Vacuum-assisted core biopsy of B3 lesions showing atypia on needle core biopsy: a worthwhile exercise?

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ORAL PRESENTATIONS
O1
Validation of a new automated volumetric breast density measurement
system as a marker of breast cancer risk
K Pinker1,2, N Perry2, S Milner2, K Mokbel2, S Duff y3
1Department of Radiology, Division of Molecular and Gender Imaging, Medical
University Vienna, Austria; 2Princess Grace Hospital, The London Breast Institute,
London, UK; 3Wolfson Institute, Queen Mary College, University of London, UK
Breast Cancer Research 2010, 12(Suppl 3):O1 (doi: 10.1186/bcr2648)
Purpose To validate the predictive power for determining breast cancer risk
of an automated breast density measurement system with full-fi eld digital
mammography (FFDM).
Materials and methods Two hundred cancers and 200 controls were imaged
with FFDM. Density was measured separately on MLO and CC images using
an integral automated volumetric breast density measurement system
(Hologic, Quantra). For each cancer, the contralateral mammogram was
used. Each cancer was matched to a control case by date of birth, age at
examination and laterality of mammogram used for density determination.
Breast density (percentage of fi broglandular tissue) was analyzed by Quantra.
Data were analyzed by conditional logistic regression to determine the eff ect
on breast cancer risk.
Results The percentage of breast density ranged from 6% to 63%. Density
declined signifi cantly with age (P <0.001). Overall, there was no signifi cant
association of density with risk of breast cancer (P = 0.4). There was a
suggestive increase in risk with dense volume higher than 35% (OR = 1.80,
95% CI = 0.96 to 3.39, P = 0.07). There was signifi cant heterogeneity by age
in the eff ect of density on risk (P = 0.04). In women aged <50, density was
signifi cantly associated with increased risk (P = 0.02), with odds ratios of
6.06, 3.98 and 10.59 for density volumes of 15 to 24%, 25 to 34% and ≥35%
respectively, relative to those with <15%. In women aged ≥50 years there
was no association of density with risk (P = 0.5).
Conclusions Quantra automated volumetric breast density measurement is
strongly associated with breast cancer risk in women aged under 50, but not
in women aged ≥50 years or over.
O2
Ultrasound elastography as an adjuvant to conventional ultrasound in
the preoperative assessment of axillary lymph nodes in suspected breast
cancer: a pilot study
K Taylor1, S O’Keeff e1, GM Treece2, R Sinnatamby1, PD Britton1, MG Wallis1
1Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK;
2Department of Engineering, Cambridge University, Cambridge, UK
Breast Cancer Research 2010, 12(Suppl 3):O2 (doi: 10.1186/bcr2649)
Introduction NICE guidelines recommend conventional ultrasound (CU) of
the axilla as preliminary staging in patients with breast cancer. However,
up to one-third of nodes showing normal morphology are metastatic
on surgical histology [1]. Ultrasound elastography (UE) uses received
radiofrequency data to produce an elastogram depicting tissue stiff ness. UE
has been researched in the breast but there are no published data regarding
UE of the axilla.
Methods Fifty women attending the breast unit as symptomatic GP referrals
with breast lesions sonographically suspicious of breast cancer underwent
UE of the axilla simultaneously with routine CU examination. Elastograms
were visually scored, strain measurements calculated and nodal perimeter
and area measurements recorded. UE was compared with CU with histology
as the reference standard.
Results Twenty-nine nodes were histologically normal, 21 were metastatic.
Normal nodes were indistinguishable from surrounding tissue on UE. Using
cut-off points for biopsy selected for the study, sensitivity was 90% for UE
visual scoring, 100% for strain scoring and 76% for CU. Specifi cities were 86%,
48% and 78% respectively. ROC analysis yielded AUC values of 0.9 for UE
visual scoring, 0.86 for strain scoring and 0.82 for CU. There was no signifi cant
diff erence between any area and perimeter measurements.
Conclusions UE can demonstrate axillary lymph nodes and diff erentiate
benign from malignant nodes. UE visual scoring shows greatest promise in
improving yield without excessive benign biopsies.
Reference
1. Britton P, et al.: Use of ultrasound guided axillary node core biopsy in
staging of early breast cancer. Eur J Radiol 2009, 19:561-569.
O3
Size matters: second breast cancer size following treatment for primary
cancer as a predictor of survival
GS MacLennan1, G Lawrence2, C Boachie1, SD Heys3,4, FJ Gilbert4
1Health Services Research Unit, University of Aberdeen, UK; 2West Midlands Cancer
Intelligence Unit, Birmingham Women’s NHS Foundation Trust, Birmingham, UK;
3Division of Applied Medicine, School of Medicine and Dentistry, University
of Aberdeen and Aberdeen Royal Infi rmary, NHS, Aberdeen, UK; 4Aberdeen
Biomedical Imaging Centre, University of Aberdeen and Aberdeen Royal Infi rmary,
NHS Grampian, Aberdeen, UK
Breast Cancer Research 2010, 12(Suppl 3):O3 (doi: 10.1186/bcr2650)
Introduction The purpose of surveillance mammography following primary
breast cancer treatment is to detect subsequent cancers at the smallest
size. We examined the prognostic eff ect of size of ipsilateral breast tumour
recurrence (IBTR) and metachronous contralateral breast cancer (MCBC) to
assess potential benefi t of surveillance mammography after breast cancer
treatment.
