Aktuelles zur Mammadiagnostik – Stärken und Schwächen der bildgebenden Methoden

Entgegen regelmäßiger Kritik – auf der Basis der sehr komplexen Datenbasis – spricht die verfügbare Evidenz für die Reduktion der Brustkrebsmortalität durch ein Mammografie-Screening. Die Limitierungen sind bekannt, sodass technische Möglichkeiten zu deren Überwindung höchst willkommen sind: Die Tomosynthese erreichte in 2 randomisiert kontrollierten Studien und weiteren Beobachtungsstudien eine signifikant verbesserte Sensitivität und Spezifität, damit eine Erhöhung der diagnostischen Zuverlässigkeit, sodass sie vermutlich in naher Zukunft die klassische digitale Mammografie für das Mammografie-Screening ersetzen wird.

Die Ultraschallelastografie ist eine neue bildgebende Methode zur Charakterisierung fokaler Brustläsionen in Ergänzung zum B-Bildmodus. Ihre Zusatzinformation scheint in der weiteren Differenzierung von im B-Bild als BIRADS III bzw. BIRADS IVa charakterisierten Läsionen zu liegen mit der Chance, die Biopsierate zu reduzieren. Ob damit eine gleichwertige Methode vorliegt mit dem gewünschten Effekt von Arzt-Zeit-Reduktion, ist noch offen. Die KM-MRT hat ihren festen Stellenwert bei definierten Indikationen im Rahmen der Diagnostik sowie des Hochrisiko-Screenings, jedoch nicht als regelmäßige präoperative Staging-Methode vor brusterhaltender Behandlung.

Contrary to persistent criticism (mostly based on the complex data analysis) all available evidence confirms that mammography screening is capable of significantly reducing breast cancer mortality. The limitations of mammography are well-known, so that new technologies to overcome these constraints are highly welcome. Within two randomized controlled trials and further cohort studies tomosynthesis (DBT) proved to increase significantly both sensitivity and specificity, thus improving diagnostic accuracy. In the near future DBT can be expected to replace standard 2D mammography for mammography screening.

Ultrasonographic elastography is an evolving new imaging technology to further characterize focal breast lesions additionally to B-mode sonography in the differentiation of BIRADS 3- and BIRADS 4a masses and may help to decrease the false-positive biopsy rate. Automated whole-breast ultrasound examination (ABUS) promises to reduced physician examination time and operator dependence, further research is necessary to demonstrate equal accuracy as with standard hand-held ultrasound examination.

Contrast-enhanced MRI plays an important role in acknowledged indications in diagnostic breast imaging as well as in high-risk “screening”. It should not be used generally for preoperative staging purposes in case of breast conserving treatment.

Key words

Breast imaging - mammography screening - tomosynthesis - breast ultrasound elastography - contrast-enhanced MRI

• Literatur

• 1 Wall C, Baines CJ, Sun P et al. Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomized screening trial. BMJ 2014; 348: 1-10
• 2 Marmot MG, Altman DG, Cameron DA et al. The Independent UK Panel on Breast Cancer Screening. The benefits and harms of breast cancer screening: an independent review. Brit J Cancer 2013; 108: 2205-2240
• 3 Paap E, Verbeek ALM, Botterweck AAM et al. Breast cancer screening halves the risk of breast cancer death: A case referent study. The Breast 2014; 23: 439-444
• 4 Helvie MA, Chang JT, Hendrick RE, Banerjee M. Reduction in late-stage breast cancer incidence in the mammography era. Cancer 2014; 120: 2649-2656
• 5 Coldman A, Phillips N, Wilson C et al. Pan-Canadian study of mammography screening and mortality from breast cancer. J Natl Cancer Inst 2014; 106
• 6 Lam DL, Pandharipande PV, Lee JM et al. Imaging-based screening: Understanding the controversies. Am J Roentgenol 2014; 203: 952-956
• 7 Beckmann KR, Lynch JW, Hiller JE et al. A novel case-control design to estimate the extent of overdiagnosis of breast cancer due to organized population-based mammography screening. Int J Cancer 2015; 136: 1411-1421
• 8 Skaane P, Bandos AI, Gullien R et al. Comparison of digital mammography alone and digital mammography plus tomosynthesis in a population-based screening program. Radiology 2013; 267: 47-56
• 9 Caumo F, Bernardi D, Ciatto S et al. Incremental effect from integrating 3D-mammography (tomosynthesis) with 2D-mammography: Increased breast cancer detection evident for screening centres in a population-based trial. The Breast 2014; 23: 76-80
• 10 Skaane P, Bandos AI, Eben EB et al. Two-view breast tomosynthesis screening with synthetically reconstructed projection images; Comparison with digital breast tomosynthesis with full-field digital mammographic images. Radiology 2014; 271: 655-663
• 11 Lobbes MB, Lalji U, Houwers J et al. Contrast-enhanced spectral mammography in patients referred from the breast cancer screening programme. Eur Radiol 2014; 24: 1668-1676
• 12 Berg WA, Blume JD, Cormack JB et al. Combined screening with ultrasound and mammography vs mammography alone in women at elevated risk of breast cancer. JAMA 2008; 299: 2151-2163
• 13 Skaane P, Gullien R, Eben EB et al. Interpretation of automated breast ultrasound (ABUS) with and without knowledge of mammography: a reader performance study. Acta Radiol pii: 0284185114528835 ( Epub ahead of print) 2014;
• 14 Houssami N, Turner R, Macaskill P et al. An individual person data meta-analysis of preoperative magnetic resonance imaging and breast cancer recurrence. J Clin Oncol 2014; 32: 392-401
• 15 Marinovich ML, Houssami N, Macaskill P et al. Meta-analysis of magnetic resonance imaging in detecting residual breast cancer after neoadjuvant therapy. J Nat Cancer Inst 2013; 105: 312-333