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Sensitivity and specificity of the breast screening program in the Isereregion based on positive results between 1991 and 1999 Purpose. The screening program guidelines specify that the call back rate of women for additional imaging (positive mammogram) should not exceed 7% at initial screening, and 5% at subsequent screening. Materials and methods. Results in the Isere region (12%) have prompted a review of the correlation between the call back rate and indicators of quality (detection rate, sensitivity, specificity, positive predictive value) for the radiologists providing interpretations during that time period. Results . Three groups of radiologists were identified : the group with call back rate of 10% achieved the best results (sensitivity : 92%, detection rate : 0.53%, specificity : 90%). The group with lowest call back rate (7.7%) showed insufficient sensitivity (58%). The last group with call back rate of 18.3%, showed no improvement in sensitivity (82%) and detection rate (0.53%), but showed reduced specificity (82%). Conclusion. The protocol update in 2001 does not resolve this problematic situation and national results continue to demonstrate a high percentage of positive screening mammograms. A significant increase in the number of positive screening examinations compared to recommended guidelines is not advantageous and leads to an overall decrease in the quality of the screening.

Les performances de l’IRM ont ete colligees recemment [1] dans le Rapport d’evaluation technologique (mars 2010) edite par la Haute Autorite de Sante (HAS) : ce rapport est telechargeable sur www.has-sante.fr [1].

PURPOSE: To determine the diagnostic value of mammographic criteria in cases of isolated clustered microcalcifications. MATERIALS AND METHODS: Four hundred mammographic studies of isolated clustered microcalcifications for which surgical verification was available were reviewed. A descriptive statistical study was performed to evaluate the distribution of each criterion relative to histopathologic results, followed by a multivariate study to determine statistically significant criteria. Seven breast specialists gave a consensus opinion on the need for surgery. RESULTS: There were 302 benign lesions and 98 cancers. The most useful criteria were vermicular form, linear/branching shape, and irregular size of microcalcification. The number of biopsies recommended with use of these three criteria was 177 instead of the 172 recommended by the experts. CONCLUSION: Use of these three preoperative criteria permits correct diagnosis of most such malignancies (90% in our series vs 67% diagnosed by the experts).

The screening program guidelines specify that the call back rate of women for additional imaging (positive mammogram) should not exceed 7% at initial screening, and 5% at subsequent screening. Materials and methods. Results in the Isere region (12%) have prompted a review of the correlation between the call back rate and indicators of quality (detection rate, sensitivity, specificity, positive predictive value) for the radiologists providing interpretations during that time period.Three groups of radiologists were identified: the group with call back rate of 10% achieved the best results (sensitivity: 92%, detection rate: 0.53%, specificity: 90%). The group with lowest call back rate (7.7%) showed insufficient sensitivity (58%). The last group with call back rate of 18.3%, showed no improvement in sensitivity (82%) and detection rate (0.53%), but showed reduced specificity (82%).The protocol update in 2001 does not resolve this problematic situation and national results continue to demonstrate a high percentage of positive screening mammograms. A significant increase in the number of positive screening examinations compared to recommended guidelines is not advantageous and leads to an overall decrease in the quality of the screening.

The objective of this study is to analyse detection rates and stage of diagnosis of interval cancers in the mass screening mammography programme of Isere (France), launched in 1990. Interval cancers are defined as breast cancers diagnosed within 30 months after a negative screening assessment, for women attending the programme between November 1990 and December 1994. Stages of diagnosis of these cancers are compared with those of screened cancers and to those of cancers diagnosed outside the programme. The rates of invasive interval cancers are 17.7% of the expected incidence rate during the first year, 60.0% during the second year and 58.8% after the second year. Sensitivity of the programme (one test every 30 months) is 74%; sensitivity at one year is 82%. Results are better for women aged 60-69 years than for younger women (50-59 years). Diagnosis is made at an early stage with 8% of in situ cases, and with 40% of very small tumours (sizes < or = 10 mm). Those stages are very close to the ones for screened cases. Interval cancer rates are low during the first year. Higher rates for the second year and early stages of diagnosis could be explained by self-referred screening practice in our area.

The mass screening program for cancer in the Isere department offers women between 50 and 69 years a medical consultation and three tests: mammography for breast cancer screening, Pap smear for cervical cancer screening, and hemoccult for colorectal cancer. During the first round, 29,570 women took part in the program, 21% had a mammography, 20% Pap smears and 25% a hemoccult. In breast cancer screening, the rate for further examination was 11.9%, the breast cancer detection rate was 5.4 per 1,000 women screened and the detection rate of invasive tumoror = 10 mm: 2.0 per 1,000. In cervical cancer screening, the rate of abnormal examinations was 1.2%. The cervical cancer detection rate was 1.5 per 1,000. The rate of positive hemoccult was 2.7% and the rate of colorectal cancers and polyps 10 mm or larger was 2.7 per 1000. Results of screening are satisfying, but compliance rate is too low. Acceptance rate must be examined in following rounds.

