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DOI: 10.1055/s-2002-25167
Präoperative Magnet-Resonanz-Mammographie (MRM) beim Mammakarzinom: Überflüssiger Luxus oder relevante Einflussgröße auf die OP-Strategie?
Preoperative magnetic resonance mammography in breast cancer:Useless luxury or relevant factor influencing surgical strategy?
Publication History
Publication Date:
18 April 2002 (online)
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Zusammenfassung
In einer prospektiven Studie wurden der Stellenwert der Magnetresonanz-Mammographie (MRM) in der Detektion multifokaler, multizentrischer und kontralateraler Mammakarzinome und der daraus resultierende Einfluss auf das operative Vorgehen (brusterhaltende Therapie [BET] versus Mastektomie [Mx]), geprüft. Im Zeitraum von 3/94 - 10/98 wurde bei 140 Patientinnen (Pat.; Alter: 57,4 ± 12,6 J.; Median: 58 J.), bei denen aufgrund der konventionellen Diagnostik (klinische, sono- u. mammographische Untersuchung) der Verdacht auf ein Mammakarzinom bestand, eine bilaterale MRM durchgeführt. Nach R0-Resektion (tumorfreier Resektionsrand > 5 mm) aller detektierten Läsionen (72 × BET, 40 × Mx) erfolgte die Ermittlung der Sensitivität, Spezifität und Effizienz der diagnostischen Methoden sowie die Evaluation der durch die MRM-Befunde geänderten OP-Strategie. Bei 33 Pat. konnten die in der konventionellen Diagnostik als suspekt angesehenen Läsionen entsprechend der Vorhersage der MRM als benigne Befunde bestätigt werden: 21 × Fibroadenome, 6 × zystische Mastopathien, 5 × Parenchymvernarbungen und 1 × Papillom. Demgegenüber lagen bei 107 Pat. insgesamt 112 Malignomläsionen vor (4 × DCIS, 108 × Mammakarzinome; UICC-Stadien unilateral: 0 = 2, I = 46, IIa = 37, IIb = 11, IIIa = 6; synchron bilateral: I = 2, IIa = 3). Die Prävalenz betrug 76 %. Die Sensitivität der klinischen Untersuchung, der Sonographie, der Mammographie und der MRM lag bei 69 %, 58 %, 89 % und 97 %, die Spezifität bei 67 %, 85 %, 30 %, 30 % und die Effizienz betrug 69 %, 64 %, 75 % und 81 %. Bei 73 Pat. (52 % des Gesamtkollektivs) wurden per MRM zusätzlich zu den aus der konventionellen Diagnostik bekannten Indexläsionenen weitere Herdsetzungen detektiert: 16 dieser Läsionen wurden von der MRM a priori im Vergleich zur Histologie korrekt als benigne eingestuft. Von 57 (41 %) MR-mammographisch als suspekt eingeschätzten Läsionen waren 35 maligne und 22 benigne. Bei 30 Pat. wurden die malignen Herdbefunde ipsilateral entdeckt; und bei 16 × multifokalen Läsionen erfolgten 12 Quadrantenresektionen und 4 Mx. In 14 Fällen ließen sich durch die MRM multizentrische Läsionen nachweisen, die allesamt mastektomiert wurden. 5 weitere, allein durch die MRM detektierte kontralaterale Läsionen wurden 4 × per BET und 1 × per Mx operiert. Aufgrund der MRM-Befunde wurde das initial geplante chirurgische Vorgehen ipsilateral 12 × von der alleinigen Tumorektomie zur Quadrantenresektion und 19 × von der initial geplanten BET zur Mx geändert. Somit stieg die Anzahl ablativer OP-Verfahren von ursprünglich geplanten 21/107 Mx (20 %) auf 40/107 Mx (37 %) an. Die Rate falsch positiver MRM-Befunde lag bei 21 % (22 Pat.), wobei aus onkologischer Sicht unnötigerweise 10 × ipsi- und 12 × kontralateral operiert wurde. Aufgrund des alleinigen präoperativen MRM-Nachweises multifokaler/-zentrischer u. kontralateraler Karzinomherde wurde in 33 % (35/107 Pat.) das onkologisch-chirurgische Vorgehen geändert. Unserer Ansicht nach kann durch ein MRM-Tumorstaging die R0-Resektionsrate erhöht und voraussichtlich auch die Prognose - unabhängig von der Systemtherapie - durch Vermeidung eines frühen Lokalrezidivs beeinflusst werden. In interdisziplinären Studien sollten die Vorteile der MRM hinsichtlich einer Verbesserung der adjuvanten Mammakarzinom-Therapie geprüft werden.
