Diagnosis and Treatment of Patients with

Primary and Metastatic Breast Cancer

AGO

e. V.

in der DGGG e.V.

sowie
in der DKG e.V.
Guidelines Breast
Version 2012.1

Early Detection
and Diagnosis

Early Detection and Diagnosis

AGO

e. V.

in der DGGG e.V.

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in der DKG e.V.
Guidelines Breast
Version 2012.1

Versionen 20052011:
Albert / Blohmer / Junkermann /
Maass / Schreer
Version 2012:
Schreer / Scharl

www.ago-online.de

Early Detection
Mammography
AGO

e. V.

Oxford

in der DGGG e.V.

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Guidelines Breast
Version 2012.1

www.ago-online.de

AGO

Age

Interval

LOE /

GR

< 40

na

--

4050

1218

1b

5070*

24

1a

++

>70

24

* National Mammography-Screening-Program

Effective Biennial Mammographic

Screening in Women 4049 Years
AGO

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in der DGGG e.V.

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Age

Guidelines Breast
Version 2012.1

www.ago-online.de

4049
5059
6069

Cases
screened

Odds ratio (CI)

0.50 (0.300.82)
0.54 (0.350.85)
0.65 (0.381.13

Van Schoor et al. 2010

Mortality Reduction for Women

Ages 4049 years
AGO

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in der DGGG e.V.

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Guidelines Breast
Version 2012.1

Trials

Follow-up
(years)

Mortality
reduction (%)

All 8 RCTs

10.518.0

18

7 RCTs

7.018.0

24

Five Swedish
RCTs

11.415.2

29

18

24

Malmo

15.5

36

Gothenburg

14.0

45

UK Age Trial

714

17/24* (n.s.)

HIP
www.ago-online.de

*Adjusted for non compliance

Feig SA 2004
Moss SM 2006

Early Detection
Sonography
AGO

Oxford / AGO
LOE / GR

e. V.

in der DGGG e.V.

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in der DKG e.V.
Guidelines Breast
Version 2012.1

Screening

--

3b B

++

1b C

++

3b B

++

As an adjunct:

Dense mammogram (ACR 3 4)

Elevated risk

www.ago-online.de

Mammographic lesion

* Trial ACRIN 6666: No follow-up data yet

Early Detection
Clinical Examination
AGO

e. V.

Oxford / AGO
LOE / GR

in der DGGG e.V.

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Guidelines Breast
Version 2012.1

As stand alone procedure

Self-examination

1a

-*

Clinical breast examination (CBE)

by health professionals

3b

-*

CBE because of mammo/sonographic lesion 5

++

www.ago-online.de

CBE in combination with imaging

BCP

++

* May improve breast cancer awareness

* May increase breast awareness

Assessment of Breast Symptoms or

Lesions
AGO

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in der DGGG e.V.

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Oxford /
LOE / GR

Guidelines Breast
Version 2012.1

www.ago-online.de

Clinical examination
Mammography
Sonography
MRT*
Minimally invasive biopsy

* If clinical examination, mammography and

sonography do not allow a definite diagnosis

3b
1b
3b
3b
1c

B
A
B
D
A

AGO

++
++
++
+/++

Pretherapeutic Assessment
of Lesion Extension
AGO

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Oxford /
LOE / GR

AGO

++

Guidelines Breast
Version 2012.1

www.ago-online.de

Clinical examination

Mammography

2b

++

Sonography

2b

++

MRT (in special cases*)

1c

+/-

Minimally invasive biopsy**

1c

* No reduction in reexcision rate. Lobular invasive tumors, suspicion of

multilocular disease, high-risk patients. MRI-guided vacuum biopsy
mandatory in case of MRI-detected additional lesions.
** If clinical examination, mammography and sonography (e.g. plus MRI)
do not allow assessment of lesion extension

Contrast-enhanced MRI:
Preoperative Staging?
AGO

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Guidelines Breast
Version 2012.1

False negative rate

412 %

False positive rate

up to 40 %

No fewer positive margins

Odds ratio for mastectomy

1.80

Delay in pretreatment evaluation

22.4 days

www.ago-online.de

J Bleicher et al J Am Coll Surg 2009; 209

COMICE TRIAL (RCT)

MRI preop. vs. no preop. MRI
AGO

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Guidelines Breast
Version 2012.1

End Points
Improved tumor localization
Reduction of reoperation rate
Cost-effectiveness
www.ago-online.de

L Turnbull et al. Lancet 2010

COMICE TRIAL (RCT)

MRT preop. vs. no preop. MRI
AGO

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Guidelines Breast
Version 2012.1

Results
No significant reduction of reoperation rate
More costs with low or no benefit
Reduction of unnecessary mastectomies due to
better localization of MRI-only detected lesions
and image guiding

www.ago-online.de

L Turnbull et al. Lancet 2010

CE-MRI Sceening (High-risk)

Benefit
AGO

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Guidelines Breast
Version 2012.1

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Early detection of cancer cases

additionally to conventional imaging
Improved patient prognosis?
(Mortality reduction? Reduction of
interval cancers?)

CE-MRI Screening (High-risk)

Risk
AGO

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Guidelines Breast
Version 2012.1

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MRI in addition to
mammography

RR

Assessment of benign
lesions

3,434,86

Benign biopsies

1,229,50

Benign surgical biopsies

(MARIBS)
False-negative MRI (MRISC)

2
22%

False-negative MR Imaging in
High-risk Women (MRISC)
AGO

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in der DGGG e.V.

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Guidelines Breast
Version 2012.1

97 malignant breast tumors

19 /97 (20%) DCIS
21 /97 (22%) false-negative
9 /21 ( 20%) DCIS
.. Necessity of screening not only with
MRI but also with mammography.

www.ago-online.de

Obdeijn IMA et al. 2010

CE-MRI and DCIS

AGO

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Study

No.
Cases

Overall
accuracy (%)

Sens.
(%)

Spec. (%)

Gilles et al 1995

172

70

95

51

Westerhof et al
1998

63

56

45

72

Bazzocchi et al
2006

112

80

79

68

Kuhl et al 2007

75

88

Guidelines Breast
Version 2012.1

www.ago-online.de

Negative breast MRI findings should not be considered a sure

marker of benignancy.