Comprehensive dose survey of breast screening in Ireland
2011. 2011. 2011. 2011. November 2011. 2011. 2011. 2011

P Baldelli
J Mccullagh
N Phelan
F Flanagan

School of Medicine and Medical Science
Dundee Cancer Centre, Ninewells Hospital and Medical School
Charing Cross Hospital
Imperial College Healthcare NHS Trust
London, Dublin, DundeeUK, Ireland, UK

The Royal Marsden Hospital
LondonUK

South West of Scotland Breast Screening Unit
IrvineUK

Queen Margaret University
EdinburghUK

Ayrshire and Arran Health Board
KilmarnockUK

Queen Elizabeth Hospital
South London Healthcare NHS Trust
LondonUK

King' s College Hospital NHS Foundation Trust
LondonUK

South East London
Cancer NetworkLondonUK

UCD, School of Medicine and Medical Science
DublinIreland

G Bansal, H Farmer, B Orr, H Russell, L Hobson, D Godden, I Lyburn Gloucestershire Breast Screening Service
BreastCheck Irish National Breast Screening
Dublin, CheltenhamIreland, UK

University of Aberdeen
UK

St George' s Hospital
LondonUK

University of Dundee
77 ± 4

Pennine Breast Unit, St Luke' s Hospital
BradfordUK

Haematological Malignancy Diagnostic Services
LeedsUK

S Garnett University Hospital
CoventryUK

Dundee Cancer Centre
Loughborough University
LoughboroughUK

Ninewells Medical School
University of Dundee
DundeeUK, UK

Gateshead Health NHS Foundation Trust
GatesheadUK

Newcastle University
NewcastleUK

National Co-ordinating Centre for the Physics of Mammography
GuildfordUK

Jarvis Breast Screening and Diagnostic Centre
GuildfordUK

St George' s Healthcare NHS Trust
LondonUK

Cambridge University Hospitals NHS Foundation Trust
CambridgeUK

University of Pittsburgh
PAUSA

University of Surrey
GuildfordUK

University of Dundee
UK

Kings College Hospital NHS Trust
LondonUK

South East London BSP
LondonUK

Comprehensive dose survey of breast screening in Ireland

Breast Cancer Research
Glasgow, UK, 7-813152011. 2011. 2011. 2011. November 2011. 2011. 2011. 2011Royal College of Radiologists Breast Group Annual Scientifi c Meeting 2011 Published: 4 November 2011 P O S T E R P R E S E N TAT I O N S
IntroductionThe automated breast volume scanner (ABVS) is the fi rst of its kind and utilises a large, 17 cm × 15 cm high-frequency ultrasound probe which sweeps across the whole breast generating images that can be reformatted into multiple planes and a 3D volume. ABVS will change breast ultrasound practice by: introducing operator standardisation, reproducibility and repeatability of measurement and interpretation; changing who acquires the volume set and how breast ultrasounds are reported; and allowing accurate comparison of previous and current examinations for screening and assessing treatment change. Methods Patients presented to the symptomatic clinic for conventional 2D ultrasound assessment with a variety of conditions. An additional ABVS was performed. Results Cases were classifi ed into: benign -for example, cysts, fi broadenomas, diabetic mastopathy; and malignant. Conclusion We present a review of our initial experience and highlight its advantages over conventional ultrasound, which include: improved mapping of lesions enabling more accurate future assessment and follow-up, and improved assessment of distortion over conventional 2D ultrasound. Further research is required to explore other potential benefi ts.O2Symptomatic breast services in Ireland: how do they compare with national and international standards? D O'Leary, L Rainford Introduction A study of symptomatic breast units geographically spread over Ireland collected image quality, compression and radiation dose data from 18 mammography units; so how do these optimisation parameters compare nationally and internationally? The mean glandular dose (MGD) diagnostic reference level was proposed for the all-digital breast screening service [1] but not for the symptomatic breast service. Methods The quantitative and qualitative data were analysed using SPSS. Recommendations of MGD diagnostic reference levels were made at various levels for fi lm-screen mammography (FSM) and full-fi eld digital mammography (FFDM) units to match those levels published in worldwide.ResultsMGDs received by symptomatic breast patients within Ireland are higher than those received in the all-digital Irish Breast Screening service, although the diff erences for FFDM are not substantial; 55 to 65 mm breast: 1.75 mGy (screening) versus 2.4 mGy (symptomatic) at the 95th percentile. The four-view routine mammography MGDs obtained in symptomatic breast units in Ireland are, however, substantially diff erent from other screening units with mixed FSM/FFDM modalities: 4.5 mGy (UK); 4.98 mGy (USA) versus 5.96 mGy (FFDM, symptomatic) and 9.63 mGy (FSM, symptomatic). Various reasons are proposed for the diff erences. Conclusion MGD diagnostic reference levels achieved in the screening service may be lower due to the exacting requirements for radiographer training, nonsurgical alteration of patient breasts and equipment quality assurance levels. Greater training of radiographers performing mammography in the symptomatic breast services is required to standardise mammographic projections with regard to MGDs delivered.Introduction Shear wave elastography is a new ultrasound technique which shows promise in the diff erential diagnosis of solid breast masses. This study compares the mean tumour stiff ness with mammographic fi ndings and mammographic density in women with invasive breast cancer. Methods Mammographic morphological features and BIRADS density assessment of the contralateral breast were documented in 96 consecutive patients with operable invasive breast cancer who had undergone shear wave elastography. Mammographic assessment was performed blinded to the elastography and pathological fi ndings. Mean stiff ness values of individual tumours were classifi ed as either above or below the average mean stiff ness of the cancers. Chi-squared tests for trend were used to compare mean stiff ness with mammographic features and density. Results There was no statistically signifi cant diff erence in the mean stiff ness of tumours according to their mammographic features. Mean tumoural stiff ness increased with breast density (average mean stiff ness 126 kPa, 132 kPa, 154 kPa, and 179 kPa for BIRADS densities 1 to 4, respectively), with a statistically signifi cant trend of stiff ness being above average for a cancer in a denser breast. No statistically signifi cant correlation was shown between tumour size or grade (factors known to be associated with increased stiff ness) and mammographic density. Conclusion Tissue stiff ness of breast cancers is greater in women with mammographically denser breasts. Assuming elastographic stiff ness refl ects characteristics of stroma and tumour, our fi ndings suggest that tumour-stroma interactions may vary with mammographic density.IntroductionOur breast surgery service receives many breast cancer referrals from neighbouring breast screening centres with analogue mammography systems. As hospital protocol we perform repeat fullfi eld digital mammography (FFDM) in these women in an attempt to better stage the primary tumours. The aim of this study is to assess whether FFDM detects more disease than analogue mammography in patients with screen-detected cancer with pathological correlation. Methods Three experienced mammography readers evaluated repeat FFDM in 60 women whilst blinded to the prior analogue studies. Sixty age-matched controls were also assessed. The mammographic fi ndings were then compared with the fi nal surgical pathology. Breast density scores were recorded using Quantra™ software to assess whether this infl uenced diagnostic accuracy. Results Sixteen (26.7%) analogue mammography-detected cancers were not detected by at least one reader on FFDM. Three (5%) analogue mammography-detected cancers were missed by all three readers on FFDM. Small soft tissue masses represented all of the cancers missed by all three readers. Mean fi broglandular density as assessed by Quantra™ was 15.3 for controls, 13.9 for cancers and 14.2 for cancers not identifi ed by at least one reader. FFDM more accurately staged the DCIS extent than analogue mammography when comparing fi nal surgical pathology, although the result was not signifi cant (P = 0.2). Conclusion Not all cancers visualised on analogue mammography can be seen on repeat FFDM performed within 2 weeks, even allowing for biopsy-related bruising. Although DCIS is possibly better staged by FFDM compared with analogue, small soft tissue masses are less well distinguished. This eff ect does not seem related to background breast density.O5Correlation of ethnicity with breast density as assessed by Quantra™A, Minkin S, Yaff e MJ: Mammographic density and the risk and detection of breast cancer. N Engl J Med 2007, 356:227-236. 2. Turnbull AE, Kapera L, Cohen ME: Mammographic parenchymal patterns in Asian and Caucasian women attending for screening. Clin Radiol 1993, 48:38-40. O6 A comparison of the accuracy of digital breast tomosynthesis with supplementary views in the diagnostic workup of mammographic lesions Introduction Needle core biopsy (NCB) is frequently used in assessing screen-detected breast lesions. Uncertainty remains over appropriate management of NCBs reported as 'uncertain malignant potential' (B3) or 'suspicious of malignancy' (B4). This study aims to analyse a large screening dataset to establish positive predictive values (PPVs) for malignancy on excision biopsy, for diff erent classifi cations of B3 and for B4 NCBs. Methods Retrospective analysis was conducted of prospectively collected data for South East London Breast Screening Service. A total of 5,324 patients underwent NCB between 2000 and 2010, including 14G (ultrasound-guided) and 10G vacuum-assisted biopsies (stereoguided). A total of 444 were B3 (8.3%) and 38 (0.7%) were B4. NCBs reported as B3 were classifi ed by pathological subtype and PPVs for malignancy calculated for each subtype. Outcomes following B4 NCB were also assessed.Results The overall PPV for malignancy for B3 NCBs was 25% and for B4 NCBs was 74%. The PPVs for each subtype of B3 classifi cation were as follows: papillary 14%, atypical intraductal epithelial proliferation 35%, phyllodes 11%, lobular 47%, complex sclerosing lesion/radial scar 6%, columnar cell 29%. Conclusion Our fi ndings indicate that NCBs reported as B4 should be excised as they have a high likelihood of malignancy on excision biopsy. The PPVs for subtypes of B3 NCBs vary considerably. However, B3 subtypes with atypia should be treated with a higher level of suspicion and preferably be surgically excised. Decisions regarding further assessment should be made in a multidisciplinary setting.P3Objective critical appraisal of mammography images in clinical audit: can we achieve this?P7Abstract withdrawn by author.P8Ultrasound staging and fi ne needle aspiration cytology: how well do they predict breast cancer nodal involvement?

