Volker Duda

Early detection of breast cancer: benefits and risks of supplemental breast ultrasound in asymptomatic women with mammographically dense breast tissue. A systematic review

BackgroundMammographic screening alone will miss a certain fraction of malignancies, as evidenced by retrospective reviews of mammograms following a subsequent screening. Mammographic breast density is a marker for increased breast cancer risk and is associated with a higher risk of interval breast cancer, i.e. cancer detected between screening tests. The purpose of this review is to estimate risks and benefits of supplemental breast ultrasound in women with negative mammographic screening with dense breast tissue.MethodsA systematic search and review of studies involving mammography and breast ultrasound for screening of breast cancer was conducted. The search was performed for the period 1/2000-8/2008 within the data source of PubMed, DARE, and Cochrane databases. Inclusion and exclusion criteria were determined prospectively, and the Oxford evidence classification system for diagnostic studies was used for evidence level. The parameters biopsy rate, positive predictive value (PPV) for biopsy, cancer yield for breast ultrasound alone, and carcinoma detection rate by breast density were extracted or constructed.ResultsThe systematic search identified no randomized controlled trials or systematic reviews, six cohort studies of intermediate level of evidence (3b) were found. Only two of the studies included adequate follow-up of subjects with negative or benign findings. Supplemental breast ultrasound after negative mammographic screening permitted diagnosis of primarily invasive carcinomas in 0.32% of women in breast density type categories 2-4 of the American College of Radiology (ACR); mean tumor size for those identified was 9.9 mm, 90% with negative lymph node status. Most detected cancers occurred in mammographically dense breast ACR types 3 and 4. Biopsy rates were in the range 2.3%-4.7%, with PPV of 8.4-13.7% for those biopsied due to positive ultrasound, or about one third of the PPV of biopsies due to mammography. Limitations: The study populations included wide age ranges, and the application to women age 50-69 years as proposed for mammographic screening could result in less striking benefit. Further validation studies should employ a uniform assessment system such as BI-RADS and report not only PPV, but also negative predictive value, sensitivity and specificity.ConclusionSupplemental breast ultrasound in the population of women with mammographically dense breast tissue (ACR 3 and 4) permits detection of small, otherwise occult, breast cancers. Potential adverse impacts for women in this intermediate risk group are associated with an increased biopsy rate.

Pathologic breast conditions in childhood and adolescence: evaluation by sonographic diagnosis.

The growing awareness of female breast cancer has led to increased sensitivity toward pathologic breast conditions in children and adolescents. Thus, approximately 15% of patients in child and adolescent gynecology are referred for the first time because of conspicuous features of the breast such as pain, palpable masses, and other findings on visual inspection. The aim of this study was to analyze the underlying diagnoses and diseases and determine the status of breast sonography in the diagnostic process.

2008 update of the guideline: early detection of breast cancer in Germany

IntroductionThe goal of the 2008 updated guideline: early detection of breast cancer in Germany is to support physicians as well as healthy and affected women in the decision-making process involved in the diagnostic chain for the early detection of breast cancer by providing them with evidence- and consensus-based recommendations. The updated guideline replaces the guideline issued in 2003.Materials and methodsThe guideline forms the basis for developing an effective and efficient national early breast cancer detection program that meets the standards set by the Council of Europe and WHO for cancer control programs. The guideline presents the current, evidence- and consensus-based state of scientific knowledge in a multidisciplinary approach for the entire diagnostic chain, consisting of history taking and risk consultation, information on health behavior, clinical breast examination, diagnostic imaging, image-guided percutaneous tissue-acquisition techniques, open surgical excisional biopsy and pathomorphological tissue evaluation. The guideline recommends a set of quality indicators to assure resource availability, performance quality and outcomes enhancing total quality management for early breast cancer diagnosis.Conclusion Currently, early detection of breast cancer offers the most promising possibility to optimize the diagnosis and treatment of breast cancer and, as a result, reduce breast cancer mortality and improve health related quality of life in women.

Imprint cytology of core needle biopsy specimens of breast lesions. A rapid approach to detecting malignancies, with comparison of cytologic and histopathologic analyses of 173 cases.