Methods Second cancers (IBTR n = 1,174, MCBC n = 975) diagnosed
between 1 January 1990 and 31 January 2007 from the West Midlands
Cancer Intelligence Unit Breast Cancer Registry were analysed. Survival from
diagnosis of second cancer was examined using Cox regression models. Risk
factors included were prognostic factors of the primary tumour and size of
the second tumour. Outcomes were time to all-cause death and to breast
cancer death. Estimates are hazard ratios (HRs) and 95% confi dence intervals.
Results There were 613 all-cause deaths and 422 breast cancer deaths
after IBTR. For both outcomes, second cancers >2 cm had poorer prognosis
compared with those <1 cm, HRs were 1.75 (1.29 to 1.37) and 1.99 (1.37 to
2.89). In MCBC there were 358 all-cause deaths, HR 2.14 (1.49 to 3.06), and 23
breast cancer deaths, HR 1.99 (1.38 to 2.83).
© 2010 BioMed Central Ltd
Royal College of Radiologists Breast Group Annual
Scientifi c Meeting 2010
Brighton, UK. 1–2 November 2010
Published: 25 October 2010
MEETING ABSTRACTS
Breast Cancer Research 2010, Volume 12 Suppl 3
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© 2010 BioMed Central Ltd

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Conclusions With either IBTR or MCBC the size of the second tumour is
important, patients with cancers >2 cm in diameter being at a signifi cantly
greater risk of death. Lead-time bias from the mode of detection may be a
factor in these results. The frequency of surveillance mammography should
be considered for maximum benefi t.
O4
Reduced breast biopsy rates with a combined high temporal and high
spatial resolution MR imaging protocol at 3 Tesla
K Pinker1, W Bogner2, S Gruber2, G Grabner2, S Trattnig2, TH Helbich1
1Department of Radiology, Division of Molecular and Gender Imaging, Medical
University Vienna, Austria; 2Department of Radiology, MR Centre of Excellence,
Medical University Vienna, Austria
Breast Cancer Research 2010, 12(Suppl 3):O4 (doi: 10.1186/bcr2651)
Purpose To develop a 3.0 Tesla breast imaging protocol that combines high
temporal and spatial resolution 3D MR sequences for quantitative time
course and morphological analysis of breast lesions.
Materials and methods One hundred and sixty-fi ve breast lesions classifi ed
by mammography or ultrasound as BIRADS 4 and 5 were included in this
prospective IRB-approved study. The MRI protocol consisted of a coronal T2-
weighted TIRM and a coronal combined high temporal and spatial resolution
T1-weighted sequence before and after application of a standard-dose
Gd-DOTA (VIBE with a high temporal resolution of SI 1.7 mm isotropic; TA
3.45 min for 17 measurements; FLASH with high spatial resolution of SI 1 mm
isotropic; TA 2 min). Lesion size and morphology were assessed according to
the BIRADS classifi cation. ROIs for suspicious areas were manually drawn and
evaluated for contrast-enhancement behavior by plotting intensity courses
against time. Sensitivity and specifi city with a 95% confi dence interval and
the negative predictive value (NPV) and positive predictive value (PPV)
were calculated. Diagnostic accuracy was assessed. The histopathological
diagnoses were used as the standard of reference.
Results All malignant breast lesions were identifi ed correctly with a sensitivity
of 100%, a specifi city of 84% and a diagnostic accuracy of 95.7%. PPV was
0.94 and a NPV 1. All seven false positive lesions were lesions with atypia.
Conclusions The proposed combined 3 Tesla MR imaging protocol,
comprising both high temporal and spatial resolution, enabled an accurate
detection and assessment of breast lesions with high sensitivity and
specifi city reducing false positive breast biopsies
O5
MR visible only lesions: what are the predictors for malignant outcome?
M Bhattacharyya, F Ng, W Teh
Northwick Park Hospital, Harrow, UK
Breast Cancer Research 2010, 12(Suppl 3):O5 (doi: 10.1186/bcr2652)
Introduction To correlate pathological outcomes of MRI vacuum biopsies on
MRI visible only breast lesions with lesion morphology, time-enhancement
curves and clinical indications to determine the use of these as predictors
for malignancy.