Introduction It is widely accepted that there is an association between mammographic density and breast cancer risk [1]. Various studies have examined relationships between ethnicity and breast density patterns using the Wolfe classifi cation system [2], with a view to investigating potential breast cancer risk. Quantra™ is a volumetric assessment tool, which allows reproducible objective measurement of mammographic breast density, eliminating inter-observer variability. Our study sought to investigate the correlation between ethnicity and breast density using Quantra™ measurements. Methods The Quantra™ value was recorded from the mammograms of symptomatic breast patients at St George's Hospital, London over a 6-month period. We compared three distinct ethnic groups; Black (African and Afro-Caribbean), Asian (Indian subcontinent) and White (Caucasian). Mean Quantra™ values were calculated for each group and the Kruskal-Wallis test was applied. Results A total of 428 patients were included in the study. Mean breast density values for the three ethnic groups were as follows: Black, 24.31%; Asian, 21.94%; White, 24.74%. P = 0.0046 (Kruskal-Wallis). Conclusion There is a statistically signifi cant diff erence between the objectively measured breast densities of these three ethnic groups. This is of relevance to the assessment of breast cancer risk. References Introduction Supplementary views (SV) are routinely used in the diagnostic workup of mammographic lesions. Previous studies have demonstrated that digital breast tomosynthesis (DBT) increases the accuracy of classifi cation of mammographic lesions [1]. In this study the diagnostic accuracy of SV is compared with DBT. Methods The study included cases from screening assessment and symptomatic clinics requiring further mammographic workup. The cases were read by seven specialist breast radiologists. In the fi rst session, readers read bilateral two-view full-fi eld digital mammography (FFDM) and SV of the lesion. In the second session, at least 1 week later, readers read bilateral two-view FFDM plus one-view DBT in the same projection as the SV. Mammographic scores (1 to 5), lesion type and fi nal outcome were recorded. Results A total of 356 cases were assessed using receiver operative characteristic analysis to evaluate the diff erence between the two modes. For FFDM plus SV, the area under the curve (AUC) was 0.8807 (95% CI = 0.84374 to 0.91766) and for FFDM plus DBT the AUC was 0.9186 (95% CI = 0.88821 to 0.94895); diff erence in AUCs was 0.0379 with P value 0.055. Conclusion These results demonstrate that the accuracy of DBT has borderline superiority to SV in the diagnostic workup of mammographic lesions. Reference 1 Introduction In 2009, the South West of Scotland Breast Screening Unit (SWSBSU) had to repeat 236 examinations due to mammographic image unsharpness. Such recalls were undesirable because of radiation safety issues, anxiety caused and cost. The aim of this study was to model predictors of recall that could be used in clinical practise to help reduce the numbers of repeat examinations required due to blurring. Methods This retrospective study compared two sample groups (n = 118), randomly selected from a cohort of women who attended the SWSBSU in 2009 (n = 16,194). Tests of signifi cance were used to compare a range of variables in each group and logistic regression was employed to produce four predictor models for recall. Statistical analysis was carried out by the authors using SPSS version 18. Results A 12 mm increase in compressed breast thickness (CBT), a 50 mAs increase in exposure or a 350 ms increase in exposure time will double the odds of recall due to unsharpness. Also, an increase of 2 kVp, when imaging a breast with a CBT of 60 mm, will reduce the odds of recall by approximately 39%. Conclusion CBT is a major determinant of recall due to unsharpness. Within the context of the reported increase in average CBT [1] and rising national obesity, reconsideration of kVp selection criteria may be necessary to minimise the incidence of recall due to unsharpness.

Introduction Objective critique of mammographic image quality (IQ) is vital to assess effi cacy of services provided by mammography units. The European Guidelines for Screening Mammography require an inadequate image rate of 3%. The subjectivity within current IQ criteria allows symptomatic mammograms with surgically altered breasts to appear to achieve these requirements; however, as evidenced in the analysis of symptomatic breast images within a national optimisation study, current methods of classifi cation for symptomatic mammograms are largely subjective, resulting in poor inter/intra-departmental agreement on IQ.  Introduction Numerous publications suggest the compression force applied in mammography must be reduced to encourage initial/ continued attendance by women. These studies (many with limited patient populations) have not used suffi cient statistical correlation of compression force data to image quality to reinforce these contentions. The growth of digital mammography has enabled a comparison of compression force and image quality in analogue and digital images.

Methods A quantitative and qualitative study of mammography units within Ireland collected comprehensive image quality, compression (force and depth) and radiation dose data from 4,790 patient images. The data were analysed using univariate analysis of variance and SPSS statistics including ANOVA to re-examine the connections between all parameters for optimisation of mammographic imaging. Data presented as mean ± SD.

Results The amount of compression force consistently showed signifi cant eff ects on the image quality; perfect and good images consistently required signifi cantly more compression force than moderate and inadequate images. This was especially apparent in digital images. The mean compression force (Newtons) required to produce a perfect image was: 121.34 N for digital craniocaudal; 134.23 N for digital mediolateral oblique; 112.23 N for analogue craniocaudal; and 129.66 N for analogue mediolateral oblique. Only 2% of patients expressed dissatisfaction with the higher compression forces that were applied. Conclusion Compression forces are too low, aff ecting image quality; greater compression force by 11 to 15 N is needed to achieve a perfect image especially in full-fi eld digital mammography. Greater training of radiographers performing mammography is required to standardise the undertaking of the mammographic projections with regard to achievable compression depth and the application of compression force delivered to the breasts of Irish women attending the symptomatic breast services. Introduction Third-reader screen-reading is undertaken in our unit to reconcile discordant reader results. An audit has been conducted to analyse the nature of cancers diagnosed at assessment for arbitration recalls. The objective was to identify and describe discordant cancer types and appearances.

