CHICAGO (EGMN) – Women younger than 40 years with focal breast signs or symptoms should be evaluated by targeted ultrasound, and probably not mammography or biopsy, according to findings from two studies of more than 1,800 patients treated at one medical center.

“This is particularly timely with the recent [U.S. Preventive Services Task Force] recommendations that women not perform self breast exam,” said Dr. Constance Lehman of the University of Washington in Seattle.

“One of the USPSTF’s concerns was that women will go through unnecessary harms and procedures. We think imaging can better guide us in reducing harms that can be associated with a self breast exam.”

The studies’ findings could have broad implications for practice patterns and cost. Reducing biopsies and surgical excision of lumps would lessen trauma and cost, while limiting mammography would reduce cost and unnecessary radiation.

Dr. Lehman described the two studies in a press briefing at the annual meeting of the Radiological Society of North America. Both were retrospective reviews of data from the University of Washington.

In the first analysis, investigators reviewed all breast exams performed on women under age 30 from Feb. 1, 2002, to Aug. 30, 2006, and found 1,091 lesions in 830 patients. Three malignancies were found, and all were identified as suspicious by ultrasound. No malignancy was found in any patient with a negative, benign, or probably benign ultrasound.

The rate of biopsy was high, and the yield was low. For example, a third (46/40, 33%) of patients with a Breast Imaging–Reporting and Data System (BI-RADS) 3 lesion (probably benign) underwent tissue sampling, and none of these lesions was found to be malignant.

The authors concluded that mammography was not indicated in this setting, and that close surveillance might be a preferred alternative to tissue sampling.

The second study, which included women aged 30-39 years, also found ultrasound to have 100% sensitivity. In this study, investigators reviewed 1,327 lesions in 1,032 patients, finding that 98% (1,301/1,327) were benign and 2% (26/1,327) were malignant. Ultrasound and mammography had been used to evaluate 91% (1,207/1,327) of cases, yet all cancers at the site of clinical concern were detected by ultrasound and none by mammography alone.

In a solitary case (1/1,327, 0.08%), mammography resulted in detection of a malignancy in an asymptomatic area.

The authors concluded that ultrasound has 100% sensitivity in evaluating women 30-39 years of age presenting with focal signs or symptoms.

“The added value of mammography in this setting is less apparent,” Dr. Lehman said. “It did help one woman who had an area of cancer identified in another region of the breast, but in all other women, there was no added value of the mammogram.”

In answer to a question from the audience, Dr. Lehman said that ultrasound is recommended as a diagnostic tool and not as a screening tool.

“We strongly recommend women have screening mammography annually, age 40 and older, and if they are shown to be at high risk, that they add MRI to that. We don’t recommend ultrasound as a screening tool,” she said, because the specificity of ultrasound is low.

At the scientific session, Dr. Michael Portillo, one of Dr. Lehman’s coauthors, was asked whether his institution had changed its practice in the wake of this study. “At this point we’re still following the [American College of Radiology guidelines], but we are currently considering changing our practice,” said Dr. Portillo, who worked on the project while a fellow at the University of Washington.

Scientific session moderator Dr. Ellen B. Mendelson of Northwestern University in Chicago commented: “For every patient 30 years old or older who we’d biopsy, we’d do mammography first.

“In a patient younger than that ... the first imaging exam you’d do for something palpable, or that is symptomatic, would be ultrasound. Then, depending on what you find ... we would go to bilateral mammography first, before biopsy,” she said.

Both studies were funded by the University of Washington. Dr. Lehman disclosed work as an instructor with General Electric Co. Dr. Portillo had nothing to disclose.

Copyright (c) 2009 Elsevier Global Medical News. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.

芝加哥(EGMN)——对在一个医学中心接受治疗的1,800余例患者进行的两项研究发现，40岁以下有局灶性乳腺体征或症状的女性应接受靶向超声检查，而不是乳腺X线照相或活检。

 

“这一发现对于美国预防服务工作组(USPSTF) 近期提出的女性不要进行乳腺自检的建议是一个非常及时的支持，”西雅图市华盛顿大学的Constance Lehman博士说。

 

“USPSTF的顾虑之一是女性可能接受不必要的损害和操作，而影像学检查可以更好地指引我们降低乳腺自检相关的危害。”

 

研究结果对临床实践模式和医疗费用均有广泛影响。减少对乳腺肿块的活检和手术切除将减少创伤和费用，同时限制乳腺X线照相的应用将减少费用和不必要的辐射损伤。

 

Lehman博士在北美放射学会年会的一次新闻发布会上介绍了这两项研究。两项研究均为对华盛顿大学临床数据的回顾性分析。

 

在第一项分析中，研究者回顾了2002年2月1日~2006年8月30日间对30岁以下妇女进行的乳腺检查，共发现830例患者中的1,091处病变；并发现了3例恶性肿瘤患者，对这3例患者进行的超声检查均提示病变为可疑恶性。在任一超声提示病变为阴性、良性或可能为良性的患者中均未发现恶性病变。

 

研究患者中的活检率很高，但阳性检出率很低。例如，乳腺影像学报告及数据系统(BI-RADS)3级病变(可能为良性)患者中有1/3接受了组织活检，但结果显示无一病变为恶性。

 

作者总结道，乳腺X线照相不适用于这类患者，密切监测可能是组织取样的首选替代方法。

 

第2项研究纳入的是30~39岁女性，结果也发现超声检查具有100%的灵敏度。在这项研究中，研究者回顾了1,032例患者的1,327处病变，发现98% (1,301/1,327例) 为良性，2% (26/1,327)为恶性。在评估其中91% (1,207/1,327例)的病例时使用了超声检查和乳腺X线照相两种方法，临床关注部位的所有癌变均被超声检出，无一处病变由单纯乳腺X线照相检出。

 

在一孤立病例(1/1,327例，0.08%)中，乳腺X线照相检出无症状区域的一处恶性病变。

 

作者总结道，超声检查对于30~39岁表现局灶性体征或症状女性的评估具有100%的灵敏度。

 

“在这种情况下，乳腺X线照相的附加价值不太明显，” Lehman博士说，“乳腺X线照相确实帮助1例妇女检出了乳腺另一区域的癌变，但对于所有其他女性，其未显示出任何附加价值。”

 

在回答一位听众的提问时，Lehman博士指出，建议将超声检查作为一种诊断工具，而不是筛查工具。

 

“我们强烈建议40岁或40岁以上妇女每年接受乳腺X线照相筛查，如显示为高风险，则还需进行MRI检查。我们不建议将超声作为一种筛查工具，”她说，因为超声检查的特异性很低。

 

在学术会议上，Lehman博士的合著者之一Michael Portillo博士被问及其所在机构是否在这项研究之后改变了临床实践模式。Portillo博士回答说，“关于这一点，我们目前仍遵照美国放射学会的指南，但正在考虑改变临床实践模式。” Portillo博士曾作为华盛顿大学的研究员参与这项研究。

 

学术会议的主持人芝加哥市西北大学的Ellen B. Mendelson博士评论道：“对于需要乳腺活检的30岁或30岁以上患者，我们会首先进行乳腺X线检查。”

 

“至于30岁以下患者，如触诊到肿物或出现症状，首先进行的影像学检查应是超声检查。然后，根据超声所见，我们会在活检前进行双侧乳腺X线照相检查，”她说。

 

两项研究均由华盛顿大学资助。Lehman博士披露其本人担任通用电气公司的讲师。Portillo博士报告无利益冲突。

 

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