BreastScreen WA

Phyllodes tumours constitute an uncommon but complex group of mammary fibroepithelial lesions. Accurate and reproducible grading of these tumours has long been challenging, owing to the need to assess multiple stratified histological parameters, which may be weighted differently by individual pathologists. Distinction of benign phyllodes tumours from cellular fibroadenomas is fraught with difficulty, due to overlapping microscopic features. Similarly, separation of the malignant phyllodes tumour from spindle cell metaplastic carcinoma and primary breast sarcoma can be problematic. Phyllodes tumours are treated by surgical excision. However, there is no consensus on the definition of an appropriate surgical margin to ensure completeness of excision and reduction of recurrence risk. Interpretive subjectivity, overlapping histological diagnostic criteria, suboptimal correlation between histological classification and clinical behaviour and the lack of robust molecular predictors of outcome make further investigation of the pathogenesis of these fascinating tumours a matter of active research. This review consolidates the current understanding of their pathobiology and clinical behaviour, and includes proposals for a rational approach to the classification and management of phyllodes tumours.

The International Academy of Cytology (IAC) gathered together a group of cytopathologists expert in breast cytology who, working with clinicians expert in breast diagnostics and management, have developed the IAC Yokohama System for Reporting Breast Fine-Needle Aspiration Biopsy (FNAB) Cytology. The project was initiated with the first cytopathology group meeting in Yokohama at the 2016 International Congress of Cytology. This IAC Yokohama System defines five categories for reporting breast cytology, each with a clear descriptive term for the category, a definition, a risk of malignancy (ROM) and a suggested management algorithm. The key diagnostic cytopathology features of each of the lesions within each category will be presented more fully in a subsequent atlas. The System emphasizes that the crucial requirements for diagnostic breast FNAB cytology are a high standard for the performance of the FNAB and for the making of direct smears, and well-trained experienced cytopathologists to interpret the material. The performance indicators of breast FNAB, including specificity and sensitivity, negative predictive value, positive predictive value and ROM stated in this article have been derived from the recent literature. The current practice of breast FNAB has evolved with the increasing use of ultrasound guidance and rapid on-site evaluation. Two recent publications have shown a range of ROM for the insufficient/inadequate category of 2.6-4.8%, benign 1.4-2.3%, atypical 13-15.7%, suspicious of malignancy 84.6-97.1%, and malignant 99.0-100%. The management algorithm in the System provides options because there are variations in the management of breast lesions using FNAB and core-needle biopsy in those countries utilizing the "triple test" of clinical, imaging, and FNAB assessment, and also variations in the availability of CNB and imaging in low- and middle-income countries. The System will stimulate further discussion and research, particularly in the cytological diagnostic features of specific lesions within each category and in management recommendations. This will lead to continuing improvements in the care of patients with breast lesions and possible modifications to the IAC Yokohama System.

BACKGROUND: Artificial intelligence (AI) has been proposed to reduce false-positive screens, increase cancer detection rates (CDRs), and address resourcing challenges faced by breast screening programs. We compared the accuracy of AI versus radiologists in real-world population breast cancer screening, and estimated potential impacts on CDR, recall and workload for simulated AI-radiologist reading. METHODS: External validation of a commercially-available AI algorithm in a retrospective cohort of 108,970 consecutive mammograms from a population-based screening program, with ascertained outcomes (including interval cancers by registry linkage). Area under the ROC curve (AUC), sensitivity and specificity for AI were compared with radiologists who interpreted the screens in practice. CDR and recall were estimated for simulated AI-radiologist reading (with arbitration) and compared with program metrics. FINDINGS: The AUC for AI was 0.83 compared with 0.93 for radiologists. At a prospective threshold, sensitivity for AI (0.67; 95% CI: 0.64-0.70) was comparable to radiologists (0.68; 95% CI: 0.66-0.71) with lower specificity (0.81 [95% CI: 0.81-0.81] versus 0.97 [95% CI: 0.97-0.97]). Recall rate for AI-radiologist reading (3.14%) was significantly lower than for the BSWA program (3.38%) (-0.25%; 95% CI: -0.31 to -0.18; P < 0.001). CDR was also lower (6.37 versus 6.97 per 1000) (-0.61; 95% CI: -0.77 to -0.44; P < 0.001); however, AI detected interval cancers that were not found by radiologists (0.72 per 1000; 95% CI: 0.57-0.90). AI-radiologist reading increased arbitration but decreased overall screen-reading volume by 41.4% (95% CI: 41.2-41.6). INTERPRETATION: Replacement of one radiologist by AI (with arbitration) resulted in lower recall and overall screen-reading volume. There was a small reduction in CDR for AI-radiologist reading. AI detected interval cases that were not identified by radiologists, suggesting potentially higher CDR if radiologists were unblinded to AI findings. These results indicate AI's potential role as a screen-reader of mammograms, but prospective trials are required to determine whether CDR could improve if AI detection was actioned in double-reading with arbitration. FUNDING: National Breast Cancer Foundation (NBCF), National Health and Medical Research Council (NHMRC).

