Zusammenfassung
Die Aussagekraft der Mammographie (MG) als Screeninguntersuchung zum Ausschluss eines Mammakarzinoms ist unter einer Hormonsubstitutionstherapie (HST) vermindert. In den zu dieser Fragestellung vorliegenden Untersuchungen werden signifikante Reduktionen der Sensitivität und Spezifität zwischen 7 und 21 %, bzw. 0,6 und 12 % angegeben. Mehrere Ursachen werden für diesen Effekt verantwortlich gemacht. Einerseits ist anzuführen, dass unter HST die Dichte des Brustdrüsenkörpers zunimmt. Dies führt zu einer erhöhten Röntgendichte der Brust, wodurch die Unterscheidung zwischen Parenchym und Tumoren erschwert wird. Dieser Effekt ist von der Art der durchgeführten HST abhängig, wobei eine kontinuierlich kombinierte HST mit dem stärksten Dichtezuwachs vergesellschaftet ist. Weiterhin könnte die unter HST auftretende höhere Schmerzhaftigkeit des Drüsengewebes zu einer Verminderung der diagnostischen Treffsicherheit beitragen, da die Brustdrüse zur MG komprimiert werden muss, um eine optimale Bildqualität zu erhalten.
Schließlich scheint es auch Unterschiede in den histologischen Charakteristika der Tumoren zu geben, die sich unter HST entwickeln. Im Vergleich zu Mammakarzinomen, die unabhängig von einer HST auftreten, findet sich unter HST ein höherer Anteil lobulärer Karzinome. Lobuläre Karzinome sind in der MG schwieriger zu diagnostizieren als duktale Karzinome.
Ein kurzfristiges Aussetzen der HST führt zu einer signifikanten Aufhellung des Mammographiebildes. Es ist jedoch unklar, ob und in welchem Ausmaß dadurch der HST-bedingte Sensitivitäts- und Spezifitätsverlust der MG ausgeglichen werden kann. Die Einnahme von Tibolon ist mit einer signifikanten Abnahme der Brustdichte assoziiert. Daten zur Sensitivität und Spezifität der MG unter Tibolon liegen derzeit nicht vor.
Angesichts der vorliegenden Daten erscheint vor allem bei Patientinnen mit primär röntgendichter Brust der Verzicht auf eine kontinuierlich kombinierte HST, das Aussetzen der HST 2 - 4 Wochen vor der MG und die Verwendung von Tibolon als Alternativtherapie empfehlenswert. Es sollte jedoch darauf hingewiesen werden, dass kein direkter Nachweis einer qualitativen Verbesserung der Sensitivität und Spezifität der MG durch derartige Maßnahmen vorliegt.
Abstract
Hormone replacement therapy (HRT) is associated with reduced sensitivity and specificity of mammography, probably due to increased breast density. The increase in breast density depends on the particular HRT regimen, with continuous combined HRT associated with the largest increase. In addition, women on HRT have a higher incidence of mastalgia compared with women not using HRT. This may also contribute to the reduced sensitivity and specificity of mammography, because adequate compression of the breast may be less likely in these women. There is also evidence that women with HRT develop a higher proportion of lobular carcinomas, which are less likely to be detected by mammography than ductal carcinomas. Short-term cessation of HRT before mammography can reduce breast density, but whether cessation can compensate for the HRT-mediated loss of sensitivity and specificity is unclear. Tibolone, as an alternative to estrogen-containing HRT, is associated with reduced breast density but there are as yet no data on the sensitivity and specificity of mammography in women taking tibolone. In summary, these data support the omission of continuous combined HRT, the cessation of HRT 2 - 4 weeks before mammography, and the use of tibolone, especially in women with dense breasts. However, the effect of these interventions on the sensitivity and specificity of mammography are unproven.
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