Attualità in Senologia

Rassegna della letteratura – gennaio/marzo 2021
Epidemiologia, prevenzione, diagnosi e screening

Digital breast tomosynthesis: sensitivity for cancer in younger symptomatic women – Patsy Whelehan , Kulsam Ali , Sarah Vinnicombe et Al. – Br J Radiol. 2021 Mar 1;94(1119):20201105. doi: 10.1259/bjr.20201105. Epub 2021 Jan 7.

Objective: Full-field digital mammography (FFDM) has limited sensitivity for cancer in younger women with denser breasts. Digital breast tomosynthesis (DBT) can reduce the risk of cancer being obscured by overlying tissue. The primary study aim was to compare the sensitivity of FFDM, DBT and FFDM-plus-DBT in women under 60 years old with clinical suspicion of breast cancer.

Methods: This multicentre study recruited 446 patients from UK breast clinics. Participants underwent both standard FFDM and DBT. A blinded retrospective multireader study involving 12 readers and 300 mammograms (152 malignant and 148 benign cases) was conducted.

Results: Sensitivity for cancer was 86.6% with FFDM [95% CI (85.2-88.0%)], 89.1% with DBT [95% CI (88.2-90%)], and 91.7% with FFDM+DBT [95% CI (90.7-92.6%)]. In the densest breasts, the maximum sensitivity increment with FFDM +DBT over FFDM alone was 10.3%, varying by density measurement method. Overall specificity was 81.4% with FFDM [95% CI (80.5-82.3%)], 84.6% with DBT [95% CI (83.9-85.3%)], and 79.6% with FFDM +DBT [95% CI (79.0-80.2%)]. No differences were detected in accuracy of tumour measurement in unifocal cases.

Conclusions: Where available, DBT merits first-line use in the under 60 age group in symptomatic breast clinics, particularly in women known to have very dense breasts.

The role of breast MRI in newly diagnosed breast cancer: An evidence-based review – Jessica L Thompson, G Paul Wright et Al – Am J Surg. 2021 Mar;221(3):525-528. doi: 10.1016/j.amjsurg.2020.12.018. Epub 2020 Dec 9.

The utility of pre-operative MRI in patients with newly diagnosed invasive breast cancer remains a topic of debate. Those who advocate for pre-treatment imaging contend that MRI may detect additional disease not otherwise appreciated on conventional imaging and may provide more accurate staging information to guide treatment. Additionally, it has been proposed that MRI can be utilized to assess extent of residual disease in patients undergoing neoadjuvant chemotherapy. Conversely, those in opposition maintain that routine pre-operative MRI subjects patients to unnecessary ipsilateral mastectomies and prophylactic contralateral mastectomies with no difference in oncologic outcome. When stratified based on tumor biology and patient characteristics, the data suggests that pre-treatment MRI may be advantageous in certain subsets when compared to the general cohort of breast cancer patients. This review recapitulates the current literature on the impact of breast MRI on the surgical management and outcomes of newly diagnosed breast cancer.

Magnetic Resonance Imaging in Screening of Breast Cancer – Yiming Gao, Beatriu Reig , Laura Heacock  et Al. –  Radiol Clin North Am. 2021 Jan;59(1):85-98. doi: 10.1016/j.rcl.2020.09.004. Epub 2020 Oct 29.

Magnetic Resonance (MR) imaging is the most sensitive modality for breast cancer detection but is currently limited to screening women at high risk due to limited specificity and test accessibility. However, specificity of MR imaging improves with successive rounds of screening, and abbreviated approaches have the potential to increase access and decrease cost. There is growing evidence to support supplemental MR imaging in moderate-risk women, and current guidelines continue to evolve. Functional imaging has the potential to maximize survival benefit of screening. Leveraging MR imaging as a possible primary screening tool is therefore also being investigated in average-risk women.

Overdiagnosis and Risks of Breast Cancer Screening – Colleen H Neal , Mark A Helvie et Al. – Radiol Clin North Am. 2021 Jan;59(1):19-27. doi: 10.1016/j.rcl.2020.09.005.

Since its widespread introduction 30 years ago, screening mammography has contributed to substantial reduction in breast cancer-associated mortality, ranging from 15% to 50% in observational trials. It is currently the best examination available for the early diagnosis of breast cancer, when survival and treatment options are most favorable. However, like all medical tests and procedures, screening mammography has associated risks, including overdiagnosis and overtreatment, false-positive examinations, false-positive biopsies, and radiation exposure. Women should be aware of the benefits and risks of screening mammography in order to make the most appropriate care decisions for themselves.

Contrast-Enhanced Mammography Implementation, Performance, and Use for Supplemental Breast Cancer Screening – Matthew F Covington  et AL – Radiol Clin North Am. 2021 Jan;59(1):113-128. doi: 10.1016/j.rcl.2020.08.006. Epub 2020 Oct 29.

Contrast-enhanced mammography (CEM) is an emerging breast imaging technology that provides recombined contrast-enhanced images of the breast in addition to low-energy images analogous to a 2-dimensional full-field digital mammogram. Because most breast imaging centers do not use CEM at this time, a detailed overview of CEM implementation and performance is presented. Thereafter, the potential use of CEM for supplemental screening is discussed in detail, given the importance of this topic for the future of the CEM community. Diagnostic performance, safety, and cost considerations of CEM for dense breast tissue supplemental screening are discussed

Delayed breast cancer diagnosis after repeated recall at biennial screening mammography: an observational follow-up study from the Netherlands – Joost R C Lameijer, Adri C Voogd  et Al – Br J Cancer. 2020 Jul;123(2):325-332. doi: 10.1038/s41416-020-0870-2. Epub 2020 May 11.

Background: Delay in detection of breast cancer may worsen tumour characteristics, with progression of tumour size and a higher risk of metastatic lymph nodes. The purpose of this study was to investigate delayed breast cancer diagnosis after repeated recall for the same mammographic abnormality at screening.

Methods: This was a retrospective study performed in two cohorts of women enrolled in a mammography screening programme in the Netherlands. All women aged 50-75 who underwent biennial screening mammography either between January 1, 1997 and December 31, 2006 (cohort 1) or between January 1, 2007 and December 31, 2016 (cohort 2) were included.

Results: The cohorts showed no difference in proportions of women with delayed breast cancer diagnosis of at least 2 years (2.2% versus 2.8%, P = 0.29). Most delays were caused by incorrect BI-RADS classifications after recall (74.2%). An increase in mean tumour size was seen when comparing sizes at initial false-negative recall and at diagnosis of breast cancer (P < 0.001).

Conclusions: The proportion of women with a long delay in breast cancer confirmation following repeated recall at screening mammography has not decreased during 20 years of screening. These delays lead to larger tumour size at detection and may negatively influence prognosis.