P11

Large-bore vacuum-assisted biopsy of axillary lymphadenopathy

Methods

The study period covered two screening rounds. Arbitration records were reviewed and mammographic shape, size, position, cancer type and grade, and histological size were recorded. Both fi lm and digital cases were included and compared. Descriptive statistics were produced comparing discordant and concordant cancers. Results A total of 128 arbitration cancers were analysed (3.6% of total cancers, n = 3,516). There were 5,635 total arbitrations of which 27% (n = 1,519) were assessed. A total of 8.4% were cancer. There were a higher number of smaller sized (1 to 15 mm) cancers in the arbitrated group, 61% compared with 48% in the concordant group. There was no diff erence between fi lm and digital cancer size. More cancers appeared as lobular, tubular and DCIS in the arbitration group. There was an equal spread of calcifi cation and mass type mammographic appearances. Conclusion No previous study had specifi cally analysed arbitration (third-reader) cancers. This audit showed that lesion size is smaller, all cancer types are present and both calcifi cations and masses are equally represented. Digital cases did not show any smaller cancers for the discordant group. A future audit will be to look at the arbitration interval cancers; that is, when two readers have not recalled a subsequent false positive case, to assess the features that have been ignored. Methods Information from the last round of the PERFORMS scheme was reanalysed for which the low performance threshold value was known. Data for randomly selected small groups of participants were repeatedly bootstrapped with the aim of artifi cially determining a threshold of low performance and comparing this with the known actual threshold. Using a varying number from four to 50 participants, a sample of 1,000 randomly selected small groups was constructed for each number of participants. After bootstrapping each small group, a distribution of 1,000 thresholds of low performance was constructed and median values and standard errors of this distribution calculated to determine how the number of participants aff ected the estimation accuracy.

P13

Results The standard error of the estimated threshold reduced as group size increased, indicating better estimation accuracy. Using data from as few as 10 people the artifi cial threshold approached the known actual threshold of poor performance. Conclusion Individuals who are performing less than their peers on the scheme can be identifi ed early without all screeners having fi rst taken part. Whilst not an absolute outlier measure, this information can be fed back in a timely manner, so enabling the individual to improve their cancer identifi cation performance. Introduction TARGIT-A is a recent prospective randomised multicentre controlled trial comparing intraoperative radiotherapy (IORT) and external beam whole breast irradiation (EB). The aim of this study was to compare localised and generalised fi ndings at follow-up mammography and the need for interventions such as ultrasound and biopsy between women in the two treatment arms from a single recruiting centre.

P14

Comparison of mammographic fi ndings and need for ultrasound and biopsy in women undergoing wide local excision and either intraoperative radiotherapy or external beam whole breast irradiation

Methods

We have compared the 61 women who received IORT alone with the 63 women who received EB alone. All mammograms were reviewed by radiologists blinded to the treatment received. The focal soft tissue appearance was classifi ed. The presence of generalised skin thickening and increased density was recorded. The performance of ultrasound and/or biopsy was recorded.

Results The number of follow-up mammograms and length of followup was similar in both groups (2.46 IORT vs. 2.09 EB and 3.27 years IORT vs. 3.0 years EB). There was no diff erence in the mammographic appearance of the postoperative site between the two groups. However, generalised skin thickening and increase in density were more common in the EB group compared with the IORT group (20 of 63 (37%) vs. 10 of 61 (16%), P = 0.04 and 20 of 63 (37%) vs. 5 of 61 (8%), P = 0.001, respectively). Ultrasound at follow-up was more frequent in the IORT group compared with the EB group (15 of 61 (25%) vs. 7 of 63 (11%), P = 0.049).

Conclusion Generalised reactions on mammography are more common following EB compared IORT. However, follow-up ultrasounds were more frequent in the IORT group. Introduction Vacuum-assisted core biopsy (VACB) is a highly eff ective method of sampling breast tissue. Breast care nurses, at the Queen Elizabeth Breast Unit in Gateshead, raised concerns about pain experienced by patients during this procedure. The aim of this study was to assess how patients perceive VACB.

Methods Prospective data collection for 6 months from November 2010 of consecutive patients undergoing VACB. Data were collected using a questionnaire about pain experienced immediately and 4 weeks post procedure, using the Numerical Rating Scale and Short Form McGill validated pain scores [1]. Results Fifty questionnaires were completed. Immediately post procedure, 88% felt no or mild pain. Of those reporting pain, 100% had a sensory dimension. Four weeks later the memory of the pain experienced during the procedure was worse in 46%. In this group, pain 4 weeks post procedure had an aff ective dimension in 50% of cases. Four weeks post procedure, 91% felt no or mild pain. One hundred per cent would reassure a friend about the procedure. Conclusion Minimal pain was experienced immediately or 4 weeks post procedure. There is a discrepancy between pain experienced during the procedure compared with the memory of it. The eff ect of the biopsy result could be a contributory factor. Further work linking responses to histology may be revealing. Reference In 14 women the NPI group was worse than the PNPI, and in two it was better because the tumours were downgraded at postoperative pathology.

Conclusion Preoperative estimation of the NPI approximates to the defi nitive NPI in the majority of women studied, and could therefore be used to guide systemic treatment decisions preoperatively.

Introduction In 2009 the Royal College of Radiologists Breast Group set out a classifi cation system for breast imaging scoring [1]. A score of 4 'suspicious of malignancy' or 5 'highly suspicious of malignancy' should be used 'in most cases' of proven breast cancer. However, there is no universally accepted target for this in the UK. The American BIRADS system suggests a 98% target [2]; however, their scoring system is slightly diff erent. Methods We examined imaging reports (mammography, ultrasound and MRI) of patients diagnosed with a breast malignancy attending the symptomatic breast clinic in 2009. Our aim was to determine an achievable target for correctly scoring breast imaging. Results A total of 203 patients' imaging was examined. One hundred per cent of reports included a score. Ninety per cent of the cancers were scored 4 or 5. In three underscored cases, radiologist opinion was clouded by the fact the patient had had proceeding FNA. Cases of cancer recurrence also proved diffi cult to correctly score. Conclusion We suggest a target of 90 to 95% of all breast cancers being scored 4 or 5. A 95% target is achievable especially if FNA/biopsy is left until after imaging has been performed.

Introduction

In the NHS Breast Screening Programme (NHSBSP) there is a transition to digital mammography following recommendations made by the Cancer Reform Strategy [1]. A number of US studies have demonstrated that the time taken to interpret digital mammography is longer than that for analogue [2,3]. There are no published data about this from the NHSBSP.

Methods Over a 2-month period, 11 readers were timed in their interpretation of batched analogue or digital mammograms. These were either hung on a multiviewer or preloaded onto Sectra PACS.

Previous images were not digitised. A total of 396 batches were included in the analysis (unpaired t test), 330 digital and 66 analogue.

Results It takes more time to report a digital mammogram compared with analogue (40 ± 1 vs. 35 ± 2 seconds, P <0.05). There is no diff erence in the time taken to report prevalent screens between the analogue and digital groups (34 ± 7 vs. 39 ± 2 seconds). The incident screens were quicker to interpret as analogue.

Conclusion Our data support the hypothesis that digital interpretation is slower than analogue (albeit by 5 seconds) but in the absence of needing to compare with previous images there is no diff erence between the two modalities.

References

Introduction In our Trust, in line with NICE guidance, all breast cancers undergo preoperative axillary ultrasound and, where indicated, needle testing. The current overall sensitivity of this process in our Trust is 57%. This study investigates tumour size, type and location as possible factors for patient triage to repeat preoperative axillary staging, aiming to increase our preoperative axillary staging sensitivity. Methods This prospective study included all patients diagnosed and operated on for unifocal breast cancer in our Trust from September to December 2010. Descriptive statistics, chi-squared and logistic regression were performed upon data collated at MDT meetings. Results Logistic regression of 101 females implies that as tumour size increases by 1 cm, nodal disease risk is 1.75 times larger, with 95% confi dence limits. Comparing tumours <20 mm with those >20 mm, nodal disease risk is 5.818 times larger in the >20 mm group (P <0.0005). No signifi cant diff erence was found in nodal disease risk between the histological tumour types, although numbers of lobular and tubular carcinomas were small (P = 0.633). Data suggested a diff erence (0.27× smaller risk in UIQ versus UOQ) in probability of axillary node metastasis with tumour location with 95% confi dence limits. Conclusion This study demonstrates a clear and statistically signifi cant association between tumour size and nodal disease. The data also suggest a diff erence in probability of nodal disease with diff erent tumour location, although increased patient numbers are needed to confi rm this. A larger trial for stratifying patients for single or double preoperative staging of the axilla is recommended. We used a 14G Achieve needle to make four passes into the node. Results Out of 41 CBs, on histology, eight were negative and 33 were positive. All positives were proven to be true positive at ANC. Seven out of eight negatives were found to be true negative (87.5% true negative) at SNB and ANS. One out of eight negative CBs was found to be false negative (12.5% false negative) requiring axillary clearance. Conclusion We found that our results were comparable with published recent studies from the UK and abroad. Aggressive and more focused sampling could be suggested to further reduce false negatives.