OBJECTIVES: To review the performance and utility of the International Academy of Cytology (IAC) Yokohama System for Reporting Breast Fine Needle Aspiration Biopsy (FNAB) Cytology five category stratification and evaluate the impact of rapid onsite evaluation (ROSE). METHOD: A retrospective analysis of breast FNAB cytology cases with matched histopathological results at a single institution over a 32 months period using a structured reporting system with 5 diagnostic categories ("inadequate/insufficient," "benign," "atypical," "suspicious of malignancy" and "malignant") closely paralleling the proposed IAC System. RESULTS: Of 2,696 breast FNAB cases, there were 579 with matched histopathology and 456 of these had ROSE. ROSE decreased the number in the "insufficient" category (17.1% without ROSE to 4.0% with ROSE) and increased the number in the "malignant" (17.9 to 39.0%) with a lesser impact on the "atypical," "benign" and "suspicious of malignancy" categories. The performance data showed a positive predictive value of 96.4%, negative predictive value of 97.6%, and a risk of malignancy of a FNAB categorized as "insufficient" to be 2.6%, "benign" 1.7%, "atypical" 15.7%, "suspicious of malignancy" 84.6%, and "malignant" 99.5%. CONCLUSION: Breast FNAB is an accurate test enabling effective diagnosis of breast lesions. ROSE improved the performance by decreasing the proportion of "insufficient" and "atypical" and increasing the "suspicious of malignancy" and "malignant" diagnoses and enabling immediate triage for further biopsy where necessary.

BACKGROUND: Coagulation disorders are seen in cancer patients, but it is not clear whether cancer predisposes stroke patients to unique characteristics. The aim of the study was to investigate risk factors, pattern,etiology and outcome in stroke patients with cancer. METHODS: A retrospective review of all ischemic stroke (IS) patients with cancer (n = 56) admitted to Bankstown-Lidcombe Hospital, Sydney, Australia, between January 1999 and December 2004 was conducted and comparison made to age- and gender-matched noncancer IS patients admitted to the same hospital during the same period. RESULTS: Vascular risk factors and stroke pattern were comparable in cancer and noncancer groups. Post-stroke thrombotic episodes (myocardial infarction, deep vein thrombosis or pulmonary emboli) were more common in the cancer group than in the noncancer group (11 vs. 0%, p = 0.031). Depression was also more common in the cancer group than in the noncancer group (14 vs. 2%, p = 0.039). There was a tendency for more patients in the cancer group to die in hospital (30 vs. 14%, p = 0.078). CONCLUSIONS: Coagulation disorders were more likely to be seen in stroke cancer patients, and patients with cancer tended to have a higher in-hospital post-stroke mortality. Larger sample size studies may identify further differences in the characteristics of stroke patients with cancer.

