment.

In over 40 years old patients tomosynthesis helped locate the lesion and identified further lesions not seen on CT.

If biopsy was warranted, marker placement helped correlate with CT to enable correct lesion identification. Vivid enhancement on CT helped predict significant pathology. The study identified how breast malignancy can present in many remote sites and that recurrence can occur 30 years following treatment of the primary.

Vacuum-assisted breast MRI-guided biopsy is required for indeterminate or suspicious breast lesions that cannot be identified on second look ultrasound, when this will affect patient management. We reviewed our tertiary referral centre’s performance of MRI biopsy with reference to the European Interdisciplinary Consensus Meeting following an initial audit from January 2013 to March 2016. Our standards were % of biopsy results discussed at MDT (100%) and % of B2 lesions undergoing further assessment - either short term MRI follow-up or re-biopsy (100%). We reviewed our electronic patient data system for MRI biopsies performed from April 2016 to May 2018. 66 biopsies were performed (69% increase from previous audit). 100% of results were discussed at MDT. 21/66 (32%) lesions were B5 at biopsy (23% in 2016). Of the remaining cases, 6 were B1, 27 B2, 11 B3 and 1 B4. All B3 and B4 lesions were surgically excised. Of the B1 lesions, 3 had follow up MRI, 2 underwent surgery and 1 agreed MDT decision to accept outcome due to existing medical co-morbidities. 13/27 B2 lesions (48%) underwent further assessment (20% in 2016). 7 had no documented follow up and 7 were lost to external follow up. Our results from our re-audit demonstrate an increased demand for MRI biopsy and cancer detection rate, in line with the literature. It also highlights the importance of BIRADS grading of MRI suspicion, allowing accurate assessment of concordance with biopsy results, and providing clear recommendation of follow up for non-concordant lesions and external referrals.

A multi-centre, randomised (1:1), Phase III Trial of Surgery versus Active Monitoring for Low Risk Ductal Carcinoma in Situ (DCIS)

1) Female, aged ≥ 46 years

2) Screen-detected or incidental micro calcification

3) Histologically confirmed diagnosis of non-high grade DCIS confirmed by local pathologist (for both breasts if bilateral disease)

By Small volume core biopsy and Vacuum Assisted Core Biopsy (VACB) Or Vacuum Assisted Core Biopsy (VACB) alone as first line diagnostic approach Or Small volume biopsy or VACB plus open diagnostic surgical biopsy (without clear margins) Or Open diagnostic surgical biopsy (without clear margins).

4) DCIS diagnosed ≤90 days before registration

5) Bilateral disease is permitted if both sides are confirmed to be non-high grade DCIS by local pathologist and the diagnosis is made within the same treatment episode

6) Able to give informed consent and comply with the trial schedule

7) Patient fit and willing to undergo surgery

8) Written Informed Consent obtained

We will update on current status of the trial and recruitment

A large Phase III trial in which patients with multiple negative ultrasound guided tumour-bed biopsies after neo-adjuvant chemotherapy with combined multi-targeted anti HER2-directed therapy in ER-negative patients are randomised to surgery plus radiotherapy or radiotherapy alone is required.

The trial requires a Feasibility Study to explore both the willingness of patients to consent to randomisation and the accuracy with which multiple, post-treatment image-guided tumour-bed biopsies can detect residual disease.

1) To confirm concordance of local assessment of pathological complete response with central pathology review

2) To confirm that the multiple image-guided tumour-bed biopsies are able to exclude significant residual cancer burden

3) To explore the willingness of patients to be randomised

The willingness of those patients who have had a clinical response and negative post treatment image-guided tumour-bed biopsies to be randomised to either surgery and radiotherapy or radiotherapy alone will be explored via structured telephone interview prior to surgery. All patients in the feasibility study will undergo surgery.

The poster will provide an update of the trial status and describe the process for and documentation of tumour bed biopsies

A Phase III, randomised, multi-centre trial addressing overtreatment of small, screen-detected breast cancer by comparing standard surgery with minimally invasive vacuum-assisted excision.

The SMALL trial aims to determine whether, in a selected low-risk population of women with small, biologically-favourable, screen-detected breast cancer:

1. The extent of surgical treatment can safely be reduced in the context of standard adjuvant radiotherapy and endocrine therapy.

2. The VAE technique is non-inferior in terms of requirement for a second operation to achieve complete resection of the cancer.