Objectifs Connaitre les facteurs de risque de la recidive mammaire. Savoir identifier les anomalies liees au traitement conservateur. Savoir poser les indications de l’IRM, dans ce contexte, a partir des resultats de l’examen clinique et du bilan radiologique standard. Messages a retenir Chez les patientes deja traitees pour un cancer du sein, le risque de survenue d’une lesion evolutive est largement superieur aux autres categories de seins sous surveillance. En moyenne, 2 % des patientes surveillees feront, chaque annee, soit une recidive soit une deuxieme tumeur. L’IRM presente une sensibilite de 84 % et surtout, contrairement aux donnees rapportees dans d’autres indications, une specificite importante de 90 %, probablement en raison des antecedents therapeutiques chez ces patientes. Resume Notre experience porte sur une serie de 250 explorations. Les explorations ont ete motivees par une anomalie du bilan standard ou a titre systematique, du fait de la presence d’un facteur de risque de recidive. Les facteurs favorisant la recidive apres traitement radio-chirurgical sont l’âge, la qualite de l’exerese macroscopique initiale, la presence d’embols lymphatiques ou d’un contingent important de carcinome intracanalaire lors de l’exerese de la tumeur initiale. Les performances de l’IRM seule, dans l’indication retenue, sont : sensibilite de 0,84, specificite de 0,90 soit une valeur predictive positive de 0,79 et une valeur predictive negative de 0,93.

Objectifs Savoir utiliser le lexique ACR pour l’interpretation d’une IRM mammaire. Connaitre les limites de la semeiologie IRM des rehaussements mammaires dans l’etat actuel de l’evaluation clinique de cette technique. Preciser quelques regles de decision diagnostique en fonction de la classification ACR BI-RADS. Points cles L’IRM mammaire presente une sensibilite elevee (0,90) et une specificite moindre (0,72). La realisation de prelevements sous guidage IRM reste difficile en raison d’un manque d’acces (procedures longues) et d’une technique delicate a maitriser par un apprentissage suffisant. La classification ACR BI-RADS doit etre utilisee dans la partie descriptive du compte rendu d’IRM et la conclusion doit proposer une conduite a tenir claire. Resume La definition du cadre ACR 3 IRM n’est pas encore aboutie en IRM mammaire. Aucune etude publiee ne permet de definir un cadre semeiologique repondant a la definition de l’ACR 3, a savoir une probabilite de malignite inferieure a 2 %. Il est possible de definir un certain nombre de rehaussements ou la probabilite de benignite est elevee : masse de forme ronde ou ovale, de contours lisses evoquant morphologiquement un ganglion intra-mammaire ou une lesion benigne voire du parenchyme normal, masse de forme ronde ou ovale, de contours lisses dont le rehaussement interne revele des cloisons internes en hyposignal, zones de rehaussement sans masse, multifocales voire bilaterales, rehaussement regional multiple voire bilateral, rehaussement diffus ou bilateral, de type ponctue ou micronodulaire sans predominance segmentaire, rehaussement bilateral diffus symetrique. Pour le reste, en l’absence de correlation echographique ou mammographique topographiquement certaine, le rehaussement doit etre classe ACR 4 et beneficier d’une prise en charge histologique par biopsie, sous reperage IRM, ou chirurgicale. Le contexte clinique, dans lequel survient la decouverte du rehaussement, influe directement sur l’interpretation comme l’ont montre les metaanalyses recentes sur le sujet et donc, in fine, sur la conduite a tenir.

Objectifs pedagogiques Comprendre la place respective de l’echographie et de l’IRM dans le bilan pre-therapeutique des cancers du sein et comment ces examens associes aux prelevements percutanes modifient la prise en charge therapeutique initiale. Messages a retenir La qualite de la demarche senologique pre-operatoire permet de reduire les indications de chirurgie mammaire « exploratrice », de preparer la strategie du geste chirurgical, de choisir la conduite therapeutique, de contourner les difficultes actuelles de mise en œuvre des traitements.

Resume L’exploration IRM mammaire a considerablement evolue techniquement, en meme temps qu’etaient evalues ses resultats en fonction des differents types de lesion mammaire et precisees d’une part ses limites, d’autre part ses indications. La preparation des patientes, la qualite du protocole et sa standardisation par les equipes soignantes sont un prealable a la performance de cette exploration dont l’interpretation, a premiere vue, peut paraitre simple (presence ou absence de rehaussement). Pour eviter les pieges en IRM mammaire, il faut les artefacts les plus frequents, connaitre et savoir identifier ce qui n’est pas pathologique. L’essentiel des erreurs diagnostiques en IRM mammaire provient des erreurs d’interpretation : nous rappelons les causes de faux negatifs et celles de faux positifs, l’imperieuse necessite de prendre en compte les resultats cliniques, radiologiques et cyto-histologiques de nos patientes. Deux principes fondamentaux sont a retenir : savoir recuser les « mauvaises » indications de cette exploration ; avoir recours au bilan post-IRM, pour comprendre et interpreter les resultats de cette technique. Conclusion Interpreter une IRM mammaire ne peut etre valablement realise que par un senologue experimente et le debat en concertation multidisciplinaire des dossiers difficiles doit etre privilegie.