BARC/2013/E/019 BARC/2013/E/019. AUDIT OF MAMMOGRAPHY PERFORMED IN OUR HOSPITAL by Surita Kantharia Medical Division

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1 BARC/2013/E/019 BARC/2013/E/019 AUDIT OF MAMMOGRAPHY PERFORMED IN OUR HOSPITAL by Surita Kantharia Medical Division

2 BARC/2013/E/019 GOVERNMENT OF INDIA ATOMIC ENERGY COMMISSION BARC/2013/E/019 AUDIT OF MAMMOGRAPHY PERFORMED IN OUR HOSPITAL by Surita Kantharia Medical Division BHABHA ATOMIC RESEARCH CENTRE MUMBAI, INDIA 2013

3 BARC/2013/E/019 BIBLIOGRAPHIC DESCRIPTION SHEET FOR TECHNICAL REPORT (as per IS : ) 01 Security classification : Unclassified 02 Distribution : External 03 Report status : New 04 Series : BARC External 05 Report type : Technical Report 06 Report No. : BARC/2013/E/ Part No. or Volume No. : 08 Contract No. : 10 Title and subtitle : Audit of mammography performed in our hospital 11 Collation : 14 p., 3 tabs. 13 Project No. : 20 Personal author(s) : Surita Kantharia 21 Affiliation of author(s) : Dept. of Radio-Diagnosis, BARC Hospital, Medical Division, Bhabha Atomic Research Centre, Mumbai 22 Corporate author(s) : Bhabha Atomic Research Centre, Mumbai Originating unit : Medical Division, BARC, Mumbai 24 Sponsor(s) Name : Department of Atomic Energy Type : Government Contd...

4 BARC/2013/E/ Date of submission : August Publication/Issue date : September Publisher/Distributor : Head, Scientific Information Resource Division, Bhabha Atomic Research Centre, Mumbai 42 Form of distribution : Hard copy 50 Language of text : English 51 Language of summary : English 52 No. of references : 5 refs. 53 Gives data on : 60 Abstract : A medical audit is a compilation of patient outcomes over a certain period of time. Audit of Mammography provides an objective criterion of the appropriateness and accuracy in image interpretation, and is the best measure of a mammographer s performance. The audit assesses 3 important outcomes: i) detection of the percentage of cancers in a population, ii) finding these cancers while they are still curable (small and node negative), iii) finding these cancers through an acceptably low number of recalls and biopsies. With this background, I am presenting an audit of Mammography done at our centre from the period May 2010 to April Keywords/Descriptors : MAMMARY GLANDS; NEOPLASMS; X-RAY DOSIMETRY; BIOPSY; NUCLEAR MEDICINE 71 INIS Subject Category : S62 99 Supplementary elements :

5 Audit of Mammography Performed in our hospital Dr Surita Kantharia Department of Radio-Diagnosis BARC Hospital Address for correspondence: Dr Surita Kantharia Department of Radio-Diagnosis BARC Hospital Abstract A medical audit is a compilation of patient outcomes over a certain period of time. Audit of Mammography provides an objective criterion of the appropriateness and accuracy in image interpretation, and is the best measure of a mammographer s performance (1 3). The audit assesses 3 important outcomes: i) detection of the percentage of cancers in a population, ii) finding these cancers while they are still curable (small and node negative), iii) finding these cancers through an acceptably low number of recalls and biopsies. (4, 5).. With this background, I am presenting an audit of Mammography done at our centre from the period May 2010 to April 2013.

6 Introduction What is Mammography: Mammography is a imaging of breast and axillary tail using a low-dose x-ray system. It includes Sono-mammography other than Conventional Mammography. Indications for Mammography 1) Screening: a) Asymptomatic patients. b) Patients on hormonal replacement therapy. c) Patients with one or more 1st degree relatives diagnosed with breast cancer. 2) Patients with breast lump. 3) Patients with mastalgia 4) Follow up of an abnormality diagnosed on previous mammograms. 5) Patients with nipple discharge. 6) Surveillance of opposite breast following mastectomy for cancer. 7) Surveillance in previous conservative surgery for breast cancer. All these cases were subjected to mammography and subsequently correlated with Sonomammography and Color Doppler. 1

7 Routine views Figure1. MLO mediolateral oblique Figure 2. CC craniocaudal Figure 3: NORMAL MAMMOGRAM- BIRADS 1. 2

8 BI-RADS(Breast Imaging- Reporting and Data System) assessment categories 0 Need additional imaging evaluation. 1 Negative. There is nothing on the mammogram to suggest presence of malignancy. 2 Benign finding. No likelihood of malignancy. 3 Probably benign. <2% malignant. Short interval follow up suggested. 4 Suspicious abnormality biopsy should be considered. 2-95% chances of malignancy. 4a- 2 to 49%, 4b- 50 to 90%, 4c 90 to 95% chances of malignancy. 5 Highly suggestive of malignancy. >95% chances of malignancy. Appropriate action to be taken. 6 known biopsy proven malignancy. Appropriate action to be taken. A medical audit is a compilation of patient outcomes over a certain period of time. Audit of Mammography provides an objective criterion of the appropriateness and accuracy in image interpretation, and is the best measure of a mammographer s performance (1 3). The audit assesses 3 important outcomes: i) detection of the percentage of cancers in a population, ii) finding these cancers while they are still curable (small and node negative), iii) finding these cancers through an acceptably low number of recalls and biopsies. (4, 5).. With this background, I am presenting an audit of Mammography done at our centre from the period May 2010 to April