P21

Can radiation dose in mammography be further reduced by

appearance of images from a CR imaging system at the same dose and on both systems at half this dose. Seven experienced observers marked the location of suspicious regions, assigning a fi ve-point score for confi dence that the suspicious region was a cluster. The data were analysed using the area under the alternative free-response receiver operating characteristic (AFROC) and the area under the receiver operating characteristic (ROC) as fi gures of merit. Results There was a signifi cant reduction in detection using CR compared with DR; the AFROC area decreased from 0.83 to 0.63 and the ROC area decreased from 0.91 to 0.79 (P <0.0001). A signifi cant reduction in detection was also evident at half the original dose for both DR and CR. Conclusion The detection of subtle clusters was reduced signifi cantly with CR compared with DR and it is possible that CR will miss cancers manifesting as microcalcifi cation that would be found by DR. Calcifi cation detection was sensitive to the dose used, which should be refl ected in image quality standards to ensure adequate image quality is achieved even at the cost of a higher dose.

P24

Improving the validity of breast density assessment

Conclusion

The study shows that MRI is superior to DBT in predicting the histological size of lobular carcinoma although there is disparity with both techniques. With the advent of contrast-enhanced 2D mammography, we hope for the future development of contrastenhanced DBT to give us a technique that will be comparable with MRI.

Introduction

The objective was to compare the image quality obtained from a dedicated specimen modality with the image quality from a standard direct digital mammography unit. Methods All wide local excision (WLE), vacuum-assisted 10G core biopsy and 14G core biopsy samples were imaged with a Hologic Dimensions mammography unit and a Bioptics Biovision digital specimen radiography system. WLE specimens were imaged without magnifi cation on both systems. Biopsy specimens were imaged with magnifi cation. Two readers assessed each set of images. The number of microcalcifi cations was recorded and visibility of each lesion was assessed on a four-point scale.

Results The total number of specimens was 97. Of these specimens, 67 contained microcalcifi cation, 23 masses, four distortions and three masses with calcifi cation. In 44/67 specimens, the Biovision system demonstrated >20 microcalcifi cations as opposed to only 24/67 with the Hologic system; this is shown to be signifi cant with P = 0.001. In two of the specimens no calcifi cation was demonstrated on the Hologic system, whereas the Biovision system demonstrated <5 in these cases. A signifi cant diff erence was also shown in the conspicuity of the lesions between the two systems, with the lesions having greater conspicuity on the Biovision system (P = 0.027). Conclusion Signifi cantly more microcalcifi cation is demonstrated by the Biovision system and conspicuity is signifi cantly better. This provides increased confi dence that a representative sample has been obtained at biopsy, and therefore increased diagnostic confi dence.

screening radiologists from both countries examined the same FFDM case set, albeit using diff erent resolution displays. Methods Sixteen experienced American breast screening radiologists interpreted 40 diffi cult FFDM cases containing various mammographic features, excluding small calcifi cations, using dual 202 DICOM calibrated monitors. For comparison purposes, the anonymous data were used of 16 experienced UK breast radiologists who had read the same cases as part of the PERFORMS scheme using clinical mammographic workstations.

Results

The 16 American radiologists were split into two groups of low volume (<5,000 cases p.a.) and high volume (≥5,000 cases p.a.) and performances were compared. There was no signifi cant diff erences (t = 0.23, P >0.05). Consequently their performance data were combined and compared with those of the 16 UK radiologists. There was no signifi cant diff erence between the two groups in correct recall decisions (UK, 97.1%; USA, 92.9%; t = 0.042, P >0.05) although there were signifi cant diff erences in correct return to screening decisions (UK, 88.9%; USA, 80%; t = 0.089, P <0.05) and the number of malignancies detected (UK, 98.7%; USA, 93%; t = 0.049, P <0.05).

Conclusion The use of lower resolution monitors (approximately half that of a mammographic workstation) by the American group was off set by their experience (>15 years) such that even very experienced but low-volume readers performed well. Whilst the UK group overall performed better on these cases, the American group still recalled more, refl ecting their real-life screening criteria. Introduction Digital breast tomosynthesis (DBT) has the potential to improve the accuracy of standard digital mammography (DM) [1]. The TOMMY Trial is a multicentre, multireader, retrospective matched comparison of the diagnostic performance of DBT and DM. Methods Study population Women (47 to 73 years old) recalled for further assessment after routine breast screening and women <50 years with a family history of breast cancer, attending annual mammographic screening. Intervention Women who consent to participate in the trial undergo standard two-view DM and DBT imaging of both breasts. Images are acquired in a single examination under the same degree of breast compression on a commercially available (Hologic) digital mammography system. Outcome measures The primary outcome measure is the relative sensitivity and specifi city of DM and DBT in the detection of early-stage cancers and subtle lesions, particularly in women with dense breasts. This will be evaluated in a retrospective reading study where readers at each centre conduct blinded independent reviews of anonymised DM, or DBT, or DM and DBT images of cases from other centres.

Results

The trial set-up has involved lengthy and complex legal negotiation with collaborating sites, the equipment manufacturer and the grant-awarding body. Designated readers from each centre have completed tomosynthesis training and recruitment has commenced. Conclusion It should be noted that the negotiation of contracts and commercial agreements adds a considerable time burden to the set-up phase of multicentre trials.  Introduction Axillary ultrasound staging with core biopsy (CB) or fi ne needle aspiration (FNA) in primary breast cancer is well established. Negative patients will have a sentinel lymph node biopsy (SLNB). This study compares the initial ultrasound fi nding versus fi nal axillary histology in patients undergoing SLNB. Methods A total of 249 breast carcinoma patients, who underwent SLNB between August 2007 and January 2011, were included. Axillary ultrasound and histology results were reviewed. Ultrasound fi ndings and any subsequent biopsies were recorded in positive and negative SLNB groups. The axillary lymph node biopsy histology slides were reviewed in the false negative axillary ultrasound biopsy/FNA group.

Results

Of 249 patients, 191 (76.7%) were SLNB-negative and 58 (23.3%) were SLNB-positive. Thirty out of 191 (16%) patients without axillary metastases had ultrasound-guided sampling. Two out of 191 did not have ultrasound-guided sampling as the procedure was deemed unsafe. Twelve out of 58 (21%) SLNB-positive patients had abnormal ultrasound appearances; 8/12(67%) had CB and 4/12 (33%) had FNA, not signifi cantly diff erent to the CB/FNA rates in SLNBnegative patients (24/32 (75%) and 6/32 (25%), respectively; P = 0.2). See Figure 1. Review of 12 false negative histology slides revealed 1/12 (8%) had micrometastasis and 11/12 (92%) were benign. Conclusion There are no signifi cant diff erences in the rate of axillary ultrasound abnormality between SLNB-positive and SLNB-negative patients. This suggests that ultrasound nodal abnormalities due to malignancy are probably being diagnosed by ultrasound-guided sampling and do not progress to SLNB. It also supports SLNB for sonographically abnormal lymph nodes as opposed to axillary nodal dissection, as many of these patients will not have metastases, if USS sampling is negative. Our small study has not shown signifi cant benefi t of CB over FNA in axillary staging. We found a low upgrade rate on reviewing original ultrasound-guided histology slides, supporting current pathology techniques. Introduction It is accepted that a proportion of patients treated by breast-conservation surgery for unifocal malignancy will undergo further surgery for residual disease. Preoperative planning for impalpable lesions involves a radiological prediction of the extent of disease. The optimal outcome is disease clearance achieved by one operation only. We have revisited our cases which required a subsequent theatre visit in order to facilitate an understanding of the factors involved in accurate lesion sizing and thereby reduce reexcision rates. Methods All women screened through the Wrexham centre with a positive diagnosis of in situ or invasive disease going on to have operative treatment over a 1-year period have been included. The lesions were double-read by experienced fi lm readers to obtain a maximal dimension on two-view mammography and ultrasound where applicable. Each case was attributed a grading, 1 to 3, for ease of measurement. This was compared with the postoperative histology, reported by a specialist breast histopathologist. The size, type, grade, receptor status and nodal status were recorded for each case. Results A total of 61 cases were selected. The preoperative prediction of size was closest to the mammographic measurement in 74% of cases, and to the ultrasound dimension in 21%. The remainder showed equal measurements on both.

