既往胸部放疗者每年需行乳腺MRI筛查

科罗拉多州埃斯特斯公园——美国科罗拉多大学肿瘤内科的Jennifer R. Diamond博士表示，初级保健医生应安排有胸部淋巴瘤放疗史的年轻成年女性患者每年进行1次乳腺MRI筛查。

Jennifer R. Diamond博士

双乳上内侧象限行套细胞放疗的患者发生乳腺癌的风险非常高，但很多时候肿瘤医生不再对这些患者随访，而且许多患者可能也不知道在这么年轻时就应进行乳腺癌筛查，因此需依靠初级保健医生来提醒和安排这些患者进行此类筛查。

美国国立综合癌症网络(NCCN)指南建议从胸部放疗后8~10年或25岁时(以先到的时间为准)开始，每年进行1次乳腺MRI和乳腺摄影，并且每6~12个月进行1次临床乳腺检查。Diamond博士对其患者进行乳腺MRI和乳腺摄影的间隔通常为6个月。

Diamond博士表示，每年1次的乳腺MRI和X线摄影均有必要进行。在高危女性中，MRI筛查的敏感性明显高于单纯乳腺X线摄影，可在较早期就检出癌症。NCCN指南也建议终生估计风险超过20%或携带BRCA 1/2突变的高危乳腺癌女性进行每年1次乳腺MRI和乳腺X线摄影。Diamond博士表示，在估计既往无乳腺癌女性的终生乳腺癌风险时，BRCAPRO是非常有用的工具。

Diamond博士非常推崇乳腺断层摄影(亦称为3D乳腺摄影)，这是一种除了能够提供乳腺组织的标准二维图像之外，还可提供3D影像的技术，压迫1次(压迫时间仅增加2 s)即可获得所有影像。研究显示，这种技术可显著减少因乳腺摄影图像不清楚而召回患者的情况。借助这一以技术，乳腺摄影医生能够像CT扫描一样上下检视乳房，但没有相同的放射暴露风险。

Diamond博士声明无经济利益冲突。

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By: BRUCE JANCIN, Internal Medicine News Digital Network

ESTES PARK, COLO. – Primary care physicians are uniquely positioned to help their younger adult female patients who have a history of thoracic radiation therapy for lymphoma by arranging for them to begin undergoing annual screening breast MRI, Dr. Jennifer R. Diamond said.

"That mantle cell radiation includes the upper inner quadrants of both breasts; those patients are at extremely high risk for developing breast cancer," explained Dr. Diamond, a medical oncologist at the University of Colorado, Aurora. "Many times, they’re no longer being followed by their oncologist, and it’s up to their primary care physician to pull the trigger and order the test."
 
Many patients likely wouldn’t know that they should do breast cancer screening at such an early age, she added, because breast cancer wasn’t an anticipated outcome back when they had their radiotherapy.

National Comprehensive Cancer Network guidelines call for annual breast MRI and mammography along with clinical breast exams every 6-12 months, beginning 8-10 years after thoracic radiotherapy or at age 25 years, whichever occurs later. Dr. Diamond typically has patients stagger the two imaging modalities 6 months apart.

Both annual breast MRI and mammography are necessary. Screening MRI is far more sensitive than mammography alone in high-risk women, and it leads to cancer diagnosis at an earlier stage. However, MRI can miss ductal carcinoma in situ that would be evident as abnormal calcifications on screening mammography, she continued.

Annual breast MRI, in addition to mammography, is also indicated for women at high breast cancer risk as defined by a lifetime estimated risk in excess of 20%, or because they possess a BRCA 1 or 2 mutation, according to the NCCN. Dr. Diamond recommended BRCAPRO as a very useful tool for estimating the lifetime risk of breast cancer in women with no previous breast cancer.

In response to an audience question, she said she’s had no problem in getting insurers to pay for annual breast MRI to supplement annual mammography, so long as she clearly documents in her note that the patient has a greater than 20% lifetime estimated risk of breast cancer.

"They won’t cover it even a week earlier than annually, though," Dr. Diamond added.

She is a big fan of breast tomosynthesis, also known as three-dimensional mammography. The Food and Drug Administration–licensed technology produces a 3-D view of the breast tissue in addition to the standard two-dimensional images, all obtained in one compression with only about 2 seconds of additional compression time. Studies have shown that this tool substantially reduces patient recall rates for nondefinitive mammograms, Dr. Diamond said.

"It allows the mammographer to scroll through the breast, looking up and down sort of like with a CT scan, but without the same radiation exposure," she explained. "It’s a really great new technology, and I think most mammography centers will increasingly turn to it."

Dr. Diamond reported having no financial conflicts.