3. There is an acceptable local recurrence risk in the VAE arm with long-term follow up.

The study will also compare surgical complications, patient reported outcome measures and carry out a health economic evaluation of the procedures.

Women > 50 years

Screen detected breast cancer < 15mm in size, ER/PR positive, HER2 negative

Patients randomised in a 2:1 ratio in favour of VAE

Single arm analysis of VAE patients to assess LR

We aimed to investigate our use of, and results of, breast histology in men, with a view to changing practice and improving patient care in our Unit.

28 men underwent diagnostic breast core biopsy, age range 24-96 years; 13 results were benign, 14 malignant, 1 indeterminate (confirmed as DCIS at surgery).

All men with diagnosed malignancy were >53 years (mean 71). All had bilateral mammogram and ipsilateral US performed at initial visit except one patient with a clinically fungating cancer. In all malignancies the imaging was classified indeterminate or suspicious (≥M3 and/or ≥U3), as was the clinical palpation score (≥P3).

There have been no subsequent breast cancer diagnoses in any males considered benign in this study.

This study aimed to determine the accuracy of imaging measurements in invasive lobular cancer patients who had undergone all 3 imaging modalities preoperatively.

Maximum tumour dimension on MRI had the highest correlation of the three imaging modalities when individually compared with final histology lobular carcinoma size (mammogram r²=43%, ultrasound r²=62%, MRI r²=68%).

Multivariate regression showed that the combination of ultrasound, mammogram and MRI was the most effective way of estimating size of malignancy in invasive lobular carcinoma (r²=70%, versus r²=61% for the combination of ultrasound and mammogram).

Ultrasound had a tendency to underestimate disease measurement, whereas MRI had a tendency to overestimate it.

Only 22% (38/174) women had one (26), two (11) or more (1) ipsilateral prominent axillary lymph nodes and normal contralateral axilla on MRI (mean time to MRI 18 days, median 16 days; 8% (3/38) macrometastatic lymph node disease on final surgical pathology, versus 10% (17/174) of whole group studied).

In 66% (114/174) women axillary MRI was normal and symmetrical bilaterally, with prominent node(s) bilaterally in 9% (15/174). In 4% (7/174) the ipsilateral axilla appeared normal and the contralateral axilla demonstrated 1-2 prominent lymph nodes.

All study patients underwent axillary ultrasound. The overall combined sensitivity and specificity of ultrasound/core biopsy in lobular cancer study patients was 63% and 100%, respectively.

163 patients were operated upon with a radiologically normal axilla; 91% (149/163) were lymph node negative at operative histology (sentinel lymph node biopsy), but 9% (14/163) did have lymph node macrometastases. In 64% (9/14) cases of unexpected lymph node metastasis, further axillary surgery was performed, and in 7% (1/14) axillary radiotherapy was planned. 29% (4/14) had no further axillary treatment.

Following MRI, in 9 cases no further surgery was performed. 16 had re-excision, 1 of which subsequently underwent mastectomy. In total, 9 patients underwent mastectomy, four based on MRI findings.

The Breast Unit Research Team at the Royal Marsden recently launched the LIESL trial which aims to determine the performance of the MARIA^® breast imaging system. There have been previous studies using MARIA^® with earlier iterations. In this trial we will gain experience in interpreting this novel breast imaging modality. Our experience and the data generated will also inform further development of the system by Micrima.

The study has been designed to investigate the performance in 3 different cohorts.

Stream 1 Will determine the accuracy in identifying known breast cancers.

Stream 2 Will investigate the imaging characteristics of MARIA^® in patients attending the symptomatic clinic.

Stream 3 Will evaluate the utility of MARIA^® scans in assessment of patients undergoing neoadjuvant treatments.

The study will recruit 994 patients from women attending the breast imaging department, with 53 cases recruited to date.

Utilising an entirely new imaging modality is challenging and the team are continuing to develop understanding and experience in interpreting findings. Current viewing software requires three generated fields of view to be interpreted separately. Revised software will be available in July which allows faster and easier use. We will report on this also.

Contralateral MD was retrospectively assessed using VOPLARA and the BIRADS classification and visual analogue scale (VAS) by breast radiologists blinded to treatment outcomes. The immediate peri-tumoural tissues were classified as either fatty, mixed or dense. Associations between MD and pCR rates were assessed using ROC curves.