Conclusion The mammogram provides a more accurate prediction of lesion size when compared with ultrasound images. It should be borne in mind that a certain proportion of women will choose mastectomy over conservation regardless of the available option of conservation.

Introduction Symptomatic mammogram machines in trusts that do not run screening services are rarely used by the National Breast Screening Service. This is a potential untapped site for screening. This study surveyed whether women attending current screening sites would go to hospital-based symptomatic units instead. Methods All women who attended NHS breast screening in fi ve diff erent sites in South East England were surveyed over 1 day. One site was at the screening centre. The others were mobile, two being rural and two urban. Home postcodes were used to calculate how far women had travelled and the distance to the nearest symptomatic unit. This was correlated with a questionnaire about mode of transport and whether the women would be ready to attend screening at a symptomatic unit. Results Women at four of the sites said they would just as likely to attend their local hospital for screening. This included one of the rural sites, where the average women would have had to travel no further to her local hospital. The fi fth site was also rural but here most women would have to travel more than 15 miles to the hospital, and most had travelled less than 5 miles to the mobile unit. One woman in three would be less likely to attend screening at the local hospital than this site. Conclusion Women going for screening would be happy to have this in their local hospital symptomatic unit as long as this did not entail extra travel. Breast Cancer Research 2011, Volume 13 Suppl 1 http://breast-cancer-research.com/supplements/13/S1 S11 most appropriate diagnostic pathway, the prognosis and the best form of treatment may be uncertain. To answer these questions, we have examined the outcomes of women presenting in this way over a number of years. Methods Thirteen women were identifi ed prospectively over a 12year period, presenting with suspicious lymphadenopathy but no identifi able breast tumour on initial mammography or ultrasound. Biopsy of the abnormal nodes was consistent with a breast primary in all cases. All women had further imaging with breast MRI (11 cases), breast scintigraphy (one case) and CT scanning of the chest and abdomen. Second-look ultrasound was targeted to suspicious areas identifi ed on second-line imaging. The type of treatment, presence of distant metastases and survival were recorded. Results Further imaging revealed a primary breast lesion in seven cases, six remained truly occult. Follow-up ranged from 3 to 144 months (mean 38 months). Three patients died, one is alive with distant metastases and nine remain disease free. Those with no identifi able primary were treated with chemotherapy usually in combination with radiotherapy.

Conclusion The use of MRI and targeted ultrasound-guided biopsy revealed primary tumours in approximately half our cases presenting with lymphadenopathy and negative conventional imaging.

Chemotherapy with radiotherapy appears to be an eff ective treatment for occult breast cancer. The initial staging tests are crucial and if clear the prognosis appears similar to patients with breast cancer and positive axillary nodes.

P10
Image quality and compression force: the forgotten link in optimisation of digital mammography? D O'Leary, T Grant, L Rainford UCD, School of Medicine and Medical Science, Dublin, Ireland Breast Cancer Research 2011, 13(Suppl 1):P10 (doi: 10.1186/bcr2962)

P15
Vacuum-assisted core biopsy of the breast S Saikia, L Lunt Queen Elizabeth Hospital, Gateshead, UK Breast Cancer Research 2011, 13(Suppl 1):P15 (doi: 10.1186/bcr2967)

P28
TOMMY Trial (a comparison of tomosynthesis with digital mammography in the UK NHS breast screening programme) setting up a multicentre imaging trial FJ Gilbert 1 , MGC Gillan 1 , MJ Michell 2 , KC Young 3 , HM Dobson 4 , J Cooke 5 , H Purushothaman 6 , YY Lim 7 , SM Astley 8 , SW Duff y 9 1 University of Aberdeen, UK; 2 King' s College Hospital, London, UK; 3 NCCPM, Guildford, UK; 4 West of Scotland Breast Screening Service, Glasgow, UK; 5 Jarvis Breast Screening Centre, Guildford, UK; 6 Barts & The London NHS Trust, London, UK; 7 University Hospital of South Manchester, Manchester, UK; 8 University of Manchester, UK; 9 Barts and The London School of Medicine and Dentistry, London, UK Breast Cancer Research 2011, 13(Suppl 1):P28 (doi: 10.1186/bcr2980)

Reference 1 .
1Dobbins JT,Godfrey DJ: Digital X-ray tomosynthesis: current state of the art and clinical potential. Phys Med Biol 2003, 48:R65-R106.

P40
Occult breast carcinoma presenting with axillary lymphadenopathy MA Crotch-Harvey Macclesfi eld District General Hospital, Macclesfi eld, UK Breast Cancer Research 2011, 13(Suppl 1):P40 (doi: 10.1186/bcr2992) Introduction Occult breast carcinoma presenting with axillary lymphadenopathy is an uncommon but diffi cult clinical problem. The

. Michell MJ, Iqbal A, Wasan RK, Douiri A, Evans DR, Peacock C, Morel JC, Lawinski CP: Phase I trial to determine the performance of digital breast tomosynthesis versus two dimension digital and fi lm-screenmammography [abstract SSQ01-02]. In 96th Scientifi c Assembly and Annual
Meeting; 28 November-3 December 2010; Chicago, IL, USA. RSNA [http://
rsna2010.rsna.org]

Methods The European Quality Criteria for mammographic IQ and the Breast Screening quality criteria classifi cation of images as inadequate/ moderate/good/perfect were modifi ed to remove all subjective criteria. These objective classifi cations of IQ were tested for inter/intrarater reliability by a panel of experts and compared with original IQ criteria. Further objective measures such as breast volume, density and pectoral-nipple measurements were carried out.Conclusion A method of scoring images combining the most objective components of major European, national and international image scoring systems is suggested. The removal of subjectivity from the scoring systems will remove all doubt regarding the achievement of high image-quality goals for all mammography departments. Conclusion The study shows that ADC values are not aff ected by the normal hormonal fl uctuations during the menstrual cycle. Methods The reports of 3,149 mammograms performed over a 10-month period within the symptomatic breast service at St George's Hospital, London were analysed. The corresponding histopathology reports were collected for identifi cation of malignant cases. Percentage cancer risk was calculated for each category within the UK fi ve-point classifi cation system.Results When tested with 278 surgically modifi ed breast images from
the larger research sample, inter-rater reliability (K >0.701; P <0.001) and
agreement (Pearson's correlation r >0.884; P <0.01) by the evaluation
panel were higher than when the original quality criteria methods were
used. The intra-rater reliability was equally high (K >0.7; P <0.001) with
agreement via Pearson's correlation at r >0.844; P <0.01.

P4
Comparison of analogue and digital mammographic appearances
of screen-detected invasive breast cancers
TW Jones, G Bansal, H Farmer, B Orr, H Russell, L Hobson, D Godden,
I Lyburn
Gloucestershire Breast Screening Service, Cheltenham, UK
Breast Cancer Research 2011, 13(Suppl 1):P4 (doi: 10.1186/bcr2956)

