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There is scope to improve the content and the electronic environment, achieve better integration into decision-making processes, and achieve better compliance. A linkage between imaging pathways and electronic requesting could provide alerts to 'non-compliant' requesting. The assignment of a higher cost, or a lower remuneration, to non-authorized and non-compliant imaging would provide tangible incentive to comply, unless there are compelling clinical contraindications.

SummaryA decision support tool has been developed as part of a suite of on-line evidence-based and consensus-based guidelines Diagnostic imaging Pathways (DIP): www.imagingpathways.health.wa.gov.au) in the form of an algorithmic flow chart with supporting evidence and consensus to inform referrers to diagnostic imaging and radiologists as to the optimum strategy for surveillance and diagnosis of primary hepatocellular cancer (HCC) in those patients with risk factors of this disease. A literature review, including reference to several international consensus-based expert guidelines, has been employed to develop this tool.

Background: B3 breast lesions identified on core needle biopsy have uncertain malignant potential. Traditional management of these lesions has been surgical excision, but there is growing interest in less invasive and more cost-effective alternatives such as vacuumassisted excisional biopsy (VAEB). Determining the rate of malignant upgrade for B3 lesions is important as it may identify low-risk lesions where VAEB could be considered. Methods: A retrospective study was conducted of women undergoing an elective excisional biopsy for a B3 lesion identified on core needle biopsy at a tertiary Australian breast centre. The pre-operative biopsy diagnosis and subsequent excisional biopsy diagnosis were used to calculate the proportion of cases where the diagnosis was upgraded to malignancy. Results: A total of 299 eligible patients were identified. Pre-operative diagnosis of papillary lesion with atypia was associated with the highest upgrade rate (50%, n = 12). The next highest upgrade rates occurred in those with flat epithelial atypia (37.50%, n = 8); atypical ductal hyperplasia (24.71%, n = 85); lobular carcinoma in situ (LCIS)/atypical lobular hyperplasia with calcification (17.65%, n = 17); and papillary lesion without atypia (4.72%, n = 106). Patients with radial scar (n = 51), classical LCIS without calcification (n = 7) and mucocoele-like lesion (n = 8) had a 0% upgrade rate. Conclusion: VAEB may be appropriate for low malignant risk lesions such as papillary lesion without atypia, mucocoele-like lesion and radial scar lesion without atypia. Opensurgical-excisional biopsy remains appropriate for high upgrade lesions such as atypical ductal hyperplasia, papillary lesion with atypia, flat epithelial atypia and classical LCIS with calcification. Long-term prospective randomized multicentre studies and continuing multidisciplinary approach is recommended for future clinical implementation.

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