9 Mammography Audit at BARC Hospital A total number of 564 patients underwent Mammography over a period from May 2010 to April Of these, 223 patients were subjected to Screening Mammography, 203 patients Diagnostic Mammography and 138 patients Surveillance Mammography. Table 1: Distribution of Mammography Types SCREENING MAMMOGRAPHY: The distribution of the 223 patients who underwent screening Mammography based on their BIRADS category is as follows: Table 2: BIRADS distribution of Screening Mammography BIRADS CATEGORY NUMBER OF PATIENTS BIRADS BIRADS 2 71 BIRADS 3 8 BIRADS 4 2 (HP PROVEN) BIRADS 5 0 4

10 Table 3: Bar diagram depicting BIRADS distribution of Screening Mammography Of this group, 1 patient had remained in BIRADS 1 category for two years. However at the end of two years follow-up she presented with a lump and was graded as BIRADS 5, which was histo-pathologically proved, and she was operated successfully for the same. Of eight patients in BIRADS 3, one was benign on HP. In remaining 7 patients no biopsy was done and they have remained stable on yearly follow up. Of two patients of BIRADS 4, 1 patient had history of daughter having undergone surgery for breast carcinoma ten months back. Hence she had presented for screening mammography. The other patient had history of mammography done two years back which was BIRADS 1 then, and was on two year follow up screening mammogram with no palpable lump. Mammography detected two subcentimeter size multicentric lesions in segmental distribution, reported as BIRADS 4, which was proved to be malignancy on USG guided biopsy. 5

11 DIAGNOSTIC MAMMOGRAPHY: DIAGNOSTIC MAMMOGRAPHY N=203 LUMP DISCHARGE MASTALGIA MORE THAN ONE N=171 N=14 N=48 N=203 BIRADS CATEGORY BIRADS PTS BIRADS PTS BIRADS PTS BIRADS PTS Of the 8 patients with BIRADS category 3, presenting with lump, 1 patient had phylloides, 1 grade II infiltrating ductal carcinoma,1 duct Carcinoma, 1 was benign proliferating lesion, 1 had normal FNAC and 3 remained stable on short interval follow-up so no FNAC was done. Thus there were two patients were false negative (sensitivity of BIRADS 3 is that malignancy rate should be less than 2%). Of the 20 patients with BIRADS category 4, presenting with lump 16 patients had infiltrating ductal carcinoma, and rest was a case each of sclerotic fibroadenoma, benign proliferative lesion, granulomatous lesion, and giant fibroadenoma. So the false positive cases were four. 6

12 Of the 34 patients with BIRADS category 5 all were histo-pathological proven cases of carcinoma. The remaining 14 patients were found to have post-operative seroma. Of the 14 patients presenting with discharge, 4 were BIRADS 1 category, 5 were BIRADS 2 category, 2 were BIRADS 4 category ( both had intraductal papillary lesion, of which 1 had atypical duct hyperplasia, other was papillary carcinoma), 3 patients BIRADS 5 category ( 2 had intraductal carcinoma and 1 proliferative duct lesion). There was no patient belonging to BIRADS 3 category. Of the 48 patients presenting with mastalgia, 16 patients were BIRADS 1 category, 25 BIRADS 2 category, 3 patients BIRADS 3 category (2 benign proliferative disease, 1 intraductal carcinoma - grade 2), 3 patients BIRADS 4 category (1 was granulomatous mastitis, 1 papillary ductal carcinoma in-situ, 1 fibroadenoma) 1 patient BIRADS 5 category (Ductal carcinoma with lymph node metastasis). Therefore the false positive cases were two. A total of 205 patients presented with one or more than one presentation in the diagnostic group. Of these 40 patients were BIRADS 1, 97 patients BIRADS 2, 11 patients BIRADS 3, 22 patients BIRADS 4 and 33 patients of BIRADS 5 (1 case was of bilateral BIRADS 5). Total 55 cases have been reported to have malignancy (BIRADS 4 and BIRADS 5). Of 109 cases BIRADS 2 and 3, 76 patients were subjected to FNAC and proven to be benign on histopathology. 3 patients were proven on FNC to have malignancy of which 2 were Inflammatory carcinoma (by literature the mamaography images of infective inflammation and malignant inflammation are similar) and 1 patient was found to have malignant phylloides. SURVEILLANCE MAMMOGRAPHY: A total of 138 patients underwent surveillance mammography. Of these, in 1 patient there was a suspicion of scar recurrence, in whom a Breast MRI was done which did not reveal an increased uptake, thereby ruling out recurrence. 7

13 SUMMARY OF RESULTS TOTAL MAMMOGRAPHY 564 PATIENTS (MAY 2010-APRIL 2013) SCREENING MAMMOGRAPGHY 223 PATIENTS DIAGNOSTIC MAMMOGRAPGHY 2O3 PATIENTS SURVEILLANCE MAMMOGRAPGHY 138 PATIENTS BIRADS 4: 2 BIRADS 5: 0 BIRADS 4: 25 BIRADS 5: 38 MALIGNANCY 2 PATIENTS Biblio TOTAL NOS OF MALIGNANCY: 57 FALSE POSITIVE: 6 FALSE NEGATIVE: 2 8

14 Bibliography: 1. Sickles EA. Quality assurance: how to audit your own mammography practice. Radiol Clin North Am 1992; 30: Robertson CL. A private breast imaging practice: medical audit of 25,788 screening and 1,077 diagnostic examinations. Radiology 1993; 187: Spring DB, Kimbrell-Wilmot K. Evaluating the success of mammography at the local level: how to conduct an audit of your practice. Radiol Clin North Am 1987; 25: Tabar L, Fagerberg G, Duffy SW, Day NE, Gad A, Gröntoft O. Update of the Swedish two-county program of mammographic screening for breast cancer. Radiol Clin North Am 1992; 30: Linver MN. The medical audit: statistical basis of clinical outcomes analysis. In: Diagnosis of diseases of the breast. 2nd ed. Pennsylvania: Elsevier Saunders, 2005;