48/240 tumours (20%) achieved a pCR. VAS and BIRADS assessed baseline MD did not show significant associations with the rate of pCR. Volpara assessed baseline density had a borderline association with the rate of pCR (AUC of 0.62, p=0.053).

VOLPARA assessed baseline MD for HER2 positive patients did show significant associations with the rate of pCR (AUC 0.70, p=0.004). Associations of VAS and pCR were borderline (AUC 0.60 (P=0.06). VAS, BIRADS and VOLPARA assessed baseline MD for the triple negative patients did not show significant associations with the rate of pCR. No asociation was found between the peritumoural density and response.

A retrospective audit of 388 patients that examines the role of staging (CT/bone scintigraphy or both) in patients receiving NACT. Of the 388 patients receiving NACT, 23% were Luminal A; 18% were Luminal B Her 2+ve, 21% were Luminal B Her 2-ve, 10% were HER 2+ve and 28% were triple negative. 1 case of unknown luminal subtype. 33% (128/388) had staging.

Within this group, 18% (23/128) had metastatic disease prior or during NACT. 18/23 cases were Luminal B and Triple negative cases. 3 cases were Her 2+ve, 1 Luminal A subtype and 1 in unknown luminal subtype. 22% (28/128) who had negative staging developed metastases after NACT.

67% (259/388) did not have any staging performed and 18% (47/259) developed metastases post treatment. 32/47 cases were from the Luminal B and Triple negative cases, of which 8/9 were under the age of 40.

98/388 women developed metastatic disease. 81/98 died from metastatic breast cancer, 2/98 died of other causes and 15/98 are living with metastases.

About 25% (98/388) of patients developed metastases after treatment.

Within the limitations of this study, there does not appear to be an appreciable difference between detection of metastases for those scanned prior or during NACT versus those who were scanned symptomatically after treatment, raising the question that staging is only necessary if patients are symptomatic in the context of NACT. Staging in asymptomatic women is of limited value for those receiving NACT.

There were 16 B5 diagnoses (9 B5a, 7 B5b). In 8/16 cases, the mammographic lesion was not identified by ultrasound. In 2, DBT-biopsy allowed more accurate lesion identification (multiple lesions or initial ultrasound biopsy at inaccurate site). 6 cases (for calcification/clips) used DBT-biopsy at users discretion. In 45 cases, the DBT-biopsy was benign.

Aims:

Phase 1 of the Sloane Project (1 Apr 2003 and 31 Mar 2012) collected 13125 cases from 82 units (11331 with DCIS, 1135 with ‘atypia’, 659 await pathology form). The Sloane atypia audit from 1 Apr 2012 has collected 837 cases.

5 years follow up: Recurrence of DCIS or invasive breast cancer occurred in 6.8% (697/9,938), more commonly after BCS (7.8%) than mastectomy (4.5%; chi-square p<0.0010); 228 women (2.3%) developed contralateral DCIS or invasive breast cancer. (EJC 2018)

The length of recorded follow up in the main audit is now between 4 and 13 years and we will publish a series of paper incorporating these data.

The research arm is actively collecting tissue blocks for women who have developed an invasive recurrence and matched controls to identify biological markers of high risk disease.

There are other similar data sets but none have the level of information (particularly imaging) We need your help to make this data set world class. This year we will be contacting you for

Sloane activity is ‘audit’ and we will be providing you certificates of participation for appraisal

Breast density is well recognised as a risk factor for breast cancer with denser tissue more likely to develop cancer and less likely that such cancers are identified on mammography.

Breast densities on 277 consecutive interval cancers (ICA) screened at Breast Test Wales between 2012 and 2016 were analysed using DENSITAS 2.1.0 software, using processed images to calculate area density, percentage density, non-breast area and total breast area and BIRADS 5 density scores ABCD.

Classification and number of ICA were recorded; true 124 (44.7%), false negative 43 (15.5%), minimal signs 32 ( 11.5%), occult 20 (7%), unclassified 26 (9%) and 32 (11.6%) nonanalysed. Year one had 72 (26%) intervals, year two 129 (46.6%), year three 76 (27.4%); differing from NHSBSP standards when almost half of cases are year 3 following normal screen.

Of 268 cases with available information, there were 5 BIRADS A (1.7%), 83 BIRADS B (31%), 170 BIRADS C (63.3%) and 10 in BIRADS D (4%) categories.  Most ICA were observed in the third highest density group. The majority of true and false negative cases had breast densities of B and C grades.  In the highest density category, most (30%) were in the occult category.

