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Doc dr Dragana Bogdanović-StojanovićKatedra za radiologiju
Medicinski fakultet Novi Sad
Institut za onkologiju VojvodineSremska Kamenica, Srbija
RADIOLOŠKA DIJAGNOSTIKA
MINIMALNOG KARCINOMA DOJKE
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MAMOGRAFIJA
1950XIX vek
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MAMOGRAFSKI EVIDENTAN
KURABILAN
KLINIČKI EVIDENTAN
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97,5 93,5
79,5
66,5
24,2013,30
0
10
20
30
40
50
60
70
80
90
100
0 1 2 3 4 5 6 7 8 9 10
Desetogodišnje preživljavanje bolesnica sa rakom Desetogodišnje preživljavanje bolesnica sa rakom dojke dojke u zavisnosti odu zavisnosti od inicijalno inicijalnogg stadijum stadijumaa
Izvor: US, SEER 9 Registries for 1988-2002
Godine od postavljanja dijagnoze
Lokalizovana bolest
Regionalnoproširena
Udaljene meta
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INDIKACIJE ZA MAMOGRAFIJU
1. Evaluacija simptomatske bolesti, zbog
detekcije mogućih subkliničkih multiplih fokusa maligniteta (dijagnostička mamografija)
2. Kod asimptomatskih žena ( skrining mamografija )
3. Biopsija ili obeležavanje patološke promene
pod kontrolom mamografije (stereotaksične procedure)
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BI RADS 1 Normalan nalaz Rizik za karcinom 0%Godišnjekontrole
BI RADS 2 Benigne promene Rizik za karcinom 0%
BI RADS 3 Verovatno benigne pr. Rizik za karcinom < 2% Kontrolaza 3-6 mes.
BI RADS 4 Suspektne pr. Rizik za karcinom < 60%BIOPSIJA
BI RADS 5 Visoko suspektne pr. Rizik za karcinom ~ 95%
BI RADS 6 Histološki potvrđen Karcinom
The Breast Imaging Reporting and Data System-BI RADS
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ACR 1
ACR 3
ACR 4
ACR 2senzitivnost:
tumorska senka=0,5 cm
senzitivnost:
tumorska senka=1 cm
senzitivnost:
1-2cmsenzitivnost:
tumorska senka > 2 cm
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Ljlijana 68 god, palpabilan tumor na spoju donjih kvadranata
Tumor prema GLK se nije pipao ni od strane hirurga-
UVEK INSISTIRATI NA PREOPERATIVNOJ MAMOGRAFIJI!!!
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P=A
Slavica 52 god, asimptomatska, bazna mamografija
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65 god,obostrano palpabilni tumori !!!!
Ph-obostrano LCI
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Jelica, 60 god, hirurg napipao promenu levo
Ca tubulare G1+ DCIS 13mm Ca tubulare G1 17mm
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Vesna, 53 god, implantirana pre 25 godina, javlja se zbog kontrakture i insistira na UZ
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P A
Jelena, 58 godina, rutinska kontrola, + porodična anamneza
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Šta reći hirurgu GDE JE TUMOR?
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DCIS G3 5mm
5 mm od lezije!!!5 mm od lezije!!!
L.Liberman,AJR,2001L.Liberman,AJR,2001
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MAMOGRAFIJA
1950XIX vek
ULTRAZVUK 1985
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Indikacije za primenu ultrazvukaI . Inicijalna vizualizaciona metoda kod žena < 35 godina
II. Dopunska vizualizaciona metoda mamografiji kod žena > 35 godina:
1. Klinički palpabilne, mamografski okultne lezije2. Diferencijacija mamografski detektovanih senki (solidna/cisticna)
3. Procena regionalnih limfatika4.Sekretujuća dojka5.Dojke sa implantom
III. Posttraumatska dojka
IV. Zapaljenjske promene u dojci
V. Muška dojka
VI. Biopsije vođene ultrazvukom
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• Ehotomografija ne može da se koristi u skriningu karcinoma dojke jer ima ograničenja:– ne detektuje mikrokalcifikacije (može da previdi 11,8% svih tumora,
od kojih 32,1% nepalpabilnih)
– subjektivnost pregleda
• Ehotomografija i mamografija su komplementarne metode
• Ehotomografija pridodata kliničkom pregledu i mamografiji povećava mogućnost detekcije malignih tumora za 7-14%
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-procena prisustva invazivnog tumora
-prisustvo high grade komponente
-MR senzitivnost ~80%
Žuža, 33 god, kancerofob, nema palpabilne rezistencije, planira trudnoću
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70% Ca in situ → mikrokalcifikacije!
Savezni zakon o zaštiti od jonizujućeg zračenja,
“Službeni list SRJ”, br.46/96, član 17) : “...zabranjeno je sistematsko snimanje dojki kao skrining metoda u ranoj detekciji maligne bolesti, jer je medicinski neopravdano”.