Methods A retrospective analysis of 277 patients referred for MRI-guided
vacuum biopsies of impalpable breast lesions visible only on MRI was
performed. All patients had a minimum follow-up period of 11 months. MRI
biopsies were undertaken on a 1.5 T magnet using a minimum of 12 passes
of vacuum-assisted biopsies. The pathological fi ndings were correlated
against BI-RADS appearances and time-enhancement characteristic of the
lesions and against the clinical indications for MRI examination.
Results A total of 286 vacuum biopsies were undertaken. Eighty-one were
malignant (28.3%), of which 72.8% are masses and 27.2% are nonmasses. Only
two malignant lesions had a type 1 curve (2.5%), compared with malignant
lesions with type 2 (54.3%) and type 3 curves (43.2%). Both malignant lesions
with type 1 curve had a suspicious morphology. Nonmalignant lesions with
type 3 enhancement included lymph nodes, fi broadenomatoid hyperplasia,
papillary lesions, fi brocystic change and lobular neoplasia.
Conclusions Lesion morphology and time-enhancement curves are useful
predictors of malignancy and can be used to develop an algorithm to help
direct appropriate biopsy of MRI-detected lesions. We recommend that in
the absence of suspicious morphology, only lesions with type 2 and type 3
curves should be subjected to MRI-guided biopsy.
O6
Comparison of fi lm screen, computed radiography and direct digital
mammography in the Southern Derby screening programme
M Bagnall, AE Turnbull, S Puri
Breast Unit, Royal Derby Hospital, Derby, UK
Breast Cancer Research 2010, 12(Suppl 3):O6 (doi: 10.1186/bcr2653)
Introduction Our screening programme has been fully digital since April
2009 and utilises a combination of computed radiography (CR) (Fuji Profect)
and three direct digital mammography (DDM) mammographic systems (Fuji
Amulet, GE DS and GE Essential). This study compares the performance of
our CR and DDM systems against fi lm screen (FS) mammography in a real-life
screening environment.
Methods Southern Derbyshire screening episodes between April 2007 and
April 2010 were interrogated on NBSS using a Crystal report. Recall and
cancer detection rates were collected according to mammography type.
Data were analysed for signifi cance using the chi-squared test.
Results A total of 66,989 screening episodes were recorded, 22,039 FS (recall
rate 3.23%, cancer detection 8.08/1,000), 30,739 CR (recall rate 2.73%, cancer
detection 7.87/1,000) and 14,157 DDM (recall rate 3.87%, cancer detection
9.89/1,000). Recall rates compared with FS were statistically signifi cantly
diff erent for CR (P = 0.0007) and DDM (P = 0.0016). Cancer detection rates
compared with FS mammography were not signifi cantly diff erent for either
CR (P = 0.833) or DDM (P = 0.081), although there was a signifi cant diff erence
found between CR and DDM (P = 0.035).
Conclusions DDM in our programme has detected an increased number of
cancers but at an increased recall rate. CR has detected a similar number of
cancers as FS mammography at a lower recall rate and the study supports
the use of CR in our programme. As an interim measure in changing to a fully
DDM service it has allowed us to spread costs whilst adopting a single digital
workfl ow, which is effi cient and safe for our clients.
POSTER PRESENTATIONS
P1
Breast density as a predictor of breast cancer risk
G Lip1, N Zakharova2, SW Duff y2, MGC Gillan1, FJ Gilbert1
1University of Aberdeen, UK; 2Queen Mary University of London, UK
Breast Cancer Research 2010, 12(Suppl 3):P1 (doi: 10.1186/bcr2654)
Introduction As a part of a retrospective study of computer-aided detection
in breast cancer screening, we recorded the percentage of the breast density
on a visual analogue scale on 4,866 routine screening mammograms taken in
1996 as part of the North East of Scotland Breast Screening Service. In these
women, 284 breast cancers were diagnosed from the time of the original
mammograms up until February 2010.
Methods The main goal was to evaluate breast density as a breast cancer risk
factor by detection mode, histology and time since the original mammogram.
The association of density with risk of breast cancer was assessed using
logistic regression giving odds ratios per 10% increase in density, and by
comparison of continuous mean densities between particular groups of
cancers and those who did not develop breast cancer.
Results After adjusting for age, breast density was signifi cantly associated
with cancer in the fi rst 6 years after the original mammogram (OR per 10%
density = 1.08, 95% CI = 1.01 to 1.15, P = 0.03), but not with cancer more than
6 years after the mammogram (OR = 1.01, 95% CI = 0.93 to 1.10, P = 0.8).
There was a statistically signifi cant association between histological type
of tumour and breast density (P = 0.02). The mean densities for no cancer,
invasive ductal carcinoma, DCIS and invasive lobular carcinoma were 32%
(SD 23%), 33% (21%), 35% (26%) and 44% (24%), respectively. The eff ect of
density on risk varied signifi cantly by detection mode (P = 0.02), with highest
densities being observed in interval cancers arising more than 1 year after
the mammogram (55% compared with 32% in those with no cancer).
