CORRESPONDENCE

RESPONSE: Re: Magnetic Resonance Imaging and Mammography in Women With a Hereditary Risk of Breast Cancer

Mark J. Stoutjesdijk, Carla Boetes, Jelle O. Barentsz

Affiliation of authors: Department of Radiology, University Medical Center St Radboud, Nijmegen, The Netherlands.

Correspondence to: Mark J. Stoutjesdijk, M.D., M.Sc., Department of Radiology, University Medical Center St Radboud, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands (e-mail: marks{at} radiology.azn.nl).

We thank Dr. Goffin et al. for their contribution. Their work and several recent studies (14) strongly suggest that mammography is not the best modality to screen BRCA1/2 carriers and other women with an increased hereditary risk of breast cancer. Although this may be so, screening by means of magnetic resonance imaging (MRI) still has to prove its merit in prospective multi-center studies. Furthermore, no direct link between MRI screening and decreased risk of dying of breast cancer has been made.

Regarding Goffin et al.'s suggested reasons for the decreased mammographic sensitivity in BRCA1/2 carriers, we would like to make two comments. First, parenchymal density is usually higher for BRCA1/2 carriers than for noncarriers in a regular screening program, who are mostly age 50 years and older. We agree with Goffin et al. that this may be part of the reason why mammography performs rather badly on BRCA1/2 carriers. Second, we would also like to point out that in our study (2) malignancies were missed, even on mammograms of women with low or normal parenchymal density. Low mammographic density does not equal adequate sensitivity.

The sensitivity of MRI of the breast may be reduced for invasive lobular carcinoma and well-differentiated ductal carcinoma in situ. However, invasive lobular carcinoma is probably even more difficult to detect by mammography, and, therefore, MRI may still be the best option (5). Ductal carcinoma in situ without an invasive component is probably found less frequently in BRCA1/2 carriers than in noncarriers, perhaps because of fast progression to invasive ductal carcinoma. In light of the suspected susceptibility to radiation-induced breast cancer in BRCA1/2 carriers, and if a considerable underrepresentation of well-differentiated ductal carcinoma in situ in screening examinations can be confirmed, screening by mammography should probably be replaced with screening by MRI for these women.

REFERENCES

1 Kuhl CK, Schmutzler RK, Leutner CC, Kempe A, Wardelmann E, Hocke A, et al. Breast MR imaging screening in 192 women proved or suspected to be carriers of a breast cancer susceptibility gene: preliminary results. Radiology 2000;215:267–79.[Abstract/Free Full Text]

2 Stoutjesdijk MJ, Boetes C, Jager GJ, Beex L, Bult P, Hendriks JH, et al. Magnetic resonance imaging and mammography in women with a hereditary risk of breast cancer. J Natl Cancer Inst 2001;93:1095–102.[Abstract/Free Full Text]

3 Tilanus-Linthorst MM, Obdeijn IM, Bartels KC, de Koning HJ, Oudkerk M. First experiences in screening women at high risk for breast cancer with MR imaging. Breast Cancer Res Treat 2000;93:53–60.

4 Warner E, Plewes DB, Shumak RS, Catzavelos GC, Di Prospero LS, Yaffe MJ, et al. Comparison of breast magnetic resonance imaging, mammography, and ultrasound for surveillance of women at high risk for hereditary breast cancer. J Clin Oncol 2001;19:3524–31.[Abstract/Free Full Text]

5 Weinstein SP, Orel SG, Heller R, Reynolds C, Czerniecki B, Solin LJ, et al. MR imaging of the breast in patients with invasive lobular carcinoma. AJR Am J Roentgenol 2001;176:399–406.[Abstract/Free Full Text]



             
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