Kontrastmittel-MRT der Brust bei Staging und Früherkennung: Wo benötigen wir sie?

 

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Zusammenfassung

Fragestellung: Sowohl bei Früherkennung als auch beim präoperativen Staging werden bildgebende Methoden in hohem Ausmaß für die Beurteilung von Brüsten oder Brustgewebe eingesetzt, das sich schlussendlich als gutartig erweist. Im Gegensatz zu anderen Fragestellungen kommt neben guter Sensitivität einer hohen Spezifität besondere Bedeutung zu. Für beide Indikationen liegen umfangreiche Daten vor, die dargestellt werden. Material und Methodik: Recherchen nach PubMed und Cochrane. Originalartikel, systematische Reviews, Metaanalysen sowie die aktuellen Empfehlungen nationaler und internationaler Leitlinien wurden berücksichtigt. Ergebnisse: Für Hochrisiko ist KM‐MRT das sensitivste Verfahren. Bei 15–20 % der untersuchten Frauen ist mit falsch positiven Befunden zu rechnen, die zu kurzfristigen Kontrollen oder histologischen Klärungen führen. MR-gestützte Klärungen, insbesondere minimalinvasive Interventionen, stellen einen bedeutenden Engpass dar. Wichtiger Vorteil der intensivierten Früherkennung mit MRT dürfte bei Hochrisiko die frühere Erkennung sein, wenngleich Beweise in Ermangelung randomisierter Studien fehlen. Für präoperatives Staging fehlen derzeit Beweise für ein besseres Outcome (Nachexzisionsrate, Rezidivquote, Überleben). Aggressiveres operatives Vorgehen nach MRT ist jedoch belegt. Deshalb wird international derzeit von einer generellen Empfehlung (außer bei Subgruppen) Abstand genommen. Schlussfolgerung: Bei Hochrisiko kann Früherkennung mit MRT unter hoher Qualitätssicherung und nach adäquater Aufklärung der Frauen empfohlen werden. Für Staging kann MRT derzeit nur bei Subgruppen empfohlen werden. Außerhalb der o. g. Indikationen besteht Forschungsbedarf.

Abstract

Purpose: When imaging is used for screening or preoperative staging, a considerable number of diagnoses show normal breasts or breast tissue. Thus, in contrast to other indications, a high specificity of the methods employed is required in addition to a good sensitivity. Ample data is available for both indications and is analyzed here. Material and Methods: A search of the Pubmed und Cochrane libraries was performed. Original work, systematic reviews, meta-analyses, national and international recommendations and guidelines were considered. Results: Contrast-enhanced breast MRI proved to be the most sensitive method for high risk patients. However, false positive findings leading to “short-term” (4–6 months) follow-up recommendations or to histopathological assessment may occur in 15–20 % of cases, and MR-guided histopathological assessment and, in particular, MR-guided percutaneous biopsy, constitute a bottleneck. The most important advantage of intensified screening programs using MRI is the earlier detection of malignancy, even though evidence from randomized studies is lacking. For preoperative staging no evidence exists to date for an improved outcome, as measured by a decreased number of re-excisions, a decreased rate of recurrences, or improved survival. However, more aggressive treatment has been documented after preoperative MRI. Therefore updated guidelines have not recommended using MRI for preoperative staging in general, but only recommend it for certain subgroups. Conclusion: MRI can be recommended as an additional imaging method for the screening of high risk women. However, good quality control and appropriate patient information is necessary. Preoperative MRI is only recommended for selected subgroups. More research is needed before further recommendations can be given.

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Prof. Dr. Sylvia H. Heywang-Köbrunner

Referenzzentrum Mammografie München

Einsteinstraße 3

81675 München

Email: heywangkoe@referenzzentrum-muenchen.de