Abstract Introduction: The evaluation of breast symptoms during pregnancy or lactation can be challenging but prompt, appropriate assessment of symptoms may lead to earlier cancer detection. Methods: A review of breast imaging from 22 women with breast cancer during or within 1 year of pregnancy was undertaken as part of a large population‐based study of gestational breast cancer. Consensus findings of three reads using the Breast Imaging Reporting and Data System lexicon were recorded. Results: The commonest presenting symptom was a lump. Diagnosis by percutaneous biopsy was made correctly in 21 of 23 lesions. Lesions were predominantly invasive ductal carcinoma (91%). One third had extensive associated ductal carcinoma in situ (DCIS). Ultrasound (US) was abnormal in all symptomatic patients. The most common sonographic finding was a solitary hypoechoic mass with irregular margins. ‘Expanded stroma’ with prominent ducts and architectural distortion was noted in three cases; all had extensive high‐grade DCIS. In three women, bilateral breast US detected cancer in the asymptomatic breast. Mammography (performed in 86% of women) was abnormal in 74%, despite the presence of dense breast tissue in 47%. Widespread calcifications were visible in 26%, with detection of asymptomatic contra‐lateral disease in one patient. MRI was performed in six patients. Background parenchymal enhancement did not impair lesion detection; however, overestimation of lesion size can occur. Conclusions: Ultrasonography is recommended for the initial diagnosis of breast symptoms during pregnancy and lactation. A negative study should not delay direct fine needle aspiration of a palpable lesion. Mammography is indicated where initial assessment suggests malignancy. MRI may have a role in selected cases.

BACKGROUND AND OBJECTIVE: Vessel segmentation is the first processing stage of 3D medical images for both clinical and research use. Current segmentation methods are tedious and time consuming, requiring significant manual correction and hence are infeasible to use in large data sets. METHODS: Here, we review and analyse available coronary artery segmentation methods, focusing on fully automated methods capable of handling the rapidly growing medical images available. All manuscripts published since 2010 are systematically reviewed, categorised into different groups based on the approach taken, and characteristics of the different approaches as well as trends over the past decade are explored. RESULTS: The manuscripts were divided intro three broad categories, consisting of region growing, voxelwise prediction and partitioning approaches. The most common approach overall was region growing, particularly using active contour models, however these have had a sharp fall in popularity in recent years with convolutional neural networks becoming significantly more popular. CONCLUSIONS: The systematic review of current coronary artery segmentation methods shows interesting trends, with rising popularity of machine learning methods, a focus on efficient methods, and falling popularity of computationally expensive processing steps such as vesselness and multiplanar reformation.

Because some lesions diagnosed as radial scars (RS) on core biopsy have been found to be malignant on excision, core biopsy has not had an established role in the assessment of RS. In our breast cancer-screening program, we have avoided core biopsy if RS is suspected on imaging. Recently, two reports have expanded the experience with core biopsy of RS, prompting this review of our assessment protocols for lesions suspected as being RS. Between January 1996 and January 2003, stellate lesions with imaging features of RS in which core biopsy was omitted because of a presumptive radiologic diagnosis of RS are included. Demographic, radiologic, and cytologic data were correlated with the histologic findings in the excised specimen. On imaging, 9% (142) of all stellate lesions were suspected to be RS. Only 66.2% (94) were confirmed as RS on histology; 38 cases (28.6%) were carcinomas (36 invasive, 2 in situ) and 7% showed benign fibrocystic changes; 87.1% of the carcinomas required further surgery for positive margins. Axillary staging was also needed for the invasive cancers. Among the histologically proven RS, 28 of 94 (29.8%) showed areas of atypical ductal hyperplasia, lobular neoplasia, ductal carcinoma in situ, or invasive carcinoma. These proliferations were typically focal and unpredictable and were usually completely excised by the initial diagnostic biopsy. Core biopsy would be valuable in the assessment of lesions with imaging features suggestive of RS since 28.6% of such lesions are indeed carcinomas that mimic RS. Identification of these cancers would permit one stage breast and axillary surgery to be planned. The policy of mammographic surveillance for lesions with nonmalignant core biopsies remains controversial because of the paucity of data. Ongoing evaluation is needed as more experience is reported.

