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INTRODUCTION: Increasingly we are dealing with more and more impalpable breast lesions thanks to screening programmes, chemotherapy and in situ disease. There are various techniques already employed for assisting in surgery for impalpable lesions such as radioactive and magnetic markers. All of these have limitations and are only useful in surgery. Ultrasound can be used in clinic and theatre to locate tumours and sonographically visible markers. In our experience in the Cambridge breast unit we have found it is more satisfactory to use guidewires that are intraoperatively or preoperatively placed using ultrasound guidance. This allows for direct approach to the lesion at the same time limiting the dissection and volume of resection. The guidewire allows tactile feedback and helps with precision and accuracy of the excision as reflected in the specimen weights. In this study we look at the outcomes of intraoperatively and preoperatively placed guidewires using ultrasound for impalpable breast lesions between 2015 -2018 in the Cambridge Breast Unit. The primary outcomes are re-excision rate and average specimen weights. METHODS: Patients undergoing breast conservation surgery for impalpable lesions from 01/01/2015 to 30/07/2018 were included. Data was collected retrospectively from our electronic records system EPIC and analysed. RESULTS The results were divided into intraoperative localisations and preoperative localisations. A total of 441 lesions in 415 patients were included in this study. Preoperative localisationIntraoperative localisationNumber of patients193222Number of lesions210231*Re-excision rate per patient %19.2%14.0%Specimen weight per patient (grams)39.4g24.2g*Fishers exact 0.24 (NS) CONCLUSION: Impalpable lesions can be successfully localised using ultrasound guidance and a guidewire both intraoperatively and preoperatively with good outcomes. Intraoperative localisation has lower re-excision rates and specimen weights in our study as well as many other benefits for the patient and surgeon. We have looked into how easily and quickly we can train ultrasound naïve trainees in this technique and have achieved good results. Citation Format: Primeera Wignarajah, Vasiliki Papalouka, Parto Forouhi. The use of intraoperative ultrasound and guidewire placement to obtain low re-excision rates and increased accuracy of excision in impalpable breast lesions at the Cambridge Breast Unit [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P1-20-21.

This Editorial Comment discusses the following AJR article: Human Epidermal Growth Factor Receptor Type 2-Positive Breast Cancer: Association of MRI and Clinicopathologic Features With Tumor-Infilt...

Background: Nonpalpable breast lesions require localization, the gold standard for which is preoperative ultrasound-guided wire localization (PUGWL). Our unit also employs intraoperative ultrasound-guided wire localization (IUGWL). Here we evaluate PUGWL and IUGWL outcomes between 2014 and 2018. Primary outcomes were reoperation rates, complication rates and average specimen weights. Trainee feedback and cost analysis assessed IUGWL viability. Methods: Prospectively recorded data were collected. 511 patients were included (241 PUGWL and 270 IUGWL). Results: Reoperation rates: PUGWL 17.7% versus IUGWL 13.9% (p = 0.28) . Complication rates: PUGWL 5.8% versus IUGWL 6.6% (p = 0.72) . Average specimen weight: PUGWL 34.2 g versus IUGWL 24.3 g (p < 0.0001) . Trainees needed 15 supervised cases to be IUGWL competent. Performing IUGWL saves £289 per localization. Conclusion: IUGWL outcomes are comparable to those of PUGWL. IUGWL is cost-effective, patient-friendly and easy to learn and replicate. IUGWL merits wider dissemination and further planned research.

Hyperpolarized 13C-MRI is an emerging tool for probing tissue metabolism by measuring 13C-label exchange between intravenously injected hyperpolarized [1–13C]pyruvate and endogenous tissue lactate. Here, we demonstrate that hyperpolarized 13C-MRI can be used to detect early response to neoadjuvant therapy in breast cancer. Seven patients underwent multiparametric 1H-MRI and hyperpolarized 13C-MRI before and 7–11 days after commencing treatment. An increase in the lactate-to-pyruvate ratio of approximately 20% identified three patients who, following 5–6 cycles of treatment, showed pathological complete response. This ratio correlated with gene expression of the pyruvate transporter MCT1 and lactate dehydrogenase A (LDHA), the enzyme catalyzing label exchange between pyruvate and lactate. Analysis of approximately 2,000 breast tumors showed that overexpression of LDHA and the hypoxia marker CAIX was associated with reduced relapse-free and overall survival. Hyperpolarized 13C-MRI represents a promising method for monitoring very early treatment response in breast cancer and has demonstrated prognostic potential. Significance: Hyperpolarized carbon-13 MRI allows response assessment in patients with breast cancer after 7–11 days of neoadjuvant chemotherapy and outperformed state-of-the-art and research quantitative proton MRI techniques.