Introduction Our UK Breast Screening Service changed overnight
wholesale from analogue to digital mammography on 5 October 2009.
This has meant that we have two unmixed cohorts to directly compare.
We wish to evaluate whether any digital mammography has changed
our cancer detection, and whether any features of these cancers have
altered.
Methods A NBSS database search for all screen detected cancers in
the periods 1 year prior to the digital changeover; and 1 year after.
This period was suffi ciently historical to expect all cancer diagnosis
episodes to have closed by the time of study. The screening packets for
all these patients were pulled, and fi lms and pathology analysed by the
researchers. The information was directly entered into an anonymised
spreadsheet.
Results For 2008 to 2009 analogue: 24,876 women invited, 20,557
screened, 944 recalled for assessment, 155 diagnosed with cancer;
mean age 59.7. For 2009 to 2010 digital: 32,143 women invited, 25,088
screened, 1,230 recalled for assessment, 221 diagnosed with cancer;
mean age 61.0.
Conclusion Screening uptake fi gures were high in this unit (78% and
82% for each group). Cancer detection rates were signifi cantly increased
in the age 50 to 64 group (analogue 4.6 and digital 6.2/1,000 women
screened). Mean cancer sizes were smaller on digital mammography
but this also corresponded with smaller mean pathological sizes.
Adjusting for this, the digital system still identifi ed smaller cancers than
the analogue system. Overall, cancer detection seems improved by our
change to digital mammography.
Introduction Diff usion-weighted magnetic resonance imaging (DW-
MRI) is a quantitative MRI technique that provides physiological
information by measuring the degree of water molecule diff usion within
the extracellular space. It gives a quantitative measurement known as
the apparent diff usion coeffi cient (ADC) value. The aim of the study is to
show the infl uence of the menstrual cycle on breast ADC values and the
relationship of the ADC to transverse relaxation (T2) value.
Methods Female volunteers had one MRI scan per week over 4 weeks
using a 3 T MRI scanner. The ADC of the fi broglandular tissue was
measured using a single-shot SE-EPI with four b values (0, 50, 150, and
800 s/mm 2 ). The T2 relaxation time was measured using T2w turbo spin
echo (TSE) with four echo times (20, 40, 60, and 80 ms). ADC and T2
maps were generated automatically by standard Philips software.
Results The study was performed on 11 healthy volunteers (23 to
41 years old) with a regular menstrual cycle. There is no signifi cant
diff erence between ADC and T2 values for the 4 weeks. Pearson's
correlation coeffi cient indicated a negative correlation between ADC
and T2 values. See Table 1.
Introduction The UK fi ve-point classifi cation for radiological assessment
of mammograms and ultrasound scans broadly enables evaluation of
cancer risk [1], but no specifi c probabilities are incorporated into this
system. By comparison, the widely accepted BI-RADS scoring system
does include percentage cancer risk for each category [2]. Our study
sought to investigate the cancer probability for each of the fi ve
radiological grades in the UK scoring system amongst a large group of
mammograms.
Results The pathology reports corresponding to each of the 3,149
mammograms revealed 78 cases of malignancy. Data analysis gave the
following cancer probabilities for each category: M1, 0.3%; M2, 0.6%;
M3, 13.5%; M4, 63.6%; and M5, 83.0%.
Conclusion We propose that calculation of cancer risk for each category
within the UK fi ve-point scoring system is a valuable parameter. It
enables accurate performance monitoring within a breast unit as well
as comparison with national/international standards. Introduction Ultrasound and fi ne needle aspiration cytology (FNAC)
are used to provide presurgical axillary assessment in breast cancer, in
line with NICE guidance. An N1 to N5 ultrasound staging process has
been recently introduced. The signifi cance of the new N staging system
and overall preoperative staging results has been analysed.
Methods Patient data were collected during MDTs and from the
electronic results and analysed retrospectively. Patients with ultrasound
score N and/or axillary FNAC were included if they had subsequent
histology (sentinel lymph node biopsy or axillary clearance).

Results A total of 125 patients had histological node samples following
ultrasound assessment and/or FNAC. Fifty-eight had both ultrasound
and FNAC. Ultrasound/FNAC were found to be 82% (27/33)/79% (23/29)
sensitive and 100% (44/44)/100% (41/41) specifi c, respectively. The
overall preoperative staging process sensitivity was 65%. The positive
predictive values of N3, N4, and N5 were 31% (10/32), 50% (6/12) and
100% (11/11), respectively.
Conclusion Combining ultrasound and FNAC assessment provides a
valuable method of preoperative lymph node staging, guiding surgical
management, reducing unnecessary surgery and the number of repeat
operations. Our ultrasound N staging system correlates well with fi nal
histology, and we now plan to introduce repeat axillary biopsy with
high stage N/negative FNAC patients, to attempt an overall increase in
preoperative staging sensitivity/a more eff ective management pathway.

P9
Incidence and outcome of 18-fl uorodeoxyglucose positron emission
tomography/computed tomography-detected breast lesions
LS Haine, G Rutherford, CE Ingram, IJ Jolley, O Hatsiopoulou
The Royal Hallamshire Hospital, Sheffi eld, UK
Breast Cancer Research 2011, 13(Suppl 1):P9 (doi: 10.1186/bcr2961)

Introduction Breast cancer accounts for around 16% of female deaths
in the UK. Usual diagnosis is via the symptomatic pathway or screening.
Positron emission tomography/computed tomography (PET/CT) is
a modality with increasing applications in staging malignancies and
investigating symptoms. It increasingly detects incidental breast
lesions. The aim of this study was to evaluate the incidence and
outcome of PET/CT-detected breast abnormalities.
Methods The radiology information server (CRIS) was interrogated to
produce a list of PET/CT scan results containing the word 'breast' over
4 years. Scans performed on patients with known breast malignancy
were excluded. A further CRIS search was used to determine if
subsequent breast imaging was performed. Pathology was obtained
and hospital notes were reviewed.
Results Thirty patients were found to have incidental breast lesions
on PET/CT scanning. There were 19 masses, seven areas of focal
fl uorodeoxyglucose (FDG) uptake, two areas of calcifi cation, one case
of asymmetry and one area of thickening. In total, 16/30 patients
underwent breast assessment (11 masses, four focal increased uptake
and one bilateral calcifi cation). Out of 11 patients with masses, six were
proven to have corresponding invasive cancers and two had ductal
carcinoma in situ. The remaining three were normal or had benign
disease. Of the four patients with focal increased FDG uptake, one
patient had invasive cancer, one had a fi broadenoma and two were
normal. The bilateral calcifi cations corresponded to lymph nodes.
Conclusion The incidental detection of breast malignancy by PET/CT
was signifi cant at 56%. Breast assessment should be performed in this
population.

Table 1 (
1abstract P5)

Parameter
Week 1
Week 2
Week 3
Week 4

ADC (×10 -3 mm 2 /s)

Fibroglandular tissue
1.7 ± 0.2 1.7 ± 0.3 1.7 ± 0.3
1.7 ± 0.3

T2 (ms)

Fibroglandular tissue
57.6 ± 7
58 ± 7
58.7 ± 8
60 ± 10

Adipose tissue
78 ± 4
77 ± 4
77 ± 4
77 ± 4

Introduction Lymphoma diagnosis conventionally requires nodal excision biopsy, to allow histological subclassifi cation of tumours on samples with preserved tissue architecture. As such, diagnostic accuracy following 16G or 18G core biopsy is diffi cult. Large-bore vacuum-assisted biopsies, such as Mammotome, can percutaneously sample large volumes of breast tissue with excellent tissue architecture preservation. We describe vacuum-assisted biopsy of axillary nodes to investigate lymphadenopathy in surgically high-risk patients.ND Forester 1 , P Burrows 1 , A Jack 2 , A-M Wason 1

1

Pennine Breast Unit, St Luke' s Hospital, Bradford, UK; 2 Haematological
Malignancy Diagnostic Services, Leeds, UK
Breast Cancer Research 2011, 13(Suppl 1):P11 (doi: 10.1186/bcr2963)

Methods Eight patients (seven male, one female; median age 52, range
27 to 65) underwent ultrasound-guided, 8G vacuum-assisted biopsy
of axillary lymphadenopathy between March 2009 and February
2011. The median largest node size was 28 mm (range 14 to 87 mm).
Three patients had previous ultrasound-guided 18G core biopsies,
which were insuffi cient for diagnosis. Between three and 15 cores
were obtained (median = 7) and sent fresh to the Haematological
Malignancy Diagnostic Services.
Results In seven patients, 8G vacuum-assisted biopsy provided
suffi cient histologically intact nodal material to be fully diagnostic. In
one patient, tissue was suspicious for lymphoma, but insuffi cient for
fi nal diagnosis. In seven patients with adequate tissue sampling, six had
lymphoma and one had reactive lymphadenopathy. Of the lymphoma
diagnoses, four were new diagnoses (two Hodgkin, one follicular, one
diff use large B-cell lymphoma) and two were recurrent lymphomas. No
procedure-related complications occurred.
Conclusion Ultrasound-guided large-bore vacuum-assisted biopsy
can safely biopsy axillary lymphadenopathy. Furthermore, samples
obtained have suffi ciently preserved tissue architecture to allow a
conclusive diagnosis of lymphoma, without requiring surgical intact
node excision. In our institution, this technique has proved useful in
high-risk surgical candidates, and where nodal size would have made
surgery technically diffi cult.