OBJECTIVE To investigate whether imprint cytology of core needle biopsy (CNB) specimens from breast lesions is a useful method of rapidly obtaining additional diagnostic information and potentially can be used to reduce the number of biopsies needed. STUDY DESIGN Cytologic analysis was performed on 173 breast lesions and compared with their histopathologic diagnoses (143 malignant and 30 benign). For imprint cytology, one CNB specimen was rolled between two slides and stained with Diff-Quik and Papanicolaou stain. RESULTS The diagnostic overall accuracy of Diff-Quik stain (Papanicolaou stain) was 95.4% (95.9%), with a sensitivity of 96.5% (97.2%), specificity of 90% (90%), positive predictive value of 97.8% (97.8%) and negative predictive value of 84.3% (87.0%). There was no statistically significant difference between the stains. Histopathologic analysis had an overall accuracy of 97.7%, with a sensitivity of 97.2%, specificity and positive predictive value of 100% and a negative predictive value of 88.2%. CONCLUSION Imprint cytology of CNBs is a sensitive method of detecting malignancies in breast tumors. Diff-Quik is a rapid and reliable approach that can reduce the number of biopsies. Inadequate and suspicious cases should be evaluated based on complementary diagnostic procedures for breast lesions.

Brustkrebs-Früherkennung in Deutschland

ZusammenfassungZiel der aktualisierten Stufe-3-Leitlinie Brustkrebs-Früherkennung in Deutschland ist es, Ärzte sowie gesunde und betroffene Frauen durch evidenzbasierte und formal konsentierte Empfehlungen bei anstehenden medizinischen Entscheidungen im Rahmen der Diagnosekette zur Früherkennung von Brustkrebs zu unterstützen. Die aktualisierte Stufe-3-Leitlinie löst die 2003 erstellte Leitlinie ab.Die aktualisierte Stufe-3-Leitlinie dient als Grundlage für die Entwicklung eines effektiven und effizienten Brustkrebs-Früherkennungsprogramms, das die Anforderungen an Krebskontrollprogramme, wie sie vom Europarat und der WHO vorgegeben sind, erfüllt. Kernelement eines Früherkennungsprogramms ist die Mammographie, deren Ergebnisqualität durch Einbettung in eine qualitätsgesicherte Diagnosekette deutlich verbessert werden kann. Die Leitlinie vermittelt den aktuellen wissenschaftlichen Kenntnisstand in evidenz- und konsensbasierter Form, fachübergreifend für alle Teile der Diagnosekette, bestehend aus Anamnese und Risikoberatung, und Informationen zu Gesundheitsverhalten, klinischer Untersuchung, apparativer Diagnostik, interventioneller Gewebsentnahmetechniken, operativer Abklärung sowie pathohistologischer Befundung. Sie enthält die als Messgrößen dienenden Qualitätsindikatoren für die Sicherung von Struktur-, Prozess- und Ergebnisqualität (Outcome) der Diagnosekette.Die Früherkennung von Brustkrebs ist momentan die aussichtsreichste Möglichkeit, Diagnose und Behandlung von Brustkrebserkrankungen zu optimieren, in Folge die Brustkrebssterblichkeit zu senken und die gesundheits- und krankheitsbezogene Lebensqualität von Frauen zu verbessern. Das Ziel dabei ist, die Entdeckung von Mammakarzinomen als präinvasive Form oder als frühes invasives Stadium, in dem die Fünfjahresüberlebensrate bei adäquater Therapie über 90% liegt. Der zunehmende Nachweis präinvasiver Befunde lässt dabei auf einen präventiven Beitrag zur Senkung der Inzidenz hoffen. Die mit der sekundären Prävention mögliche Verbesserung der Heilungschancen ist im frühen Tumorstadium durch weniger radikale und damit weniger belastende Therapieansätze möglich.AbstractThe guideline Early Detection of Breast Cancer in Germany aims to assist physicians, healthy women, and patients in decision making with recommendations based on evidence and formal consensus regarding the diagnostic chain of health care for early detection of breast cancer. This guideline updates the previous version of 2003.The guideline is a precondition to establishing an effective and efficient national early breast cancer detection program in accordance with the requirements of the European Council and the World Health Organization for cancer control programs. The core imaging technique of an early detection program is mammography, whether used for screening or diagnosis. Breast health care outcomes can be improved by embedding this imaging technology in a quality-assured diagnostic chain. The guideline comprises areas of present scientific and medical knowledge, based on evidence and consensus and covering all multidisciplinary aspects of the diagnostic chain, including clinical history taking, risk consultation and communication, breast health awareness, physical breast examination, breast imaging, interventional guided biopsy, excision biopsy, and breast pathology. The guideline provides formal measures as quality indicators to ensure resource availability, process quality, and outcome of the diagnostic chain.Early detection of breast cancer is presently the most promising chance for optimizing diagnosis and treatment of breast cancer in order to reduce mortality and morbidity while improving survivors’ quality of life. The aim is to detect breast cancer as a noninvasive disease or an invasive disease at an early stage, with a 5-year survival rate of more than 90% with adequate treatment. Detecting more noninvasive breast cancer might even help reduce the incidence. Within the scope of secondary prevention, early detection offers the chance of cure at an early disease stage by less intensive treatment.

