由于女性确诊早期乳腺癌并接受保乳疗法后，仍然存在复发风险，故有必要继续对乳腺癌进行筛查。已知接受保乳疗法的年轻女性（年龄≤50岁）可能获益于将乳腺磁共振筛查作为乳腺钼靶的辅助手段。那么通过乳腺钼靶＋磁共振或超声波的筛查检出情况和肿瘤特征如何？
2017年6月22日，《美国医学会杂志肿瘤学分册》在线发表首尔大学医学院、首尔大学医院、成均馆大学医学院、三星首尔医院、蔚山大学医学院、首尔峨山医院、韩国天主教大学、首尔圣母医院、延世大学医学院、塞布兰斯医院、首尔大学盆唐医院的队列研究报告，前瞻调查了乳腺钼靶＋磁共振或超声波用于首次确诊时年龄≤50岁女性接受乳腺癌保乳疗法后乳腺癌筛查的癌症检出率和肿瘤特征。
该多中心前瞻非随机比较研究于2010年12月1日～2016年1月31日从6个学术机构共入组754例乳腺癌首次确诊时年龄≤50岁并接受保乳疗法的女性，判断标准为病理学检查和12个月随访。除了乳腺钼靶和超声波，对保留乳房和对侧乳房进行3次年度磁共振筛查，并独立读片。主要结局衡量指标为癌症检出率、敏感性、特异性、间期癌（上次检查结果阴性之后、下次复查之前出现临床症状而确诊的癌）发生率、检出癌症特征。
结果，754例女性共接受了2065次乳腺钼靶、超声波和磁共振筛查，确诊17例癌症，其中大部分（13例，占76%）为0期或1期，未见间期癌。与单用乳腺钼靶相比，联合磁共振、超声波筛查可使每1000例女性分别额外检出3.8、2.4例癌症，提高了乳腺钼靶的敏感性，减少了漏诊率。
乳腺钼靶、超声波、磁共振、乳腺钼靶＋超声波、乳腺钼靶＋磁共振相比：
检出率：4.4‰、5.3‰、7.3‰、6.8‰、8.2‰
敏感性：52.9%、64.7%、88.2%、82.4%、100%
特异性：96.0%、90.3%、89.9%、87.6%、87.0%
乳腺钼靶＋磁共振，与单用乳腺钼靶相比：
检出率较高（8.2‰比4.4‰，P=0.003）
敏感性较高（100%比52.9%，P=0.01）
特异性较低（87.0%比96.0%，P<0.001）
乳腺钼靶＋超声波，与单用乳腺钼靶相比：
检出率较高（6.8‰比4.4‰，P=0.03）
敏感性稍高（82.4%比52.9%，P=0.07）
特异性较低（87.6%比96.0%，P<0.001）
因此，年龄≤50岁女性接受保乳疗法后，将磁共振或超声波加入每年乳腺钼靶筛查，可提高早期但有生物学侵袭性乳腺癌的检出率，其特异性尚可接受。本研究结果可为患者保乳疗法后的筛查方法决策提供依据，对于接受保乳疗法的年轻女性，可以考虑将磁共振或超声波加入乳腺钼靶筛查。
JAMA Oncol. 2017 Jun 22. [Epub ahead of print]
Breast Cancer Screening With Mammography Plus Ultrasonography or Magnetic Resonance Imaging in Women 50 Years or Younger at Diagnosis and Treated With Breast Conservation Therapy.
Nariya Cho, Wonshik Han, Boo-Kyung Han, Min Sun Bae, Eun Sook Ko, Seok Jin Nam, Eun Young Chae, Jong Won Lee, Sung Hun Kim, Bong Joo Kang, Byung Joo Song, Eun-Kyung Kim, Hee Jung Moon, Seung Il Kim, Sun Mi Kim, Eunyoung Kang, Yunhee Choi, Hak Hee Kim, Woo Kyung Moon.
Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea; Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea; Seoul St Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea; Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea; Seoul National University Bundang Hospital, Bundang, Republic of Korea.
This cohort study examines magnetic resonance imaging or ultrasonography plus mammography in screening for a second breast cancer in women 50 years or younger who underwent breast conservation therapy.
QUESTION: What are the screening yield and tumor characteristics detected by combined mammography and magnetic resonance imaging (MRI) or ultrasonography in women diagnosed at 50 years or younger who underwent breast conservation and radiotherapy for breast cancer?
FINDINGS: In this multicenter comparison study of 754 women, MRI screening detected 3.8 additional cancers and ultrasonography detected 2.4 additional cancers, most of which were stage 0 or stage 1, per 1000 women and increased sensitivity over mammography alone.
MEANING: In younger women who had undergone breast conservation therapy, the addition of MRI screening or ultrasonography to mammography can be considered.
IMPORTANCE: Younger women (aged ≤50 years) who underwent breast conservation therapy may benefit from breast magnetic resonance imaging (MRI) screening as an adjunct to mammography.
OBJECTIVE: To prospectively determine the cancer yield and tumor characteristics of combined mammography with MRI or ultrasonography screening in women who underwent breast conservation therapy for breast cancers and who were 50 years or younger at initial diagnosis.
DESIGN, SETTING, AND PARTICIPANTS: This multicenter, prospective, nonrandomized study was conducted from December 1, 2010, to January 31, 2016, at 6 academic institutions. Seven hundred fifty-four women who were 50 years or younger at initial diagnosis and who had undergone breast conservation therapy for breast cancer were recruited to participate in the study. Reference standard was defined as a combination of pathology and 12-month follow-up.
INTERVENTIONS: Participants underwent 3 annual MRI screenings of the conserved and contralateral breasts in addition to mammography and ultrasonography, with independent readings.
MAIN OUTCOMES AND MEASURES: Cancer detection rate, sensitivity, specificity, interval cancer rate, and characteristics of detected cancers.
RESULTS: A total of 754 women underwent 2065 mammograms, ultrasonography, and MRI screenings. Seventeen cancers were diagnosed, and most of the detected cancers (13 of 17 [76%]) were stage 0 or stage 1. Overall cancer detection rate (8.2 vs 4.4 per 1000; P=.003) or sensitivity (100% vs 53%; P=.01) of mammography with MRI was higher than that of mammography alone. After the addition of ultrasonography, the cancer detection rate was higher than that by mammography alone (6.8 vs 4.4 per 1000; P=.03). The specificity of mammography with MRI or ultrasonography was lower than that by mammography alone (87% or 88% vs 96%; P<.001). No interval cancer was found.
CONCLUSIONS AND RELEVANCE: After breast conservation therapy in women 50 years or younger, the addition of MRI to annual mammography screening improves detection of early-stage but biologically aggressive breast cancers at acceptable specificity. Results from this study can inform patient decision making on screening methods after breast conservation therapy.
DOI: 10.1001/jamaoncol.2017.1256
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