P12
Arbitration cancers: analysis from two screening rounds for the
Coventry, Solihull and Warwickshire screening service
S Garnett
University Hospital, Coventry, UK
Breast Cancer Research 2011, 13(Suppl 1):P12 (doi: 10.1186/bcr2964)

Early identifi cation of substandard breast screening performers L Dong, Y Chen, AG Gale Loughborough University, Loughborough, UK Breast Cancer Research 2011, 13(Suppl 1):P13 (doi: 10.1186/bcr2965)Introduction All UK breast screeners can voluntarily undertake the PERFORMS scheme, where they examine recent screening cases receiving immediate feedback. Once all individuals have participated, data are calculated on how they performed compared with peers allowing poor performers to be identifi ed. A way of potentially identifying such poor performers much earlier is proposed.

A Romsauerova, J Dewar, D Brown, A Evans Dundee Cancer Centre, University of Dundee, UK Breast Cancer Research 2011, 13(Suppl 1):P14 (doi: 10.1186/bcr2966)

Introduction Eff orts to reduce radiation dose should be linked to and limited by image quality and the radiation dose should only be lowered to levels compatible with image quality for adequate diagnosis; this is optimisation of mammography. Despite this link between image quality and mean glandular dose (MGD), the MGD is proposed only with regard to compression level achieved or population percentile, not image quality required/achieved. Methods A study of symptomatic breast units geographically spread over Ireland collected image quality and radiation dose data. The quantitative and qualitative data were analysed using mathematical modelling and SPSS statistics including ANOVA. High image quality was matched to lowest achievable radiation doses; inadequate images were discarded from the dataset for recommendations of achievable MGD. Results MGDs received by perfect images are signifi cantly lower than the radiation doses received by inadequate images. This is seen in both Introduction Sentinel lymph node biopsy (SLNB) is the preferred method of axillary staging in breast cancer. If metastases are detected, axillary node clearance (ANC) is necessary. Preoperative detection of nodal metastases using ultrasound-guided core biopsy (USCB) allows the surgeon to proceed directly to ANC. Negative CBs do not exclude metastases. All patients still need SLNB. However, by minimising false negatives, unnecessary SLNBs can be minimised. We compared our USCB results with the results of subsequent SLNB + axillary node sampling (ANS) or ANC to assess our accuracy.increasing the image quality?
D O'Leary, L Rainford
University College Dublin, Ireland
Breast Cancer Research 2011, 13(Suppl 1):P21 (doi: 10.1186/bcr2973)

digital images and fi lm-screen images and for both mammographic
projections: digital craniocaudal, F(3,978) = 2.841, P = 0.37; digital medio-
lateral oblique, F(3,977) = 4.896, P = 0.002; analogue craniocaudal,
F(3,785) = 7.993, P <0.001; analogue mediolateral oblique, F(3,783) =
7.961, P <0.001). The mean MGD in mGy required to produce a perfect
image in each of the categories: digital craniocaudal, 1.23 mGy; digital
mediolateral oblique, 1.28 mGy; analogue craniocaudal, 2.10 mGy;
analogue mediolateral oblique, 2.25 mGy.
Conclusion The publication of average glandular dose must be linked
to image quality achieved and the percentage of inadequate images
in the data collection must be explicit. The radiation doses can be
lowered further in digital imaging by greater training of radiographers
to consistently achieve perfect mammography images.

P22
Audit of accuracy of ultrasound-guided axillary core biopsy
A Anand, R Henderson
Darlington Memorial Hospital, Darlington, UK
Breast Cancer Research 2011, 13(Suppl 1):P22 (doi: 10.1186/bcr2974)

Methods We performed a retrospective audit of patients having USCB
in primary breast cancer. We included patients presenting to one
consultant radiologist fi rm from our unit's symptomatic breast clinic
between 27 March 2007 and 7 December 2010. Our criteria for CB
included cortical thickness >2 mm, loss of fatty hilum and longitudinal
axis/transverse axis <2.

IntroductionAs the importance of mammographic density in risk stratifi cation and breast cancer research continues to grow, density assessment must be rigorous. Area-based human visual density assessment will continue until software is fully validated. Locally, having reviewed the literature, we chose two tools and sought to establish that these would give meaningful results in our hands for comparison with other data.A Eadie, P Whelehan, L Baker, J Berg, A Evans
University of Dundee, UK
Breast Cancer Research 2011, 13(Suppl 1):P24 (doi: 10.1186/bcr2976)

Methods In 50 mammograms, four observers each estimated the
percentage dense area, recorded on a 100 mm visual analogue scale
(VAS). On a separate occasion, each observer also assigned BIRADS
density scores. The process was repeated with a minimum interval of
1 week. Observers were blinded to each others' scores and their own
previous scores. Viewing parameters were standardised.
Results BIRADS Intra-rater agreement: Observers 1, 2 and 4, intraclass
correlation coeffi cient (ICC) and lower 95% confi dence bound all
above 0.8 (excellent agreement); below 0.8 for Observer 3. Inter-rater:
Observers 2 and 4, ICC = 0.97, 95% CI = 0.95 to 0.98; Observers 1 and 3
with any other, ICC below 0.8.
Percentage Intra-rater agreement, ICC for all observers >0.9 with lower
confi dence bound >0.8. Inter-rater: Observers 2 and 4 and 2 and 3, ICC
and lower confi dence bound >0.8; all other pairs, <0.8.
Conclusion Intra-observer and inter-observer agreement in mammo-
graphic density assessment varies. Percentage dense area estimation
using a VAS appears more reproducible than the BIRADS classifi cation.
This simple study enabled selection of the most reliable observers and
we recommend that other centres undertaking scientifi c studies where
mammographic density is a relevant variable perform similar audits to
maximise outcome measure validity.

P25
Can digital breast tomosynthesis off er an alternative to MRI in
preoperative imaging of lobular carcinoma?
PD Wall 1 , JC Morel 1,2 , R Wasan 1,2 , D Evans 1,2 , C Peacock 1,2 , MJM Michell 1,2
1 Kings College Hospital NHS Trust, London, UK; 2 South East London BSP,
London, UK
Breast Cancer Research 2011, 13(Suppl 1):P25 (doi: 10.1186/bcr2977)

Introduction Digital breast tomosynthesis (DBT) is an emerging breast
imaging technique which we have shown in our institution to more
accurately size tumours when compared with 2D mammography.
In this study we have looked at the accuracy of DBT in the sizing of
invasive lobular carcinoma (ILC) when compared with MRI, the current
imaging technique of choice.
Methods All clients diagnosed with ILC were identifi ed between
December 2008 and March 2010. Of these clients, those who had

undergone imaging with both MRI and DBT were extracted. Tumour
diameter in the single largest dimension was recorded on DBT by
two consultant radiologists. MRI and pathological tumours sizes were
extracted from the notes. The agreement between the two imaging
modalities and pathology was analysed using the methods described
by Bland-Altman. Pearson correlation coeffi cients were calculated.
Results Twenty-three cases of lobular carcinoma were identifi ed with
MRI and DBT imaging. Pearson correlation coeffi cients for DBT with
pathology r = 0.73, MRI with pathology r = 0.86, MRI with DBT r = 0.81.
See Table 1.

Table 1 (abstract P25)

DBT-pathology
MRI-pathology

Upper limit of agreement (mm)
31 (15 to 47)
25 (12 to 38)

Mean diff erence (mm)
-11 (-20 to -1)
-9 (-16 to -2)

Lower limit of agreement (mm)
-52 (-68 to -36)
-43 (-56 to -30)

95% CI presented in parentheses.

