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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
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
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
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
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
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
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
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 ++
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
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
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
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
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?)
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%
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
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.