Conclusions Breast density as measured by visual analogue assessment is
strongly associated with late interval cancers and with lobular carcinoma. Its
predictive value for risk, however, declines with time since its measurement.
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P2
Flat epithelial atypia: biological signifi cance on core biopsy
S Rajan, A Shaaban, B Dall, N Sharma
Leeds Teaching Hospitals NHS Trust, Leeds, UK
Breast Cancer Research 2010, 12(Suppl 3):P2 (doi: 10.1186/bcr2655)
Introduction Flat epithelial atypia (FEA) is seen with increasing frequency
following biopsy of calcifi cation detected through screening. FEA is often
associated with more signifi cant lesions including atypical ductal hyperplasia
and ductal carcinoma in situ (DCIS). It is postulated that FEA may even
represent the earliest morphological manifestation of DCIS and a precursor
to invasive carcinoma. However, the signifi cance of pure FEA still remains
unclear. We aim to review the radiological and pathological features of FEA
and evaluate the signifi cance of FEA on needle core biopsy.
Methods We performed a retrospective analysis of all needle core biopsies
containing FEA in the pathology database from April 2008 to April 2010.
For each case the following data were recorded: mammographic features,
method of further sampling (mammotome or diagnostic surgical biopsy)
and histology from needle core biopsy, mammotome biopsy and surgical
biopsy.
Results There were 35 needle core biopsies that contained pure FEA, of which
89% (31/35) were associated with mammographic calcifi cation. Following
initial core biopsy, 21 patients had further sampling with mammotome
biopsy, 13 patients underwent diagnostic surgical biopsy and one patient
was not suitable for further intervention. There was an upgrade to DCIS in
18% (6/34) and invasive carcinoma in 3% (1/34).
Conclusions Pure FEA on core biopsy is upgraded to carcinoma in 21% (7/34)
of cases on further sampling and it is vital that we do not underestimate the
biological signifi cance of FEA. Increasing the awareness of FEA is crucial to
ensure consistent and appropriate patient management.
P3
Two-view 2D digital mammography versus one-view digital breast
tomosynthesis
MJ Michell, RK Wasan, A Iqbal, C Peacock, DR Evans, JC Morel
King’s College Hospital, London, UK
Breast Cancer Research 2010, 12(Suppl 3):P3 (doi: 10.1186/bcr2656)
Introduction In routine breast screening using 2D digital mammography
(2DM), mediolateral-oblique (MLO) and craniocaudal (CC) views are
performed to maximise cancer detection. Digital breast tomosynthesis
(DBT) improves the visibility of lesions by eliminating the problem of
superimposition of normal structures, and there is uncertainty regarding the
need for two views. The purpose of this study is to compare the accuracy of
two-view 2DM with one-view DBT.
Methods Five hundred and one cases were evaluated from the DBT trial
dataset of clients recalled for further workup after their initial fi lm-screen
mammography. Bilateral two-view 2DM and DBT examination were
performed in all study subjects. Mammography scores (1 to 5) based on
RCR Breast Group criteria were recorded and an overall score for 2DM was
established based on the highest value of MLO and CC scores. Unblinded
interpretation of the 2DM followed by MLO-alone DBT was carried out.
Statistical analysis was done using the receiver-operative characteristic
(ROC).
Results There were 111 (22.1%) cancers. The ROC area under the curve
(AUC) for two views combined 2DM was 0.915 and for MLO-alone DBT was
0.960 (diff erence 0.045; P = 0.009). The distribution of M-scores against the
histology-proven malignant lesions is presented in Table 1.
Conclusions In this series, one-view (MLO-alone) DBT had superior sensitivity
compared with two-view 2DM.
P4
Accuracy of breast cancer detection with full-fi eld digital mammography
and integral computer-aided detection correlated with breast density as
assessed by a new automated volumetric breast density measurement
system
K Pinker1,2, N Perry2, S Milner2, K Mokbel2, S Duff y3
1Department of Radiology, Division of Molecular and Gender Imaging, Medical
University Vienna, Austria; 2Princess Grace Hospital, The London Breast Institute,
London, UK; 3Wolfson Institute, Queen Mary College, University of London, UK
Breast Cancer Research 2010, 12(Suppl 3):P4 (doi: 10.1186/bcr2657)
Purpose To assess the diagnostic performance of computer-aided detection
(CAD) for full-fi eld digital mammography (FFDM) correlated with breast
density assessed by an automated breast density measurement system
(Hologic, Quantra) in breast cancers and age-matched healthy controls.
Materials and methods Two hundred breast cancers imaged with FFDM
and 200 age-matched healthy controls were evaluated retrospectively
using CAD. A CAD mark was scored true-positive if it correctly indicated a
malignant lesion. All other CAD marks were considered false. CAD sensitivity
and specifi city were calculated and correlated with mammographic breast
density (%).