IntroductionThe Royal College of Radiologists Breast Group has formalised the UK fi ve-point breast imaging scoring system to encourage uniformity of reporting. The Breast Imaging and Reporting Data System (BI-RADS) is widely used throughout North America and Europe, and, unlike the UK scoring system, each BI-RADS category has an associated cancer likelihood. This study aims to quantify the cancer likelihood of each of the UK categories and map them to comparable BI-RADS categories to facilitate comparison of reporting, research and literature. Methods Between January 2001 and December 2008, mammograms and ultrasounds performed in a symptomatic setting were prospectively UK scored and the percentage of cancer outcomes within each group calculated. These were then compared with the percentage incidence of the BI-RADS categories. Results Of 23,741 separate assessment episodes, 15,288 mammograms and 10,642 ultrasound examinations were evaluated. There was direct correlation between UK scoring and BI-RADS for categories 1 and 5. UK score 2 lipomas and simple cysts correlated with BI-RADS 2, with the remaining UK score 2 lesions (mostly fi broadenomas) assigned to BI-RADS 3. BI-RADS 4 incorporates a wide range of cancer risk (2 to 95%) with subdivisions a, b and c indicating increasing, but unspecifi ed, likelihood of malignancy. UK score 3 correlated with BI-RADS 4 a/b and UK score 4 corresponded with BI-RADS 4c. Conclusion The cancer likelihood of the UK scoring has been quantifi ed and mapped to the appropriate BI-RADS categories with equivalentFigure 1 (abstract P33).cancer risks. This facilitates the sharing of UK research data and clinical practice on an international scale.P35Impact of presurgical breast MRI in a district general hospitalA Newland, M Dumba, S Flais Ealing Hospital, London, UK Breast Cancer Research 2011, 13(Suppl 1):P35 (doi: 10.1186/bcr2987)Introduction Routine MRI in the assessment of lobular carcinoma, invasive ductal carcinoma in dense breasts, patients younger than 35 or radioclinical discordance at the time of cancer diagnosis was introduced in the symptomatic breast unit of Ealing Hospital in 2009. We analyse the impact of this new pathway on our local practice. Methods All patients with a new diagnosis of breast cancer in two periods of 18 months, before and after the introduction of MRI, were reviewed. Mastectomy rates were compared between the two groups and the role of MRI in this change is discussed. The cost of the new pathway is reviewed, including the cost of additional imaging and biopsies generated by MRI. Results The mastectomy rate increased from 25% between 1 January 2006 and 30 June 2007, to 40% between 1 January 2010 and 30 June 2011. Other factors (patient group, cancer grade, multidisciplinary team decision-making process) were unchanged. The cost of the presurgical assessment of patients undergoing MRI has increased signifi cantly. Conclusion Presurgical MRI has changed the fi rst-line treatment off ered by our team, but at a signifi cant cost, especially for the radiology department. The local impact on overall survival and eventfree survival is still unknown.P36 Should general practitioner access to breast imaging and 2WW co-exist? ME Fletcher, N Sharma, BG Dall Leeds Teaching Hospital NHS Trust, Leeds, UK Breast Cancer Research 2011, 13(Suppl 1):P36 (doi: 10.1186/bcr2988)IntroductionThe Leeds breast service treats over 500 breast cancers a year. The general practitioners (GPs) have always had access via the one-stop breast clinic or direct access to the imaging department. Any positive imaging fi ndings are actioned within imaging and the patients are referred to the clinic for results. The GP is informed. With the introduction of 2WW it is appropriate to re-audit this practise. Methods This is a retrospective audit performed over a 6-month period using the radiology database (CRIS) and the clinical database (PPM). The data collected included the number of GP referrals, the imaging performed, the number of biopsies and the number of referrals to the breast clinic. The timeline for each patient was recorded and the costs involved where compared with referral to the one-stop clinic. Results A total of 592 patients were referred direct to imaging from 1 July 2010 to 31 December 2010. The GP referrals were seen within an average of 23 days (3 to 47 days). A total of 223 patients had mammography and ultrasound, 165 had mammography only and 204 had ultrasound only. Twenty-six patients had biopsies; 45% were performed at the same attendance. Nine cancers were diagnosed. Forty-one patients were referred to the one-stop clinic. The radiology department received payment per procedure compared with a standard percentage per patient. Conclusion The one-stop clinic with triple assessment is the gold standard. GP direct access still safely reduces the burden of a 2-week wait provided robust pathways are in place to ensure prompt biopsy and appropriate referral to the breast clinic. Breast Test Wales, Wrexham, UK Breast Cancer Research 2011, 13(Suppl 1):P37 (doi: 10.1186/bcr2989)P37
Size matters
M Powell, B Bayley

IntroductionRecent guidelines advise that mammography should only be off ered to women between the ages of 35 and 39 if clinical examination raises concern or a targeted ultrasound of the breast reveals a suspicious abnormality[1]. The aim of this study was to assess the role of mammography as a diagnostic tool in women aged 35 to 39 presenting to the symptomatic breast clinic. Methods All women aged between 35 and 39 years presenting to the symptomatic breast clinic between April 2010 and March 2011 were eligible for inclusion. Data were collected on demographics, presenting symptoms, radiological investigation and diagnosis. Results A total 112 of 124 women identifi ed had mammography performed as part of their initial assessment; one woman presented with a solid lump which was indeterminate on ultrasound but proved to be breast cancer on biopsy. The majority of patients were diagnosed with mastalgia, benign nodularity or fi broademona. Core biopsies confi rmed benign pathology in eight women. Of the 12 women who did not have mammography, benign pathology was diagnosed using clinical examination and ultrasound, with breast cysts and sepsis being the commonest causes of pathology. Conclusion The role of mammography in women aged 35 to 39 presenting to the symptomatic breast clinic should be reassessed. Our data support the guidelines that ultrasound is the imaging method of choice in this age group. Reference Introduction Vacuum-assisted biopsies (VABs) are used for both diagnostic and treatment purposes. Currently there are no set guidelines in our department as to who should proceed to a VAB. The purpose of this study is to analyse the indication for a VAB, the upgrade or downgrade rate when compared with the initial core biopsy and the overall fi nal outcome of these patients.Methods A retrospective search of all VABs performed from 1 April 2009 to 31 March 2010 was identifi ed. The indication for VAB, the initial core biopsy results and the vacuum biopsy results and fi nal outcomes were recorded. Results A total of 37 VABs were performed within the year. Two were for treatment excision of fi broadenoma. A total of 35 were diagnostic VABs. Three went straight to vacuum biopsies due to either a small lesion or suspicion for a recurrent malignancy. Of the remaining 32 cases, 21 were for indeterminate M3/U3/B3 lesions, fi ve for clinical and pathological mismatch, three for further clarifi cation of core biopsy result, two for staging the extent of the tumour, and one for inadequate core biopsy. Thirteen out of 32 (40.6%) were upgraded from the initial biopsy, 10 proceeded to further procedures. Six out of 32 (18.8%) remained the same grade, two (33.3%) required further procedure. Thirteen out of 32 (40.6%) were downgraded, fi ve (38.5%) proceeded to further procedures. Conclusion Our audit has shown VAB is useful in providing a defi nitive diagnosis in a range of breast pathology, in particular B3 lesions. We therefore strongly advise its use in cases of pathological uncertainly to save patients from further unnecessary interventions. Introduction The purpose of this study was to analyse assessment of the axilla in patients with primary operable breast cancer in a one-stop symptomatic breast unit. Methods A retrospective review of 229 patients diagnosed with new primary operable breast carcinoma over a 12-month period. All patients underwent axillary ultrasound (US). All cases with normal US had subsequent sentinel lymph node biopsy (SLNB). All cases with abnormal US underwent fi ne needle aspiration cytology (FNAC). Findings were correlated with SLNB and axillary node clearance histology. Results A total of 128 patients had normal US and subsequent SLNB, this was positive in 29 (23%); 12 (40%) had micro metastases; primary tumour size was >2 cm in 22 (76%). Positive predictive value for US and FNAC was 97%. Negative predictive value was 75%. False positive and negative rates for US axilla are discussed with analysis of tumour subgroups and pattern of positive nodes. Conclusion The combination of US and FNAC is a powerful predictive tool of axillary disease[1]. Disappointingly false negative axillary US did not correlate solely with micro metastases. This may refl ect a learning curve eff ect, and will be reassessed on follow-up data. ReferenceP47Assessment of the axilla in primary operable breast carcinoma
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Assessment of the axilla in primary operable breast carcinoma. M Twomey, abstractTwomey M, et al.: Assessment of the axilla in primary operable breast carcinoma [abstract].

. Breast Cancer Research. 13147SupplBreast Cancer Research 2011, 13(Suppl 1):P47.