Objective: To compare the reliability and validity of two classification systems used to evaluate the quality of mammograms: PGMI ('perfect', 'good', 'moderate' and 'inadequate') and EAR ('excellent', 'acceptable' and 'repeat'). Setting: New South Wales (Australia)population-based mammography screening programme (BreastScreen NSW). Methods: Thirty sets of mammograms were rated by 21 radiographers and an expert panel. PGMI and EAR criteria were used to assign ratings to the medio-lateral oblique (MLO) and cranio-caudal (CC) views for each setof films. Inter-observer reliability and criterion validity (compared with expert panel ratings) were assessed using mean weighted observed agreement and kappa statistics. Results: Reliability : Kappa values for both classification systems were low (0.01–0.17). PGMI producedsignificantly higher values than EAR. Agreement between raters was higher using PGMI than EAR for the MLO view (77% versus 74%, P&lt;0.05), but was similar for the CC view. Dichotomized ratings ('acceptable' or 'needs repeating') did not improve reliability estimates. Validity : Kappavalues between raters and the reference standard were low for both classification systems (0.05–0.15). Agreement between raters and the reference standard was higher using PGMI than EAR for the MLO view (74% versus 63%), but was similar for the CC view. Dichotomized ratings of the MLOview showed slightly higher observer agreement. Conclusions: Both PGMI and EAR have poor reliability and validity in evaluating mammogram quality. EAR is not a suitable alternative to PGMI, which must be improved if it is to be useful.

Aggressive fibromatosis is a rare, locally aggressive disease. It constitutes 0.3% of all solid tumors, but the tumor is rarely seen in the breast, particularly without pectoral muscle and fascial involvement. The etiology is unknown, but an association with Gardner's syndrome has been described. Clinical and imaging findings simulate breast carcinoma. A case in a 53-year-old female patient is reported.

BACKGROUND: Mammographic microcalcifications are associated with many benign lesions, ductal carcinoma in situ (DCIS) and invasive cancer. Careful assessment criteria are required to minimise benign biopsies while optimising cancer diagnosis. We wished to evaluate the assessment outcomes of microcalcifications biopsied in the setting of population-based breast cancer screening. METHODS: Between January 1992 and December 2007, cases biopsied in which microcalcifications were the only imaging abnormality were included. Patient demographics, imaging features and final histology were subjected to statistical analysis to determine independent predictors of malignancy. RESULTS: In all, 2545 lesions, with a mean diameter of 21.8 mm (s.d. 23.8 mm) and observed in patients with a mean age of 57.7 years (s.d. 8.4 years), were included. Using the grading system adopted by the RANZCR, the grade was 3 in 47.7%; 4 in 28.3% and 5 in 24.0%. After assessment, 1220 lesions (47.9%) were malignant (809 DCIS only, 411 DCIS with invasive cancer) and 1325 (52.1%) were non-malignant, including 122 (4.8%) premalignant lesions (lobular carcinoma in situ, atypical lobular hyperplasia and atypical ductal hyperplasia). Only 30.9% of the DCIS was of low grade.Mammographic extent of microcalcifications >15 mm, imaging grade, their pattern of distribution, presence of a palpable mass and detection after the first screening episode showed significant univariate associations with malignancy. On multivariate modeling imaging grade, mammographic extent of microcalcifications >15 mm, palpable mass and screening episode were retained as independent predictors of malignancy. Radiological grade had the largest effect with lesions of grade 4 and 5 being 2.2 and 3.3 times more likely to be malignant, respectively, than grade 3 lesions. CONCLUSION: The radiological grading scheme used throughout Australia and parts of Europe is validated as a useful system of stratifying microcalcifications into groups with significantly different risks of malignancy. Biopsy assessment of appropriately selected microcalcifications is an effective method of detecting invasive breast cancer and DCIS, particularly of non-low-grade subtypes.