Results CAD correctly identifi ed 157 of the 200 cancers, a sensitivity of
79%. Sensitivity was suggestively but nonsignifi cantly lower with increased
density (P = 0.09). In those cancer cases with density at or below the median
of 20%, sensitivity was 82%, compared with 75% in those with density
above the median. The presence of one or more false CAD prompts was
suggestively but not signifi cantly more likely in controls than cases (87%
vs. 80%, P = 0.06). The number of false prompts was signifi cantly higher in
controls (average 3.6 vs. 2.6, P <0.001). False prompts were signifi cantly less
likely with higher density (P = 0.008). False prompts were present in 86% of
cases and controls with density at or below the median, and in 81% of those
with density above the median.
Conclusions Increased breast density is signifi cantly associated with higher
specifi city of CAD, and there is suggestive evidence that it is also associated
with lower sensitivity.
P5
Surveillance following breast cancer: is it cost-eff ective?
L Ternent1,2, G MacLennan1, SD Heys3,4, F Gilbert4,5, L Vale1,2, Mammographic
Surveillance HTA Group
1Health Services Research Unit, University of Aberdeen, UK; 2Health Economics
Research Unit, University of Aberdeen, UK; 3Division of Applied Medicine, School
of Medicine and Dentistry, University of Aberdeen, UK; 4Aberdeen Royal Infi rmary,
NHS Grampian, Aberdeen, UK; 5Aberdeen Biomedical Imaging Centre, University
of Aberdeen, UK
Breast Cancer Research 2010, 12(Suppl 3):P5 (doi: 10.1186/bcr2658)
Introduction There is debate about the role and optimal organisation of
follow-up following treatment for primary breast cancer. We estimated
using the best available evidence whether early detection by surveillance of
ipsilateral breast tumour recurrence (IBTR) and metachronous contralateral
breast cancer (MCBC) was cost-eff ective.
Methods An economic model compared alternative surveillance strategies
involving mammographic surveillance and/or clinical follow-up performed
at diff ering surveillance intervals. The model structure was based upon
discussions with the clinical experts involved in the study, a survey of UK
breast surgeons and radiologists, and the literature. Data to populate the
model came from a series of systematic reviews and an analysis of the West
Midlands Cancer Intelligence Unit Breast Cancer Registry. Results of the
model were presented as incremental cost per QALYs – a measure of relative
effi ciency.
Results The surveillance strategy most likely to be cost-eff ective was mammo-
graphic surveillance alone provided every 12 to 24 months. This result held
for women who had previously received either breast-conserving surgery or
mastectomy. Results were sensitive to primary tumour characteristics (size,
Table 1 (abstract P3)

Imaging
score
MLO–CC
combined
2DM, n (%)

MLO-alone
DBT, n (%)
Percentage
diff erence, Δ
M1 1 0 0
M2 0 0 0
M3 28 (25.2%) 18 (16.2%)
9%
M4 32 (28.8%) 26 (23.4%)
5.4%
M5 50 (45.0%) 67 (60.3%)
15.3%
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grade, nodal involvement) used to defi ne the likelihoods of developing an
IBTR or MCBC. More intensive follow-up of women with higher likelihood of
developing IBTR or MCBC may be worthwhile.
Conclusions Our conclusions remain tentative due to the paucity of the
underlying evidence base but suggest surveillance is likely to improve
survival, with a strategy of mammography alone every 12 to 24 months
appearing cost-eff ective.
P6
A pilot study to evaluate assisted freehand ultrasound elasticity imaging
in the sizing of early breast cancer: a comparison of B-mode and
assisted freehand ultrasound elasticity ultrasound with histopathology
measurements
R English1, J Li2, A Parker1, D Roskell1, RF Adams1, V Parulekar1, J Baldwin1, Y Chi2,
A Noble2
1Oxford Radcliff e Hospitals NHS Trust, Oxford, UK; 2University of Oxford, UK
Breast Cancer Research 2010, 12(Suppl 3):P6 (doi: 10.1186/bcr2659)
Purpose Preoperative breast cancer sizing is required for surgical planning.
Breast ultrasound is widely used but may not be accurate. Assisted freehand
ultrasound (AFUSON) of the breast is a novel method of ultrasound scanning,
combining semi-automated elasticity ultrasound with B-mode imaging. This
pilot study investigates whether AFUSON sizing corresponds more closely
with wide local excision tumour dimensions than with B-mode alone.
Methods Twenty-three patients with early breast cancer were recruited
with ethical approval through the NHSBSP. B-mode ultrasound and
AFUSON images were acquired in predefi ned planes. Pathology slices were
taken in the corresponding longitudinal plane and were digitally scanned.
Assessment of tumour dimensions, area and contour were made on B-mode,
AFUSON and histopathology scans. The fi ndings were correlated.
Results Although there were signifi cant limitations in this pilot study, the
tumour dimension accuracy increased from 66% (B-mode alone) to 82%
(AFUSON). Tumour area accuracy increased from 61% (B-mode alone) to 90%
(AFUSON). Some AFUSON contour images showed a high visual correlation
with the equivalent histopathology scans.