Previous studies show a range of values in normal screened woman without cancer, where most were in the BIRADS B group (53%) and around 13% in BIRADS A category.  These data differ from ours and support the theory that higher breast density results in higher cancer incidence, and possibly higher interval cancer rates.

At our Centre, where >50% tumours are screen detected, 82% of patients undergo conservative surgical procedures. Second surgery for positive margins in breast cancer excision is required in nearly 20% of these, leading to delayed recovery, pressures on operating time and in patient stays and potential psychological stress for patients, knowing that 'they haven't got it all out.’

Using an Hologic Clarity HD system, all operative non-mastectomy breast cancer specimens localized due to impalpability, underwent mammography tomographic analysis between April and July 2018.  Images were reviewed at the time of surgery by the surgical team and/or radiologist and if the tumour was considered to be at margins, the surgeon would perform shaves from the tumour cavity, considered to be possibly margin positive.

60 consecutive specimens were identified, 5 excluded (localisation biopsies), 2 were incomplete. 53 were reviewed recording the mammographic feature, radiographic opinion of margin status; 79% good, 17% intermediate, 6% poor, surgical theatre notes and pathological reports.  17 cases (32%) underwent cavity shaves following review of the tomographic images; only one of which had positive pathological margin due to a coincidental, separate lesion. Of 37 without shaves, nine (24%) had positive margins and of these only one was considered tomographically close to margin.

Results were compared to conservative cases the previous year when 18% invasive cancers had second surgery for margins and 19% of DCIS only cases.

This early work may suggest that tomographic review of specimens might contribute to reducing second surgery, although further work is required.

The costs of disposable material in our unit is £22 per biopsy and £27 for histology technical preparation. Imaging biosy time is 10 min and histology time is 5 min for a fibroadenoma and 2 cores of tissue (estimated average). SWE takes 2 minutes to perform.

All imaging and histology were reviewed to document the evidence of adequate sampling as well to confirm the grade given initially.

93 implants were identified in 62 females.

37 implants were reported as intact on ultrasound; MRI agreed in 100%.

25 implants were reported as cannot rule out intracapsular (IC) rupture on ultrasound; 23 (92%) were intact on MRI, and 2 (8%) were reported as uncertain for IC rupture on MRI.

16 implants were reported as suspicious for IC rupture on ultrasound; on MRI, 14 (88%) were reported as definite IC rupture, 1 (6%) was reported as suspicious and 1 (6%) was reported as uncertain for IC rupture.

10 implants reported as definite IC rupture on ultrasound; all (100%) confirmed on MRI.

2 implants reported as suspicious for extracapsular (EC) rupture on ultrasound. 1 reported as definite IC, but not EC, rupture on MRI. 1 reported as suspicious of EC rupture on MRI.

3 implants reported as definite EC silicone on ultrasound, confirmed in all 3 on MRI.

We present a retrospective audit of our management of patients with likely fat necrosis on imaging.

Ninety-six patients (89 female, 7 male) were identified from breast clinic records.

31% (30/96) patients had one imaging attendance, 55% (53/96) had two, and 14% (13/96) >2 attendances.

43% (13/30) underwent biopsy at their first imaging attendance, with two malignancies detected.

69% (66/96) patients were assigned to follow up imaging, at which 74% (49/66) demonstrated radiological improvement or complete resolution. 26% (17/66) underwent biopsy at second visit, 8% (5/66) at a later visit. One follow up biopsy result (5%, 1/22) was malignant, all others benign (95%, 21/22). On imaging review, the malignant follow up biopsy was delayed due to image misinterpretation.

There has been no further cancer identified in this cohort of patients to date (June 2018).

Our findings do not support routine follow up imaging of fat necrosis patients who do not meet imaging criteria for biopsy.

Readers graded images as “not blurred”, “blurred/TR”, or “blurred/no TR”, scored blur severity (0-100 scale), indicated blurred areas, and graded BI-RADS® density. Volumetric breast density was computed (Volpara, v1.5.2).

Reader agreement was analysed by intraclass correlation coefficient (ICC) and Fleiss’ kappa; multiple logistic regression was used to identify best predictors of TR in the blurred images.

Severity best predicted TR (χ²=116.9, p<0.001, Pseudo R²=0.61) and dominated the regression model. Excluding severity from the model revealed significant effects of reader, size of blurred area and patient age, when also accounting for location of blur, and Volpara and BI-RADS® density (Pseudo R²= 0.43).