BACKGROUND: The Australian Capital Territory and South East New South Wales branch of BreastScreen Australia (BreastScreen ACT&SENSW) performs over 20,000 screening mammograms annually. This study describes the outcome of surgical biopsies of the breast performed as a result of a borderline lesion being identified after screening mammography and subsequent workup.A secondary aim was to identify any parameters, such as a family history of breast cancer, or radiological findings that may indicate which borderline lesions are likely to be upgraded to malignancy after surgery. METHODS: From a period of just over eight years, all patients of BreastScreen ACT&SENSW who were diagnosed with a borderline breast lesion were identified. These women had undergone needle biopsy in Breastscreen ACT&SENSW and either atypical ductal hyperplasia (ADH), flat epithelial atypia (FEA), atypical lobular hyperplasia (ALH), radial scar/complex sclerosing lesion, papillary lesion, mucocoele-like lesion (MLL) or lobular carcinoma in situ (LCIS) was found. Final outcomes for each type of borderline lesion after referral for surgical biopsy were recorded and analysed. Results of the surgical biopsy were compared to the type of needle biopsy and its result, radiological findings and family history status. RESULTS: Of the 94 surgical biopsies performed due to the presence of a borderline breast lesion, 20% showed benign pathology, 55% remained as borderline lesions, 17% showed non-invasive malignancy and 7% showed invasive malignancy. VALCS biopsy was the most common needle biopsy method used to identify the lesions in this study (76%). Malignant outcomes resulted from 24% of the surgical biopsies, with the most common malignant lesion being non-comedo ductal carcinoma in situ (DCIS). The most common borderline lesion for which women underwent surgical biopsy was ADH (38%). Of these women, 22% were confirmed as ADH on surgical biopsy and 47% with a malignancy. CONCLUSIONS: Further research is required to determine whether characteristics of the mammographic lesion (particularly calcification patterns), the area targeted for biopsy and number of core samples retrieved, can indicate a closer correlation with eventual pathology. This study identified no findings in the diagnostic assessment that could exclude women with borderline lesions from surgical biopsy.

OBJECTIVES: To examine 12-month outcomes and develop predictive models for outcomes in elderly stroke patients. METHODS: Prospective study of 186 consecutive acute stroke patients aged > or = 65 years admitted to a local hospital between March 2002 and March 2003. Outcome measurements included mortality, functional independence measure (FIM) score and nursing home placement. Two predictive models, using multiple logistic regression analysis, were developed to identify the factors associated with (i) mortality, and (ii) being alive and independent (defined as mean FIM score > or = 90) at 12 months. RESULTS: One hundred and seventy two (92%) patients were followed up at 12 months post-stroke. Mortality rate was 31%, and was significantly higher in nursing home vs non-nursing home origin patients (68% [15/22] vs 25% [38/150]). Nursing home placement for non-nursing home origin survivors was 28% (31/112). Age > or = 85 years was associated with higher mortality (odds ratio = 5.3, 95% confidence interval = 1.8-15, P < 0.01) and lower FIM for patients living at home pre-stroke. Predictive models showed that age, not living at home pre-stroke, pre-stroke FIM < 108, inability to walk on admission, dysphasia, visual field loss and haemorrhagic stroke were associated with worse outcome. CONCLUSIONS: Predictive models--by developing new strategies to improve outcomes through identifying treatable predictive factors--may be clinically useful in elderly stroke patients.

OBJECTIVE: To present information on 1st year interval breast cancer from the New South Wales mammographic screening programme and to compare with published results from trials and services. SETTING: New South Wales data were derived from a population based biennial mammographic screening programme, which achieved statewide coverage in 1995. Women aged 50-69 years screened during 1995-7 were included. METHODS: Bilateral two view mammography with reading by two radiologists is used for biennial screening examinations. Interval cancers were detected by the screening programme and by linkage with the statewide cancer registry. In situ carcinoma was excluded. Incidence of interval cancer was estimated as a proportion of the expected underlying incidence of breast cancer. Comparative data were derived from the published literature and meta-analyses were performed. RESULTS: Although randomised trials of screening have a proportional incidence by meta-analysis of 19% (95% confidence interval (95% CI) 12% to 25%), service studies yield a proportional incidence by meta-analysis of 27% (95% CI 25% to 30%), and more than half report proportional incidences greater than 25%. In the New South Wales mammographic screening programme the proportional incidence of interval breast cancer was 33% (95% CI 29% to 38%) for ages 50-59 years, 28% (95% CI 24% to 32%) for ages 60-69 years, and 31% (95% CI 28% to 34%) for ages 50-69 years combined. Proportional incidence in the New South Wales programme for ages 50-69 years was not significantly different from the rate for service studies by meta-analysis. CONCLUSIONS: Effectiveness of mammographic screening for reducing mortality from breast cancer needs to be examined relative to rates of interval cancer from actual service situations as trials may concentrate resources and expertise in ways which may be less replicable in routine delivery of the service.