Conclusions This pilot study suggests that AFUSON may be useful in early
breast cancer sizing. Further studies will be done to acquire more data and to
address some of the shortfalls in the study.
P7
Promoting early symptomatic presentation in older women with breast
cancer in the NHS breast screening programme
LJL Forbes1, L Atkins1, S Sellars2, J Patnick2, L Tucker1, AJ Ramirez1
1King’s College London, London, UK; 2NHS Screening Programmes, Sheffi eld, UK
Breast Cancer Research 2010, 12(Suppl 3):P7 (doi: 10.1186/bcr2660)
Introduction Women over 70 have poorer breast cancer survival than
younger women, and this may be due to late stage at presentation [1].
Promoting early presentation with symptoms in older women attending
for their fi nal round of breast screening may reduce stage at diagnosis cost-
eff ectively, and is unlikely to lead to overdiagnosis. We tested the effi cacy
of the 10-minute radiographer-delivered Promoting Early Presentation (PEP)
Intervention to promote early presentation by increasing breast cancer
awareness in the NHS Breast Screening Programme.
Methods We randomised 867 women attending their fi nal round of
screening to receive the PEP Intervention or usual care, measuring breast
cancer awareness at baseline and 1 year. We systematically reviewed the
evidence of eff ectiveness of interventions to promote cancer awareness and
early presentation.
Results At 1 year, the intervention increased the proportion breast cancer
aware compared with usual care (24% vs. 4%; odds ratio = 15.2, 95% CI = 4.8
to 47.8). The systematic review found one randomised trial of a one-to-one
intervention that showed a much smaller eff ect on breast cancer awareness.
Conclusions The PEP Intervention is more eff ective than any other
intervention to promote breast cancer awareness. It will now be off ered to
all women attending for a fi nal mammogram in three NHS breast screening
services, to assess costs and feasibility and to measure its eff ect on breast
cancer awareness in routine clinical practice. If implemented across the
whole Programme, the PEP Intervention has the potential to reduce
avoidable deaths from delayed symptomatic presentation in older women.
Reference
1. Moller H, Sandin F, Bray F, Klint A, Linklater KM, Purushotham A, Robinson D,
Holmberg L: Breast cancer survival in England, Norway and Sweden:
a population-based comparison. Int J Cancer 2010, 127:2630-2638.
P8
Mammographic follow-up of patients after treatment for breast cancer: is
5 years enough?
D Vaile1, LB Williams1, AC Borley2, PJ Barrett-Lee2, P Young3
1Velindre Cancer Centre, Cardiff , UK; 2Velindre Cancer Centre, Cardiff , UK; 3University
Hospital of Wales, Cardiff , UK
Breast Cancer Research 2010, 12(Suppl 3):P8 (doi: 10.1186/bcr2661)
Introduction Velindre Cancer Centre (VCC), Cardiff provides radiotherapy
and oncology services to the population of 1.5 million across southeast
Wales. Historically at Velindre, breast cancer patients are followed up for at
least 10 years, with annual mammography underpinning the service. The
optimal length for continued annual surveillance has been debated and
reduction to 5 years follow-up suggested. Therefore, a retrospective audit
of breast cancers diagnosed on follow-up mammograms was undertaken to
support the proposed reduced length of mammographic follow-up.
Methods Using the RIS and HIS electronic databases, follow-up mammograms
over a 3-year period from 1 June 2006 to 31 May 2009 were collected and
their report codes checked. All mammogram reports are coded using the
Breast Imaging Reporting and Data System (BI-RADS). All mammograms
coded 3 and above were identifi ed. Subsequent radiological and histological
reports were reviewed to identify confi rmed malignancies.
Results In this 3-year period, there were 6,294 follow-up mammogram
examinations at VCC. Ninety-seven reports were coded 3 or above (1.5%).
Fifty-six new malignancies were confi rmed. Of these, 44 (79%) occurred more
than 5 years from original diagnosis.
Conclusions The results do not support reducing the length of follow-up to
5 years. Further analysis of original pathology will be undertaken to attempt to
risk-stratify patients and thus allow tailored follow-up regimes to be developed.
P9
An investigation of workstation image manipulation usage when
examining FFDM images
Y Chen1, J James2, A Evans3, A Turnbull4, A Gale1
1Loughborough University, Loughborough, UK; 2Nottingham Breast Institute,
Nottingham, UK; 3University of Dundee, UK; 4Derby Breast Unit, Derby, UK
Breast Cancer Research 2010, 12(Suppl 3):P9 (doi: 10.1186/bcr2662)
Introduction With the introduction of digital breast screening across
the UK, screeners need to learn how best to inspect these images. A key
advantage over mammographic fi lm is the facility to use workstation image
manipulation tools.