Breast MRI plays a key role in preoperative assessment of tumour size, in detecting contralateral breast cancer and to determine if tumour is multifocal/ multi centric.

20 (54.1%) primary tumours were in the outer breast, 12 (32.4%) in the inner breast. 26 (70.3%) of tumours were grade 3, 8 (21.6%) grade 2 and 3 (8.1%) grade 1. Majority of tumours were HER2 negative (n=31, 83.8%), with no significant difference in ER status. 12 (32.4%) were triple negative. 10 (27%) patients had >= 4, 14 (37.8%) had <4 and 13 (35.1%) had 0 axillary metastases. Most patients had a moderate (35.1%) or poor (48.6%) Nottingham Prognostic Index.

217 AUS performed, 71% normal, 21% equivocal and 8% had an abnormal AUS. 19% of normal AUS had false negative result. 63/217 underwent nodal FNA. 23/63 had nodal metastases whereas 40/63 did not. However, 7/40 had false negative FNA results compared to histology.

ALN cortical thickness cut-off of 2mm, 63 ladies underwent FNA with 23 proceeding with ANC. Increasing cut-off to 4mm, 20 ALNs underwent FNA with 14 ALNCs. Lastly, 5mm cortical thickness cut-off, 16 ALN FNAs performed and 13 ALNCs.

14/23 had one abnormal ALN while 9/23 had multiple abnormal ALNs on AUS. 74% had ≤4 metastatic ALNs at histology after ALNC.

64 B3 lesions were biopsied in 61 patients (11 stereotactic biopsies, 53 US guided biopsies). 22 lesions (34%) were papillomas, 20/53 (40%) in the US group, 2/11 (18%) in the stereotactic group. All lesions were managed appropriately. 5 lesions were upgraded to malignant at subsequent biopsy or surgical excision. The proportion of papilloma was compared to the proportion of papilloma found amongst B3 lesions in our local screening centre between April 2017 and March 2018: 12/111 (11 %).

Breast MRI is widely used to assess extent of breast malignancy, problem solving and in screening and surveillance of high risk patients. However, MRI often generates further questions. Second-look Ultrasound (US) is a useful tool where further clarification is required.

We felt that we were generating a high proportion of further investigations following MRI and wanted to assess how we were performing against published data.  We retrospectively reviewed 12 months of second-look US from our Breast Unit, from January 2016 to December 2016. 286 MRIs performed in that time generated 83 Second-look US (29%). We describe the cohort of patients undergoing MRI, the reasons second-look US were recommended, our success at finding the corresponding abnormality, and our tissue sampling (core biopsy/FNA) rates and pathology.

Our pick up of MRI abnormalities on second-look US (76%) is in line with published data. 60% of US lead to core biopsy, of which 38% were B5 result. We discuss the impact of this on management plans in individual cases.  Our cancer detection rate on second-look US is in line with published data. We also discuss the 1-year follow-up of patients in whom no corresponding abnormality was seen on US.

Learning objectives:

Results were discussed at regional meetings and learning points disseminated to clinical teams. Changes in practice were noted over the 5 years of the audit. A recent matching exercise with cancer registry may increase the ratio of interval cancers compared to screen detected cancers.

Methods: A retrospective study of 143 cases in which MRI guided 2nd look breast ultrasound was carried out from 4^thJanuary 2012 to 10^thApril 2018. Data was analysed for 104 cases from our institution with completed information. This included; correlation between MRI and US findings, histology results and whether patient management was impacted, in terms of solitary or multifocal disease and subsequent treatment.

Results: Second look US was performed in 95 cases (one case was excluded due to patient mortality). 83 out of 95 (87%) had positive 2^nd look US of which 43 (45%) patients had additional malignancies with subsequent change in their surgical management. US failed to identify a lesion in 22 cases and required further MRI guided biopsy - from which 4 were histologically malignant requiring a change in surgical management.

Conclusion: We have demonstrated that MRI guided 2nd look US is effective for the detection of incidental further tumour foci and a cost effective method of altering patient management. MRI guided biopsy has proven useful in lesions not demonstrated on 2^ndlook ultrasound.

In 2007, the cancer reform strategy stated that women identified at higher risk of developing breast cancer, should be managed by the NHSBSP. This was to ensure standardisation across centres with regular intervals between screens and provide high quality screening and assessment. NHSBSP commenced the management of higher risk screening from April 2013.