Ultrasound Mammography: Possibilities and Limitations in the Detection of Early Breast Cancer

From September 1979 to September 1982 a series of 221 women with pathologically confirmed breast cancer underwent an extended diagnostic procedure at the Medical Center for Gynecology and Obstetrics in Marburg. All 221 cases were examined sonographically with the U.I. Octoson system (Ausonics/immersional scanning system with eight 3-MHz transducers) and radiologically with the Senographe 500 t system (CGR Koch & Sterzel/screen film mammography). The possibilities and limitations in the detection of early breast cancer by ultrasound and its diagnostic differentiation from other lesions, e.g., fibrocystic disease, will be illustrated with reference to 30 cases of breast carcinoma with a pathohistological diameter of 1 cm or less (= 13.6% of all carcinomas examined).

Hormonale Einflüsse auf die mammographische Gewebsdichte

ZusammenfassungSowohl endogene als auch exogen zugeführte Hormone haben Auswirkungen auf die Gewebsdichte der weiblichen Brust und somit auf die Sensitivität und Spezifität der Mammographie. Bei intakter Ovarialfunktion sollte eine Mammographie daher in der Follikelphase durchgeführt werden. Auch eine postmenopausale Hormonersatztherapie beeinflusst die Gewebsdichte, insbesondere bei kontinuierlicher kombinierter Gabe von Östrogenen und Gestagenen. Dagegen erhöhen Tibolon und Antiöstrogene die Gewebsdichte nicht. Da bislang nicht geklärt ist, welchen Einfluss eine Verminderung der mammographischen Gewebsdichte auf das Brustkrebsrisiko hat, ist sie als Biomarker in der Prävention des Mammakarzinoms nicht geeignet. Bei der Krebsfrüherkennung ist die individuelle endokrine Situation der Frau in die Bewertung der Befunde mit einzubeziehen. Unklare Befunde bedürfen der weiteren apparativen oder minimal invasiven Abklärung.AbstractEndogenous as well as exogenous hormones affect the tissue density of the female breast, and thus the sensitivity and specificity of mammographic examinations. If the ovarian function is intact, a mammography should be carried out during the follicular phase of the menstrual cycle. Breast tissue density is also influenced by post-menopausal hormone replacement therapy, particularly when estrogen/gestagen is used. However, tibolone and antiestrogens do not influence tissue density. As there is at present no clear indication of whether changes (i.e. decrease) in tissue density influence the risk of breast cancer, this can not be used as a biomarker in cancer prevention. The use of mammography for early recognition must take into account the individual endocrine situation of the woman. Ambiguous findings require additional clarification by other imaging techniques or minimal invasive biopsy.

Evaluation der DEGUM-Mammasonografiekurse nach objektivierbaren Kriterien

PURPOSE The aim of this study was to evaluate the quality standard of the nationwide breast ultrasound training program of the German Society of Ultrasound in Medicine (DEGUM) through objective parameters. MATERIALS AND METHODS 10 quality criteria, based on the recommendations of The National Association of Statutory Health Insurance Physicians (KBV), were defined for this study. All training units of the DEGUM received a questionnaire. The questionnaires and training material were analyzed. RESULTS All units met the required criteria pertaining to the trainers qualification, duration per training course and the maximum number of participants per ultrasound machine. Only 1 course did not fulfill the required 50 % practical training time. The requirements to participate in the graduate course (200 self-made and documented cases) were not clearly conceived and a defined training log could be improved. CONCLUSION DEGUM breast ultrasound training offers trainees a high level of education based on the requirements of the KBV. Despite the high quality of training, the content of course announcements could be improved and an official and structured educational index could be meaningful.