INTRODUCTION: Artificial intelligence (AI) algorithms for interpreting mammograms have the potential to improve the effectiveness of population breast cancer screening programmes if they can detect cancers, including interval cancers, without contributing substantially to overdiagnosis. Studies suggesting that AI has comparable or greater accuracy than radiologists commonly employ 'enriched' datasets in which cancer prevalence is higher than in population screening. Routine screening outcome metrics (cancer detection and recall rates) cannot be estimated from these datasets, and accuracy estimates may be subject to spectrum bias which limits generalisabilty to real-world screening. We aim to address these limitations by comparing the accuracy of AI and radiologists in a cohort of consecutive of women attending a real-world population breast cancer screening programme. METHODS AND ANALYSIS: A retrospective, consecutive cohort of digital mammography screens from 109 000 distinct women was assembled from BreastScreen WA (BSWA), Western Australia's biennial population screening programme, from November 2016 to December 2017. The cohort includes 761 screen-detected and 235 interval cancers. Descriptive characteristics and results of radiologist double-reading will be extracted from BSWA outcomes data collection. Mammograms will be reinterpreted by a commercial AI algorithm (DeepHealth). AI accuracy will be compared with that of radiologist single-reading based on the difference in the area under the receiver operating characteristic curve. Cancer detection and recall rates for combined AI-radiologist reading will be estimated by pairing the first radiologist read per screen with the AI algorithm, and compared with estimates for radiologist double-reading. ETHICS AND DISSEMINATION: This study has ethical approval from the Women and Newborn Health Service Ethics Committee (EC00350) and the Curtin University Human Research Ethics Committee (HRE2020-0316). Findings will be published in peer-reviewed journals and presented at national and international conferences. Results will also be disseminated to stakeholders in Australian breast cancer screening programmes and policy makers in population screening.

During the first 7.5 years of breast cancer screening in South Australia, 88 radial scar/complex sclerosing lesions were among the mammographically detected abnormalities. A false-positive cytological diagnosis by fine needle biopsy was given in three of 69 such cases with satisfactory smears, a false-positive rate of 4.3% in this particular group. A review of the smears suggested that the false-positive diagnoses could have been avoided if a total or near total absence of a benign epithelial component had been included among the criteria for a malignant diagnosis. However, even after review, atypia was considered sufficiently worrying to be reported as a suspicion of malignancy in 7% of cases.

OBJECTIVE: To estimate over-diagnosis due to population-based mammography screening using a lead time adjustment approach, with lead time measures based on symptomatic cancers only. SUBJECTS: Women aged 40-84 in 1989-2009 in South Australia eligible for mammography screening. METHODS: Numbers of observed and expected breast cancer cases were compared, after adjustment for lead time. Lead time effects were modelled using age-specific estimates of lead time (derived from interval cancer rates and predicted background incidence, using maximum likelihood methods) and screening sensitivity, projected background breast cancer incidence rates (in the absence of screening), and proportions screened, by age and calendar year. RESULTS: Lead time estimates were 12, 26, 43 and 53 months, for women aged 40-49, 50-59, 60-69 and 70-79 respectively. Background incidence rates were estimated to have increased by 0.9% and 1.2% per year for invasive and all breast cancer. Over-diagnosis among women aged 40-84 was estimated at 7.9% (0.1-12.0%) for invasive cases and 12.0% (5.7-15.4%) when including ductal carcinoma in-situ (DCIS). CONCLUSIONS: We estimated 8% over-diagnosis for invasive breast cancer and 12% inclusive of DCIS cancers due to mammography screening among women aged 40-84. These estimates may overstate the extent of over-diagnosis if the increasing prevalence of breast cancer risk factors has led to higher background incidence than projected.

