01 2012E Early Detection and Diagnosis
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Transcript of 01 2012E Early Detection and Diagnosis
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AGO e. V.in der DGGG e.V.
sowie
in der DKG e.V.
Guidelines Breast
Version 2012.1
Early Detection
and Diagnosis
Diagnosis and Treatment of Patients with
Primary and Metastatic Breast Cancer
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AGO e. V.in der DGGG e.V.
sowie
in der DKG e.V.
Guidelines Breast
Version 2012.1
www.ago-online.de
Early Detection and Diagnosis
Versionen 20052011: Albert / Blohmer / Junkermann /
Maass / Schreer
Version 2012:Schreer / Scharl
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AGO e. V.in der DGGG e.V.
sowie
in der DKG e.V.
Guidelines Breast
Version 2012.1
www.ago-online.de
Early Detection
Mammography
Oxford AGO
Age Interval LOE / GR
< 40 na - - - -
4050 1218 1b B +
5070* 24 1a A ++
>70 24 4 C +
* National Mammography-Screening-Program
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AGO e. V.in der DGGG e.V.
sowie
in der DKG e.V.
Guidelines Breast
Version 2012.1
www.ago-online.de
Age Cases Odds ratio (CI)
screened
4049 0.50 (0.300.82)
5059 0.54 (0.350.85)
6069 0.65 (0.381.13
Effective Biennial Mammographic
Screening in Women 4049 Years
Van Schoor et al. 2010
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AGO e. V.in der DGGG e.V.
sowie
in der DKG e.V.
Guidelines Breast
Version 2012.1
www.ago-online.de
Mortality Reduction for Women
Ages 4049 years
Trials Follow-up
(years)
Mortality
reduction (%)
All 8 RCTs 10.518.0 18
7 RCTs 7.018.0 24
Five Swedish
RCTs11.415.2 29
HIP 18 24
Malmo 15.5 36
Gothenburg 14.0 45
UK Age Trial 714 17/24* (n.s.)
*Adjusted for non compliance
Feig SA 2004
Moss SM 2006
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AGO e. V.in der DGGG e.V.
sowie
in der DKG e.V.
Guidelines Breast
Version 2012.1
www.ago-online.de
Early Detection
Sonography
Screening 5 D - -
As an adjunct:
Dense mammogram (ACR 3 4) 3b B ++
Elevated risk 1b C ++
Mammographic lesion 3b B ++
Oxford / AGO
LOE / GR
* Trial ACRIN 6666: No follow-up data yet
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AGO e. V.in der DGGG e.V.
sowie
in der DKG e.V.
Guidelines Breast
Version 2012.1
www.ago-online.de
Early Detection
Clinical Examination
* May improve breast cancer awareness
Oxford / AGO
LOE / GR
As stand alone procedure
Self-examination 1a A -*
Clinical breast examination (CBE) 3b C -*
by health professionals
CBE because of mammo/sonographic lesion 5 D ++
CBE in combination with imaging BCP ++
* May increase breast awareness
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AGO e. V.in der DGGG e.V.
sowie
in der DKG e.V.
Guidelines Breast
Version 2012.1
www.ago-online.de
Assessment of Breast Symptoms or
Lesions
* If clinical examination, mammography and
sonography do not allow a definite diagnosis
Oxford / AGO
LOE / GR
Clinical examination 3b B ++
Mammography 1b A ++
Sonography 3b B ++
MRT* 3b D +/-
Minimally invasive biopsy 1c A ++
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AGO e. V.in der DGGG e.V.
sowie
in der DKG e.V.
Guidelines Breast
Version 2012.1
www.ago-online.de
Pretherapeutic Assessment
of Lesion Extension
* No reduction in reexcision rate. Lobular invasive tumors, suspicion of
multilocular disease, high-risk patients. MRI-guided vacuum biopsy
mandatory in case of MRI-detected additional lesions.
** If clinical examination, mammography and sonography (e.g. plus MRI)
do not allow assessment of lesion extension
Clinical examination 5 D ++
Mammography 2b B ++
Sonography 2b B ++
MRT (in special cases*) 1c B +/-
Minimally invasive biopsy** 1c A +
Oxford / AGO
LOE / GR
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AGO e. V.in der DGGG e.V.
sowie
in der DKG e.V.
Guidelines Breast
Version 2012.1
www.ago-online.de
Contrast-enhanced MRI:
Preoperative Staging?
False negative rate 412 %
False positive rate up to 40 %
No fewer positive margins
Odds ratio for mastectomy 1.80
Delay in pretreatment evaluation 22.4 days
J Bleicher et al J Am Coll Surg 2009; 209
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AGO e. V.in der DGGG e.V.
sowie
in der DKG e.V.
Guidelines Breast
Version 2012.1
www.ago-online.de
COMICE TRIAL (RCT)
MRI preop. vs. no preop. MRI
L Turnbull et al. Lancet 2010
End Points
Improved tumor localization Reduction of reoperation rate Cost-effectiveness
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AGO e. V.in der DGGG e.V.
sowie
in der DKG e.V.
Guidelines Breast
Version 2012.1
www.ago-online.de
COMICE TRIAL (RCT)
MRT preop. vs. no preop. MRI
L Turnbull et al. Lancet 2010
Results
No significant reduction of reoperation rate More costs with low or no benefit Reduction of unnecessary mastectomies due to
better localization of MRI-only detected lesions
and image guiding
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AGO e. V.in der DGGG e.V.
sowie
in der DKG e.V.
Guidelines Breast
Version 2012.1
www.ago-online.de
CE-MRI Sceening (High-risk)
Benefit
Early detection of cancer cases additionally to conventional imaging
Improved patient prognosis?(Mortality reduction? Reduction of interval cancers?)
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AGO e. V.in der DGGG e.V.
sowie
in der DKG e.V.
Guidelines Breast
Version 2012.1
www.ago-online.de
CE-MRI Screening (High-risk)
Risk
MRI in addition to RRmammography
Assessment of benign 3,434,86lesions
Benign biopsies 1,229,50
Benign surgical biopsies 2
(MARIBS)
False-negative MRI (MRISC) 22%
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AGO e. V.in der DGGG e.V.
sowie
in der DKG e.V.
Guidelines Breast
Version 2012.1
www.ago-online.de
False-negative MR Imaging in
High-risk Women (MRISC)
97 malignant breast tumors 19 /97 (20%) DCIS
21 /97 (22%) false-negative9 /21 ( 20%) DCIS
.. Necessity of screening not only with MRI but also with mammography.
Obdeijn IMA et al. 2010
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AGO e. V.in der DGGG e.V.
sowie
in der DKG e.V.
Guidelines Breast
Version 2012.1
www.ago-online.de
CE-MRI and DCIS
Study No.
Cases
Overall
accuracy (%)
Sens.
(%)
Spec. (%)
Gilles et al 1995 172 70 95 51
Westerhof et al
1998
63 56 45 72
Bazzocchi et al
2006
112 80 79 68
Kuhl et al 2007 75 - 88 -
Negative breast MRI findings should not be considered a sure marker of benignancy.