Introduction Women with mammographically dense breasts have an increased risk of breast cancer. Dense breasts can limit detection of small breast lesions due to overlapping fibroglandular tissue. BRAID is a randomised, multi-centre UK study assessing the impact of supplementary imaging, including abbreviated breast MRI (ABB-MRI), in detection of breast cancer in women aged 50-70 years with dense breasts. ABB-MRI is a shorter protocol breast MRI, allowing much faster acquisition times. The aim of this study is to review the feasibility of introducing ABB-MRI into the NHS setting as a part of a research trial. Protocol ABB-MRI is performed on a 1.5 tesla MRI scanner. Sequences obtained include a 2 mm axial T2 weighted sequence, a dual echo (Dixon water/fat separation) 3D DCE acquisition consisting of one pre- and two post-contrast images with generation of post-contrast subtracted images and post-processed MIP images. Scheduling ABB-MRIs are performed on a dedicated breast MRI list. Participants arrive 30 minutes prior to appointment time with pre-filled safety questionnaire. ABB-MRIs are scheduled for a 20-minute appointment slot, allowing 10 women to be scanned in a 3-hour session. Specific roles are allocated to staff members. Improving Efficiency of ABB-MRI in the UK Challenges encountered are similar to those encountered with FDP: IV cannulation, BMI and claustrophobia. Dedicated MR sessions with standard contrast doses and prefilled safety questionnaires help improve efficiency of sessions and allow examination times under 15 minutes.

Breast magnetic resonance imaging (MRI) is the technique of choice in detection, local staging, and monitoring of breast cancer; however, breast MRI results in the detection of more indeterminate/suspicious lesions that need to be histopathologically proven to guide patient management than any other breast imaging method. If such abnormalities are not detectable in any of the conventional imaging tools (mammography (MMG) or ultrasound) then an MRI-guided biopsy needs to be performed to obtain a diagnosis. Breast MRI-guided biopsy is a time-consuming and complex procedure that requires specific equipment and experienced, well-trained staff. This review article explores and illustrates the indications, the currently available technologies, and the technique of breast MRI-guided biopsy, and explains the importance of careful imaging review and selection of cases. We correlate the radiological-pathological findings and highlight the impact on patient management in a multidisciplinary setting.

Aims To investigate whether genetic variants of the histidine-rich calcium (HRC)-binding protein are associated with idiopathic dilated cardiomyopathy (DCM) and its progression. Methods and results We screened 123 idiopathic DCM patients and 96 healthy individuals by single-strand conformation polymorphism analysis and direct sequencing for genetic variants in HRC. Six polymorphisms were detected: Leu35Leu (A/G), Ser43Asn (G/A), Ser96Ala (T/G), Glu202_Glu203insGlu (−/GAG), Asp261del (GAT/−), and an in-frame insertion of 51 amino acids at His321. The analysis of their frequencies did not reveal any significant correlation with DCM development. However, the Ser96Ala polymorphism exhibited a statistically significant correlation with the occurrence of life-threatening ventricular arrhythmias. During a follow-up of 4.02 ± 2.4 years, the risk for ventricular arrhythmias was higher (HR, 9.620; 95% CI, 2.183–42.394; P = 0.003) in the Ala/Ala patients, compared with Ser/Ser homozygous patients. On multivariable Cox regression analysis, the Ser96Ala polymorphism was the only significant genetic arrythmogenesis predictor in DCM patients (HR, 4.191; 95% CI, 0.838–20.967; P = 0.018). Conclusion The Ser96Ala genetic variant of HRC is associated with life-threatening ventricular arrhythmias in idiopathic DCM and may serve as an independent predictor of susceptibility to arrhythmogenesis in the setting of DCM.

This study assessed the long-term effect of vagotomy on the structure and passive mechanical characteristics of the thoracic aorta under a wide range of stresses in vitro. Eight healthy Landrace pigs underwent bilateral vagotomy distal to the origin of the recurrent laryngeal nerve, and 10 pigs were sham-operated. Three months post-surgery, the aorta was excised and specimens from the ascending aorta, arch, and descending thoracic aorta were subjected to histomorphometrical evaluation and uniaxial tensile-testing until failure. Elastic modulus-stress data were plotted and submitted to regression analysis. Structural remodeling after vagotomy was characterized as vascular growth in the ascending aorta and arch, and as thinning in the descending thoracic aorta. In the aortic segments of vagotomized animals, the area density of elastin and collagen was increased, but smooth muscle density was decreased. Similar differences in regression parameters and failure strength between groups were found in all aortic segments, indicating that the vessel wall was stiffer and stronger in vagotomized animals. In the clinical setting, disease states or drugs blocking the regulatory role of the vagi nerves on the aortic wall may have undesirable consequences on the mechanical performance of the thoracic aorta, and therefore on hemodynamic homeostasis.