Stufe-3-Leitlinie Brustkrebs-Früherkennung in Deutschland 2008: Auszug aus der Kurzfassung: Handlungsempfehlungen

ZusammenfassungDie aktualisierte Stufe-3-Leitlinie Brustkrebs-Früherkennung in Deutschland 2008 vermittelt den wissenschaftlichen Kenntnisstand in evidenz- und konsensbasierter Form und ist unter Beteiligung der Deutschen Gesellschaft für Chirurgie e.V, der Deutschen Gesellschaft der Plastischen, Rekonstruktiven und Ästhetischen Chirurgen e.V. und 29 weiterer Fachgesellschaften, Berufsverbänden und nichtärztlichen Organisationen erstellt. Ziel der Stufe-3-Leitlinie ist es, Ärzte sowie gesunde und betroffene Frauen durch evidenzbasierte und formal konsentierte Empfehlungen bei anstehenden medizinischen Entscheidungen im Rahmen der Diagnosekette zur Früherkennung von Brustkrebs zu unterstützen. Die Leitlinie umfasst neben den Empfehlungen zur Diagnosekette die Beschreibung zur Ausgestaltung der Qualitätssicherung von Struktur-, Prozess- und Ergebnisqualität (Outcomes) sowie deren Evaluation durch einen Qualitätsindikatorensatz.Die aktualisierte Stufe-3-Leitlinie 2008 löst die 2003 erstellte Leitlinie ab.Die Leitlinienempfehlungen werden dargestellt. Die Details sind der Publikation in Geburtsh Frauenh 2008; 68: 251–26 zu entnehmen. Die Langfassung der Leitlinie ist als Buch im W. Zuckschwerdt Verlag GmbH/München erschienen und ist, wie der Methodenreport und der Evidenzreport auch, über die Internetseite www.awmf-leitlinien.de (Reg.: Nr. 077/001) frei zugänglich.AbstractThe updated 2008 German Guideline for Early Detection of Breast Cancer provides evidence-based and consensus-based recommendations of the knowledge gained by the German Society for Surgery and the German Society of Plastic, Aesthetic, and Reconstructive Surgeons together with 29 professional societies, associations, and nonmedical organizations. The guideline is meant to assist physicians, healthy women, and patients in medical decisions with recommendations regarding the diagnostic chain in early detection of breast cancer. In addition to these recommendations, the guideline also includes descriptions of quality assurance for resources, procedures, outcomes, and evaluation using a set of quality indicators. It updates the previous version from 2003. The guideline’s recommendations are presented. They are described in detail in the full publication (in German) Geburtsh Frauenh 2008; 68:251–261. The long version of the Guideline, methods report, and evidence report are available on the internet at www.awmf-leitlinien.de (reg. no. 077/001) with free access.The updated 2008 German Guideline for Early Detection of Breast Cancer provides evidence-based and consensus-based recommendations of the knowledge gained by the German Society for Surgery and the German Society of Plastic, Aesthetic, and Reconstructive Surgeons together with 29 professional societies, associations, and nonmedical organizations. The guideline is meant to assist physicians, healthy women, and patients in medical decisions with recommendations regarding the diagnostic chain in early detection of breast cancer. In addition to these recommendations, the guideline also includes descriptions of quality assurance for resources, procedures, outcomes, and evaluation using a set of quality indicators. It updates the previous version from 2003. The guidelines recommendations are presented. They are described in detail in the full publication (in German) Geburtsh Frauenh 2008; 68:251-261. The long version of the Guideline, methods report, and evidence report are available on the internet at www.awmf-leitlinien.de (reg. no. 077/001) with free access.

Evolution and Status of Breast Sonography: Instrumentation and User Requirements

The technical evolution of ultrasound mammography is outlined in Table 6.1. To date there has been little experience with the latest generation of instruments for computed sonography, although I mentioned these systems briefly in my discussion of microcalcifications (Chap. 5.3).