Since the introduction of mammographic breast screening there has been a significant increase in the rate of detection of ductal carcinoma in situ (DCIS) without an invasive component (pure DCIS). This now comprises approximately 20% of all screen-detected breast malignancies in the uK. 1 DCIS may progress to invasive breast cancer. Apparently, pure DCIS frequently coexists with concurrent invasive breast cancer, which in cases of widespread high-grade DCIS is found unexpectedly on final histology following surgery in up to 10-25% of cases and necessitates additional staging of the axilla if axillary surgery is not performed. 2Screening mammography is very sensitive at detecting calcified high-grade DCIS. Approximately 80-90% of DCIS lesions are calcified, 3,4 which enables accurate prediction of disease extent. This is a major determinant of the suitability to treatment by wide local excision (WLE) and therefore breast conservation. It is recognised, however, that the distribution of calcification seen mammographically as well as on specimen radiographs is not always representative of the full extent of disease, leading to an underestimation of extent, both preoperatively and in intraoperative specimen radiographs.5 For example, DCIS is often found at or within a few millimetres of the initial excision margins. Re-excision procedures are often required as DCIS present at the surgical margin leads to a greater incidence of local recurrence. [6][7][8] Annual returns to the NHS Breast Screening Programme (NHSBSP) indicate that our re-excision rates for all pure screen-detected DCIS were 23% between 2008 and 2009. This figure is within normal limits for a large breast screening unit and is given as an example. As an NHSBSP centre, our unit is audited on a yearly basis against national standards. These audits confirmed that the overall rates of reexcision for DCIS historically over the period of this study were also within acceptable levels. However, we suspected from anecdotal evidence that the re-excision rates for pure The extent of calcified ductal carcinoma in situ (DCIS) detected by screening mammography is a determinant for treatment with breast conserving surgery (BCS). However, DCIS may be uncalcified and almost a quarter of patients with DCIS treated initially by BCS either require a second operation or are found to have unexpected invasive disease following surgery. Identification of these cases might guide selective implementation of additional diagnostic procedures. METHODS A retrospective review of patients with a preoperative diagnosis of pure high-grade DCIS at the Southampton and Salisbury Breast Screening Unit over a ten-year period was carried out. Mammograms were reviewed independently by a consultant radiologist and additional factors including the Breast Imaging Reporting and Data System (BI-RADS

INTRODUCTION Ductal carcinoma in situ (DCIS) usually manifests as microcalcification on mammography but may be uncalcified. Consequently, a quarter of patients undergoing excision of a presumed pure DCIS require further surgery to re-excise margins. Patients at highest risk of margin involvement may benefit from additional preoperative assessment. METHODS A retrospective review was carried out of patients treated for screen detected, biopsy proven DCIS in a single centre over a ten-year period (1999-2009). Logistic regression analysis identified factors predictive of need for further surgery to clear margins. RESULTS Overall, 248 patients underwent surgery for DCIS (low/intermediate grade: 82, high grade: 155) and 49 (19.8%) required further surgery. High grade disease was associated with greater mammographic extent (mean: 32mm [range: 5-120mm] vs 25mm [range: 2-100mm]), p=0.009) and higher incidence of mastectomy (38% vs 24%, p=0.034). Factors predictive of involvement of surgical margins necessitating further surgery included negative oestrogen receptor status (OR: 5.2, 95% CI: 2.1-12.8, p<0.001) and mammographic extent (odds ratio [OR]: 1.6, 95% confidence interval [CI]: 1.2-2.1, p=0.004). Once size exceeded 30mm, more than 50% of patients required secondary breast surgery for margins. CONCLUSIONS Reoperation rates for DCIS increase with preoperative size on mammography and negative oestrogen receptor status on core biopsy. Patients with these risk features should be counselled accordingly and consideration should be given to the role of additional preoperative imaging.

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INTRODUCTION: Physiotherapy can aid the removal of secretions following a whole lung collapse, presenting as an opaque hemithorax or “whiteout” on chest radiograph (CXR). Identifying the cause of an opaque hemithorax can prove difficult due to low sensitivity of chest radiography (CXR). Thoracic ultrasound (TUS) is a diagnostic technique able to differentiate between pathologies. The aim of this report is to highlight the impact of TUS on physiotherapy practice. CASE PRESENTATION: A 63-year-old patient underwent elective cardiac surgery. Post-operatively he sustained a cerebral artery infarct with a dense hemiplegia and an ineffective cough. He required nasal pharyngeal suction and use of a cough-assist machine. Increased oxygen requirements prompted a CXR showing an opaque hemithorax. Physiotherapy was requested to aid sputum removal and lung recruitment. Prior to initiating physiotherapy treatment TUS showed a large pleural effusion. Despite this new information a bronchoscopy elicited no significant sputum plug. A second TUS scan showed no change in the effusion. A chest drain was inserted which elicited 3500 mls within an hour. A third TUS showed an absence of any pleural effusion. Following physiotherapy treatment a final TUS scan showed normal aeration. DISCUSSION: An opaque hemithorax can be caused by a significant pleural effusion even when sputum retention is suspected. When patients are referred to physiotherapy TUS can highlight pathologies not amenable to physiotherapy treatment. It seems reasonable to address the pleural effusion first and then implement physiotherapy treatment. TUS will also allow rapid repeated imaging to assess whether treatments have been successful immediately after being administered.

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