Methods Forty two-view FFDM screening cases, representing malignant,
normal and benign appearances, were examined by 14 radiologists and
advanced practitioners from two UK screening centres. For half the cases, the
mammography workstation image manipulation tools could be employed;
and for the other half these were not used. Participants classifi ed each case
and indicated whether an abnormality was present. Throughout the study,
the participants visual search behaviour as well as their image manipulations
were recorded.
Results Whether or not image manipulation tools were used made very little
diff erence to overall performance (t test, P >0.05) as confi rmed by JAFROC
analysis fi gure-of-merit values of 0.816 and 0.838 (with and without tools,
respectively); performance not using tools was better. However, using
tools signifi cantly increased inspection time (P <0.5) as well as participants’
confi dence. Detailed examination of participants’ image inspection
behaviour elicited that when imaging tools were used then they spent 17
to 77% of their time manipulating the images; with the less experienced
participants spending more time using such tools. Eye movement data
demonstrated that when abnormalities were missed then this was typically
due to search errors.
Conclusions For these cases, whilst using imaging tools was not necessary
to identify abnormalities, their use improved confi dence, especially in
identifying normal appearances. With experience, less use of such tools was
evident.
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P10
Preliminary assessment of ShearWave™ elastography features in
predicting breast lesion malignancy
DO Cosgrove1, C Doré2, C Tourasse2, R Ohlinger3, H Madjar4, R Hooley5,
C Balu-Maestro6, E Mendelson7, W Svensson1,8, A Tardivon9, A Cossi10, L Barke10,11,
L Larsen10,12
1Imperial College, Hammersmith Hospital, London, UK; 2Jean Mermoz Private
Hospital, Lyon, France; 3University Hospital, Frauenklinik, Greifswald, Germany;
4German Diagnostic Clinic, Wiesbaden, Germany; 5Yale Medical Center, New
Haven, CT, USA; 6Centre Antoine Lacassagne, Nice, France; 7Northwestern
Memorial Hospital, Chicago, IL, USA; 8Charing Cross Hospital, London, UK; 9Centre
Antoine Lacassagne, Nice, France; 10Institut Curie, Paris, France; 11Sally Jobe Breast
Center, Denver, CO, USA; 12University of Southern California, Los Angeles, CA, USA
Breast Cancer Research 2010, 12(Suppl 3):P10 (doi: 10.1186/bcr2663)
Introduction ShearWave™ elastography (SWE) provides a quantitative
measure ment of tissue stiff ness with high spatial resolution and may
improve characterization of breast masses. The goal of this study was to
evaluate the reproducibility of SWE and the impact of adding SWE features
to the BI-RADS classifi cation of breast masses from the fi rst 1,000 cases in a
prospective multicenter trial.
Methods SWE studies were performed on a prototype of the Aixplorer
system (Supersonic Imagine, Aix-en-Provence, France). A subset of 192 breast
lesions (42.71% malignant) was analyzed. Reproducibility of SWE images and
measurements was assessed; logistic regression analysis was performed to
predict the pathology fi ndings. SWE features were added to the ultrasound
BI-RADS to generate models that were challenged by comparing the areas
under the ROC curves (Az), and the sensitivity and specifi city scores.
Results In the preliminary analysis, intra-operator reproducibility of SWE size
(R ≥0.93) and mean elasticity (R = 0.88) measurements were in near-perfect
agreement. Using the best three-variable model (BIRADS + elasticity shape
+ maximum elasticity), the Az increased from 0.77 to 0.93 and specifi city
increased from 61.8% to 87.3%, although sensitivity decreased from 92.7%
to 87.8%. Adding more variables did not eff ect further improvements.
Conclusions In this ongoing study, SWE provided reproducible information
(elasticity values and SWE mapping) that improved the characterization
of breast lesions. These features are directly linked to the characteristics of
SWE: local quantifi cation and millimeter resolution. Further evaluation of the
study is in progress.
P11
To recognise the imaging of complications from Macrolane™ injection
SE McWilliams1, L Wilding2
1Guy’s and St Thomas’ NHS Trust, London, UK; 2West Middlesex University Hospital,
London, UK
Breast Cancer Research 2010, 12(Suppl 3):P11 (doi: 10.1186/bcr2664)
Introduction Macrolane™ volume restoration factor (VRF) (Q-Med) is in vogue
for use in breast augmentation. There is sparse literature on the imaging
characteristics of complications resulting from Macrolane™ injection.
Methods This study describes the multimodality imaging of 12 patients
from three centres who had breast complications as a result of Macrolane™
injection. The patients had all undergone Macrolane™ injection at varying
intervals prior to presentation. Macrolane™ consists of non-animal
stabilised hyaluronic acid (NASHA™) and is approved for nonsurgical breast
augmentation. Treatment involves injection of up to 100 ml fl uid, superfi cial
to the pectoral muscle and deep to the glandular breast disc, and is semi-
permanent, usually only lasting up to 1 year before a top-up injection is
required.