ZA ŽENE 35+ GODINA MAMOGRAFIJA JE “ZLATNI STANDARD” DIJAGNOSTIKE RANOG KARCINOMA DOJKE
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Goca, 50 god, naglo napipala promenu levo, bolnu
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Dominantno DCIS G3
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ULTRAZVUK NIKAD NIJE ZAMENA MAMOGRAFIJI!!!
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Diferencijalna dijagnoza benignih i malignih patoloških promena u dojkama
Cystis simplex
Anehogena, ovalna, oštro ograničena promena sa centralnim posteriornim pojačanjem i rubnim slabljenjem odjeka.
Ca ductale invasivum
Nehomogena, dominantno hipoehogena promena, nepravilna i neoštro ograničena, sa zrakastim izdancima u okolinu, hiperehogenim haloom i posteriornom akustičnom senkom.
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Milica, 45 godina, upućena zbog palpabilne promene desno
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Ph-DCI G3
8-15% mamografskih nalaza su lažno negativni!!!
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P=APh-DCI G1 5mm
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Black carbon
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Kyungran Ko, Korean J Radiol,2007Kyungran Ko, Korean J Radiol,2007
Black carbon
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Black carbon
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MAMOGRAFIJA
1950XIX vek
ULTRAZVUK 1985
MR mamografija 1990
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• Nema zračenja• Visoka senzitivnost - 91%¹• Visoka specifičnost - 88%²• Visoka PPV - 35-64%³• Visoka NPV 87-100%*
1,2 Lehman, NEMJ 2007 3 Kuhl, Radiology 2000* Kuhl, Radiology, 2007
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MR mamografija
• Posterapijska dojka• Implanti• Denzna dojka• Visokorizični
pacijenti• Preoperativna
priprema• Inkonkluzivni
mamo/UZ nalazi • Procena PHT
• Neovaskularizacija• Fragilni ks• ↑ vaskularnog
denziteta• Izostanak BM
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∆S/∆t krive • TIP I-RASTE – BENIGNO • TIP II-PLATO – MALIGNO/benigno• TIP III-WASH OUT- MALIGNO
S
t
MORFOLOGIJA
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2005
Stojanka, 67 god QMLD aa IV, ph-DCI
NPV ~ 98%Kuhl, Radiology, 2007
2007
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2002 20052004
Ph-DCI,pT1,7mm
Ph-Recidivum locale, DCI, 5mm
Zorica, 46 god, rutinska kontrola, Zorica, 46 god, rutinska kontrola, evaluacija postterapijske dojkeevaluacija postterapijske dojke
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?
Goca, 47 godina, više x IVF, denzna dojka
?
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Ph-DCI, 7x4mm Ph-Ca tubulare, 15mm
23% karcinoma se ni retrospektivno ne vidi UZ!!!
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Hajnalka, 44god, bez faktora rizika, mamografski denzna dojka, palpatorno obostrano nodularne strukture
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MRM PRESUDNA ZA PREOPERATIVNU PRIPREMU DENZNE DOJKE!!!
Ekstenzivni multifokalni DCI G3
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Branislava, 62 god, napipala promenu levo, na mamografiji u DZ viđena 1 promena
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Šira lumpektomija u 14,2% slučajeva NA VREME!!!
Mastektomija u 5,7% slučajeva NA VREME!!!
Neoadjuvantni tretman u 2,1% slučajeva....!!!
Newstead GM, Breast MRI course, 2007
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NIJE INDIKOVANA:
• U toku trudnoće i laktacije
• U toku hormonske supstitucione terapije
• Inflamacija
• Mamografski suspektne mikrokalcifikacije
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Biopsija:
1. DA
2. NE
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MAMOGRAFIJA
1950XIX vek
ULTRAZVUK 1985
MR mamografija 1990
BiopsijePerkutane
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CORE NEEDLE BIOPSY
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VAB
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PREDNOSTI STEREOTAKSIČNIH BIOPSIJA DOJKE
• Visoka tačnost metode• Minoran broj komplikacija • Manja cena u odnosu na otvorene biopsije• Veći komfor i manji stres za pacijenta• Sistem lako primenljiv za lekara• Hirurg može precizno da planira operaciju!
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MAMO BI RADS 0
UZ BI RADS 0
MR BI RADS 1
SLEPA CORE BIOPSIJA-CA LOBULARE!!!
Olivera, 44 god, ascites, limfonodusi aksilarno obostrano
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“Blind spots” 85,4% NPV Bluemke, JAMA, 2004
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“If we had a diagnostic method that enabled us to detect and remove all
breast cancers 5 to 10 mm in size, we could practically eliminate breast cancer deaths.”
W.A.Keiser, Signs in MR mamography,Springer 2008
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H V A L A
na pažnji...