The Newcastle Breast Screening programme manages the higher risk screening for its own local population and two adjacent screening programmes. Up until 2013, women who were considered at higher risk of breast cancer, in the geographic region surrounding these three screening units, were managed in the Newcastle symptomatic unit predominantly. The aim of this poster is to outline the processes involved in organising the screening of this group of women from 2013. The different steps in the process, such as risk assessment, planning and delivering high-risk screening will be discussed. Our strategies for performing mammogram and MRI in a timely manner will be outlined. Effective communication between the breast screening office, the client, genetics, the MRI department and the larger breast multidisciplinary team is crucial to ensuring a high quality service.

Results:

In 32 cases (41%), the radiological abnormality was removed at initial biopsy.

15/32 did not undergo VAE and are under annual 5 year follow up.  All were microcalcification (MCC) measuring <10mm.

14/32 underwent VAE. 13/14 cases were microcalcification (MCC) and 1/14 was a mass with MCC. The mammographic abnormality was <10mm in 13/14 cases and 1/14 was 14mm. Following VAE, atypia remained unchanged from original biopsy in 4 /13 cases. 10/14 showed benign changes only. Atypia was incidental in 5 cases but benign on VAE. In 9 cases, atypia represented the radiological abnormality and in 4/9 further excision showed the same findings. Follow up between 1-3 years has resulted in one cancer detected at year 3 in the same breast but at a different site.

No upgrades were identified at VAE for any cases where the radiological abnormality was removed at VAB.

3 underwent surgical excision of which 2 showed benign changes only. One was excised along with co-existent DCIS

The number of vacuum assisted biopsies performed in our unit continues to increase. Anecdotally there is an increasing B3 diagnosis rate on both needle core biopsy (NCB) and first line vacuum assisted biopsy (VAB). According to NHSBSP guidelines for the diagnosis and management of lesions of uncertain malignant potential on core biopsy, vacuum assisted excision (VAE) should be performed to ensure a B3 lesion has been thoroughly sampled. The NHSBSP and Association of Breast Surgery audit of screen detected breast cancers demonstrated an upgrade rate of 12% from non-invasive (B5a) on diagnostic core biopsy to invasive cancer at surgery for the screening year April 2016 to March 2017.

We wished to retrospectively review our vacuum assisted biopsies including the factors above over the last 3 years including both symptomatic and screening women.

398 patients were biopsied over the 3 year period 1/7/2015 to 30/6/2018 inclusive. Total number of needle core biopsies (NCB) = 226 and total number of vacuum procedures = 424.

16 NCBs were diagnosed as B5a, 1 (6%) was upgraded to invasive disease at surgery. 41 VABs were diagnosed as B5a of which 2 (4%) were upgraded at surgery. 33 VAEs were diagnosed as B5a of which 1 (3%) was upgraded at surgery. Analysis of B3 data demonstrates a 14% (25/153) upgrade rate from B3 on NCB and a 7% (4/55) upgrade rate from B3 on VAB to either suspicious, in-situ or invasive cancer at VAE, confirmed at surgery.

Our results are within national guidelines.

The purpose of this retrospective study was to determine the accuracy of preoperative axillary sonography in patients with invasive lobular cancer (ILC)

Patients who underwent surgery for ILC from January 2014 to December 2016 were identified from postoperative histological records.

We identified 253 cases of lobular cancers of which 71 patient were node positive.

Of these 50 % percent of node positive cases had an abnormal axillary USS. Two thirds had a core biopsy to prove nodal involvement (i.e. 20 patients). However, 9 of this had a conversion from FNA to core biopsy.

Axillary disease in lobular cancers may differ slightly from NST type. The disease is sometimes difficult to quantify on standard imaging. However, we have to underline that the core biopsy is more accurate in the diagnosis of axillary nodal disease.

In ILC, metastases are thought to be difficult to detect because the cells are small and on cytology resembles lymphocytes.

In the above data collection, we found that our accuracy rate for lobular cancers was slightly variable from NST. We are in the process of reviewing our practice to ascertain if we need to proceed to core biopsy instead of FNA in proven lobular malignancies and revisit the axilla after pathology available.

Our policy at ABUHB has been to biopsy probable fat necrosis if there is no history of trauma or surgery. This is a relatively common presentation in our symptomatic service.