Results Presenting symptoms included breast lumps, breast pain and axillary
pain. The complications seen on imaging included abscess formation, in-
determinate masses, subpectoral collections and complex cystic collections.
The fl uid and indeterminate masses were not all resorbed in the timeframe
expected of Macrolane™ and remained in situ in some cases for at least
2 years.
Conclusions Macrolane™ injection is associated with long-term complica-
tions and creates diagnostic challenges on breast imaging that are only
beginning to emerge in the breast clinics and that may warrant triple
assessment.
P12
Texture analysis applied to full-fi eld digital mammography: ability to
discriminate between invasive ductal and invasive lobular breast cancer –
preliminary results
M Mayerhoefer1, N Perry2, S Milner2, K Mokbel2, S Duff y3, K Pinker1,2
1Department of Radiology, Division of Molecular and Gender Imaging, Medical
University Vienna, Austria; 2Princess Grace Hospital, The London Breast Institute,
London, UK; 3Wolfson Institute, Queen Mary College, University of London, UK
Breast Cancer Research 2010, 12(Suppl 3):P12 (doi: 10.1186/bcr2665)
Purpose To determine texture features of IDC and invasive lobular carcinoma
(ILC) of the breast on full-fi eld digital mammography (FFDM). To evaluate the
ability of texture analysis to diff erentiate between those tumor types.
Materials and methods Fourteen IDC and nine ILC imaged with FFDM were
included in this study. For each lesion the ROI was manually defi ned covering
the lesion and 1 cm normal-appearing breast tissue around the lesion.
Texture features derived from the grey-level histogram, the co-occurrence
matrix, the run-length matrix, the absolute gradient, the autoregressive
model, and the wavelet transform were calculated for the ROIs. Fisher
coeffi cients were calculated to determine which texture features were best-
suited for distinguishing between IDC and ILC. Based on the combination
of those fi ve texture features with the highest Fisher coeffi cients, lesion
classifi cation was performed, using linear discriminant analysis (LDA) and
principal component analysis (PCA) classifi ers, as well as a k-means clustering
algorithm. Classifi cation accuracy was used as the primary outcome measure.
Results Of the fi ve texture features with the highest Fisher coeffi cients, the
top four were derived from the wavelet transform. Using LDA and PCA,
classifi cation accuracies of 82.6% (19 of 23 lesions) and 78.3% (18 of 23
lesions) were achieved, respectively. k-means clustering also yielded a similar
classifi cation accuracy of 82.6% (19 of 23 lesions).
Conclusions Texture features, best suited for discrimination between ILC and
IDC, are derived from the wavelet transform. Texture analysis of breast cancer
cases imaged with FFDM allows a good degree of accuracy of discrimination
between IDC and ILC.
P13
Sensitivity of integral computer-aided detection with full-fi eld digital
mammography for detection of breast cancer according to diff erent
histopathological tumor types and appearances
K Pinker1,2, N Perry2, S Milner2, K Mokbel2, S Duff y3
1Department of Radiology, Division of Molecular and Gender Imaging, Medical
University Vienna, Austria; 2Princess Grace Hospital, The London Breast Institute,
London, UK; 3Wolfson Institute, Queen Mary College, University of London, UK
Breast Cancer Research 2010, 12(Suppl 3):P13 (doi: 10.1186/bcr2666)
Purpose To retrospectively evaluate the sensitivity of computer-aided
detection (CAD) for full-fi eld digital mammography (FFDM) in 360 breast
cancers with regard to mammographic appearance and histopathological
tumor type.
Materials and methods Three hundred and sixty breast cancers imaged with
FFDM were evaluated retrospectively using CAD. A CAD mark was scored true
positive (TP) if it correctly indicated a malignant lesion. All other CAD marks
were considered false. Cancer cases were classifi ed as microcalcifi cations (64),
masses (196), or both (100). Histopathological fi ndings were classifi ed as IDC,
ILC, DCIS or other. Sensitivity values for CAD according to mammographic
appearance and, histopathological fi ndings were analyzed using chi-squared
tests.
Results A TP mark was observed on 319 out of the 360 cancers (89%).
Calcifi cations were signifi cantly (P <0.001) more likely to be marked than
masses, 163/164 (99%) compared with 244/296 (82%). The probability
of a mass TP mark was signifi cantly related to histological type (P <0.001),
with sensitivity being greatest for IDC at 76% (167/221) compared with
67% (38/57) for ILC, 31% (16/51) for DCIS and 74% (23/31) for other types.
The probability of a calcifi cation TP mark was also signifi cantly related to
histological type, with sensitivity being greatest for DCIS at 75% (38/51),
compared with 43% (96/221) for IDC, 33% (19/57) for ILC and 32% (10/31)
for other types.
Conclusions CAD prompted the signifi cant majority of radiological
abnormalities related to cancers and was most accurate for detection of
calcifi cation and DCIS, less so for mass lesions and ILC.
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