BACKGROUND: Early detection of breast cancer using screening mammography provides an opportunity for treatment which can lead to significantly improved outcomes. Despite considerable efforts having been made, the rate at which Aboriginal and Torres Strait Islander (hereafter respectfully referred to as Aboriginal) women in Western Australia participate in BreastScreen WA's screening mammogram program remains below that for the overall female population of Western Australia. This study aimed to examine perspectives on breast screening amongst Aboriginal women in Western Australia. We explored the factors which impact on participation in breast screening and sought to identify potential initiatives to address lower participation in screening. METHODS: Semi-structured interviews, focus group discussions and yarning sessions were conducted with a total of 65 research participants. They were all Aboriginal and comprised consumers and health professionals from locations across the state. RESULTS: Our findings show that research participants generally were willing to have a mammogram. Key reasons given were having a genetic predisposition to breast cancer and a perception of investing in health for the sake of the next generation, as well as personal well-being. Barriers identified included lack of education about or understanding of screening, inadequacies in cultural appropriateness in the screening program, cultural beliefs around cancer in general and breast cancer in particular, and competing health and life priorities. However, many enablers were identified which can serve as potential strategies to assuage fear and increase screening uptake. These included increased education delivered by respected Aboriginal women, culturally appropriate promotion and the provision of care and support from other women in the community. CONCLUSION: The higher participation rates for Aboriginal women in Western Australia than are found for Aboriginal women nationally demonstrate the success of the strategies put in place by BreastScreen WA. These efforts must be supported and existing policies and practices enhanced to address the limitations in the existing program. Only by implementing and evaluating such initiatives and making breast screening programs more accessible to Aboriginal women can the current disparity between the screening participation rates of Aboriginal and non-Aboriginal women be reduced.

BACKGROUND: Previous studies have suggested improved efficiency and patient outcomes with 125I seed compared with hookwire localization (HWL) in breast-conserving surgery, but high-level evidence of superior surgical outcomes is lacking. The aim of this multicentre pragmatic RCT was to compare re-excision and positive margin rates after localization using 125I seed or hookwire in women with non-palpable breast cancer. METHODS: Between September 2013 and March 2018, women with non-palpable breast cancer eligible for breast-conserving surgery were assigned randomly to preoperative localization using 125I seeds or hookwires. Randomization was stratified by lesion type (pure ductal carcinoma in situ (DCIS) or other) and study site. Primary endpoints were rates of re-excision and margin positivity. Secondary endpoints were resection volumes and weights. RESULTS: A total of 690 women were randomized at eight sites; 659 women remained after withdrawal (125I seed, 327; HWL, 332). Mean age was 60.3 years in the 125I seed group and 60.7 years in the HWL group, with no difference between the groups in preoperative lesion size (mean 13.2 mm). Lesions were pure DCIS in 25.9 per cent. The most common radiological lesion types were masses (46.9 per cent) and calcifications (28.2 per cent). The localization modality was ultrasonography in 65.5 per cent and mammography in 33.7 per cent. The re-excision rate after 125I seed localization was significantly lower than for HWL (13.9 versus 18.9 per cent respectively; P = 0.019). There were no significant differences in positive margin rates, or in specimen weights and volumes. CONCLUSION: Re-excision rates after breast-conserving surgery were significantly lower after 125I seed localization compared with HWL. Registration number: ACTRN12613000655741 (http://www.ANZCTR.org.au/).

Most earlier reports of mucocele-like lesions (MLL) of the breast have dealt with symptomatic cases in premenopausal women or lesions found incidentally in breast biopsies performed for other reasons. The diagnosis of this lesion has special challenges in the setting of mammographic screening for breast cancer because the imaging characteristics of MLL may mimic those of ductal carcinoma in situ (DCIS), while mucinous carcinoma enters the differential diagnosis on cytologic grounds. This report focuses on our experience with MLLs detected during screening mammography. Cases with MLL as the final histologic diagnosis in our database during January 1992-June 2000 are included. The results of clinical, imaging, cytologic, core biopsy, and histologic examination of these lesions are recorded. The relevant literature is reviewed. Twenty-six cases were found, with a mean patient age of 57.5 years. Microcalcifications were the dominant radiologic abnormality in 22 cases (84.6%). Imaging was considered suspicious or almost certainly malignant in 17 cases (65.4%). Cytology was classified as atypical or suspicious in 17 cases (70.9%). However, open biopsy showed mostly benign changes, including atypical ductal hyperplasia (ADH) in five cases (19.2%). In one case, ADH merged with a 3-4 mm focus of low-grade DCIS. This, the largest series focusing purely on screen-detected MLL, suggests that the combination of clinical, imaging, and cytologic features of screen-detected MLL are different from those of mucinous carcinoma, symptomatic MLL, or incidental MLL. Correlating the cytomorphology of mucinous lesions of the breast with their mammographic appearance may permit more precise preoperative diagnosis.