One-stop diagnostic breast clinics: how often are breast cancers missed?

The aim of this study was to estimate the number of patients discharged from a symptomatic breast clinic who subsequently develop breast cancer and to determine how many of these cancers had been ‘missed' at initial assessment. Over a 3-year period, 7004 patients were discharged with a nonmalignant diagnosis. Twenty-nine patients were subsequently diagnosed with breast cancer over the next 36 months. This equates to a symptomatic ‘interval' cancer rate of 4.1 per 1000 women in the 36 months after initial assessment (0.9 per 1000 women within 12 months, 2.6 per 1000 women within 24 months). The lowest sensitivity of initial assessment was seen in patients of 40–49 years of age, and these patients present the greatest imaging and diagnostic challenge. Following multidisciplinary review, a consensus was reached on whether a cancer had been missed or not. No delay occurred in 10 patients (35%) and probably no delay in 7 patients (24%). Possible delay occurred in three patients (10%) and definite delay in diagnosis (i.e., a ‘missed' cancer) occurred in only nine patients (31%). The overall diagnostic accuracy of ‘triple' assessment is 99.6% and the ‘missed' cancer rate is 1.7 per 1000 women discharged

Magnetic resonance imaging of the low rectum: defining the radiological anatomy.

Low rectal cancer provides a particular surgical challenge of local tumour control and sphincter preservation. Histopathological studies have shown that an involved circumferential resection margin (CRM) and depth of extramural invasion are independent markers of poor prognosis and correlate with high local recurrence rates due to residual microscopic disease [1]. Recent data suggests that a CRM at risk of tumour involvement can be reliably seen on the pre-operative magnetic resonance imaging (MRI) scan with good correlation with the histological specimen [2-5]. In published series, low rectal cancers have a higher incidence of involved resection margins, with rates up to 30% for abdomino-perineal excision (APE) vs 10% for low anterior resection (LAR) [6-9]. This has been attributed to narrow surgical planes deep within the pelvis as the mesorectum becomes narrowed and tapered, forming a bare muscle tube at the level of the anal sphincter complex. The challenge for the surgeon is to undertake careful removal of a cylinder of tissue beyond the rectal wall without perforating the tumour. An overall local recurrence rate of 10% after APE for all stages of rectal cancer has been reported and this low rate was attributed to the surgical technique that included a wide peri-anal dissection and lateral division of the levator ani. The abdominal dissection was stopped above the tumour, taking care to avoid separation of the tumour from the levator ani to reduce the risk of inadvertent tumour cell spillage [8]. Therefore, rates of involved surgical margins from APE specimens may be reduced when a cuff of levators is taken compared with standard resection. In this review, we will discuss how MRI of the low rectum can aid in the staging and optimization of the best treatment strategy for low rectal cancer

Measuring the accuracy of diagnostic imaging in symptomatic breast patients : team and individual performance

Objective: The combination of mammography and/or ultrasound remains the mainstay in current breast cancer diagnosis. The aims of this study were to evaluate the reliability of standard breast imaging and individual radiologist performance and to explore ways that this can be improved. Methods: A total of 16 603 separate assessment episodes were undertaken on 13 958 patients referred to a specialist symptomatic breast clinic over a 6 year period. Each mammogram and ultrasound was reported prospectively using a five-point reporting scale and compared with final outcome. Results: Mammographic sensitivity, specificity and receiver operating curve (ROC) area were 66.6%, 99.7% and 0.83, respectively. The sensitivity of mammography improved dramatically from 47.6 to 86.7% with increasing age. Overall ultrasound sensitivity, specificity and ROC area was 82.0%, 99.3% and 0.91, respectively. The sensitivity of ultrasound also improved dramatically with increasing age from 66.7 to 97.1%. Breast density also had a profound effect on imaging performance, with mammographic sensitivity falling from 90.1 to 45.9% and ultrasound sensitivity reducing from 95.2 to 72.0% with increasing breast density. Conclusion: The sensitivity ranges widely between radiologists (53.1–74.1% for mammography and 67.1–87.0% for ultrasound). Reporting sensitivity was strongly correlated with radiologist experience. Those radiologists with less experience (and lower sensitivity) were relatively more likely to report a cancer as indeterminate/uncertain. To improve radiology reporting performance, the sensitivity of cancer reporting should be closely monitored; there should be regular feedback from needle biopsy results and discussion of reporting classification with colleagues