Abstract
In a prospective study the validity of magnetic resonance mammography (MRM) in the diagnosis of multifocal, multicentric and contralateral breast carcinomas was studied. Furthermore the impact of MRM on the choice of the surgical procedure was evaluated. From March 1994 to October 1998, an additional bilateral MRM was performed in 140 patients (age: 57.4 ± 12.6 y; median: 58 y) who were suspected of having breast cancer due to the findings of clinical examination, ultrasound and x-ray mammography. All findings and the initial surgical strategy, based on the results of ultrasound and x-ray mammography, were commonly re-evaluated by surgeons and radiologists. All suspicious lesions were resected completely and examined histopathologically. In 72 cases breast-conserving (BET) and in 40 cases ablative (Mx) surgical procedures were performed (R0-resection, tumour free margins: > 5 mm). In 33 patients the suspicious lesions were histologically benign as predicted by MRM: 21 × fibroadenomas, 6 × cystic mastopathy, 5 × scars, and 1 × papilloma. In 102 of 107 patients with breast cancer (prevalence: 76 %) unilateral malignant lesions were detected. The cancer stages were 2 × UICC-0, 46 × UICC-I, 37 × UICC-IIa, 11 × UICC-IIb, and 6 × UICC-IIIa. Furthermore, 5 patients had synchronous bilateral breast carcinomas with 2 × UICC-I and 3 × UICC-IIa stages. The sensitivity of clinical investigation, ultrasound, mammography, and MRM was 69 %, 58 %, 89 %, and 97 %, the specificity 67 %, 85 %, 30 %, and 30 %, the accuracy of the methods 69 %, 64 %, 75 %, and 81 %, respectively. The surgical therapy had to be extended in 57 patients (41 %) due to MRM-findings of additional suspicious lesions. In 30 patients additional foci of breast cancer were detected ipsilaterally (16 × multifocal lesions resulting in quadrantectomy in 12 cases, and mastectomy in 4 cases; 14 × multicentric lesions with consecutive mastectomy in all cases). 5 further malignant lesions were detected in the contralateral breast by MRM alone and treated by breast-conserving procedures in 4 cases and by Mx in 1 case. Due to the MRM findings, the surgical procedure was changed in 12 cases from tumourectomy to quadrantectomy, and in 19 cases from breast-conserving strategy to Mx. In the 107 breast cancer patients the rate of Mx increased from the initially planned 21 cases (20%) to 40 cases (37 %). MRM demonstrated false positive findings in 21 % (22 patients: 10 × ipsi- and 12 × contralateral). Further malignant lesions detected only by MRM were found in 33 % of our 107 breast cancer patients. Therefore MRM plays a very important role in the preoperative planning for breast cancer patients, especially when breast-conserving strategies are considered. At the time of tumour staging, the detection of multifocal, multicentric or synchronous bilateral breast carcinomas by MRM can increase the rate of R0-resections and might influence the longterm prognosis of patients by decreasing the number of early local recurrences, independent of systemic therapy. Further current interdisciplinary studies should demonstrate the advantages of MRM in breast cancer therapy.
Schlüsselwörter
Präoperative Magnet-Resonanz-Mammographie - Mammakarzinom - Multifokalität/-zentrizität
Key words
Preoperative magnetic resonance-Mammography - Breast cancer - Multifocal/multicentric lesions
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Dr. med. Torsten Liersch
Klinik und Poliklinik für Allgemeinchirurgie
Klinikum der Georg-August-Universität Göttingen
Robert-Koch-Str. 40
37075 Göttingen