RAMB Novembro/Dezembro 2015

azário

ACP

546

ssoc

ras

2015; 61(6):543-552

cer is unknown. It is indicated when the extent of the sus-

pected lesion cannot be determined by conventional meth-

ods, such as in dense breast tissue or when the diagnosis

is lobular carcinoma; in women at high risk for develop-

ing breast cancer, such as the carriers of

BRCA1

and

BRCA2

gene mutations; to monitor the response to neoadjuvant

chemotherapy; to assess the integrity of the prosthesis

and in diagnoses of presumed occult breast carcinoma

(i.e., presence of metastasis in the axilla without evidence

of primary disease on clinical examination, mammogram

and ultrasound).

Recently, tomosynthesis or 3D mammogram was in-

troduced, with the promise to detect more lesions than

digital mammography. However, its use as a routine did

not prove to decrease mortality.

The American Cancer Society of Breast Diseases rec-

ommends that mammogram screening starts at the age

of 40 years, being annual from this age. The Brazilian

Ministry of Health, in turn, recommends that women at

low risk for developing breast cancer undergo bi-annual

mammograms, beginning at the age of 50. In the case of

high-risk women, the ministry advises that the examina-

tion should be carried out annually from the age of 35,

or 10 years before the age of diagnosis of the youngest af-

fected relative. The Brazilian Society of Mastology sug-

gests that mammogram is made annually between 40 and

49 years, and biannually thereafter. In 2015, the Ameri-

can Cancer Society began recommending that mammo-

gram should be done annually between 45 and 54 years,

and every two years thereafter. In São Paulo, the propor-

tion of cases between 40 and 49 years (21.3%) is very close

to that found between 50 and 59 years (27%). Thus, we

recommend annual mammogram from the age of 40 years,

ending when life expectancy is less than five years. Table

2 summarizes the various guidelines.

In cases of suggestive lesions, percutaneous biopsies

are preferred. The first is biopsy with fine needle (FNAB),

an outpatient method with low cost and relatively sim-

ple

The needle (25/6

gauge

) makes the procedure com-

fortable and virtually risk-free. It can be done by palpa-

tion, but preferably ultrasound-guided, due to a higher

predictive value. FNAB is contraindicated for investiga-

tion of suspected calcifications. Its disadvantages include

the impossibility of evaluating invasion and histological

grade. Moreover, it is very difficult to determine the his-

tological type and the expression of hormone receptors.

The false positive rate is very low (between 0 and 2%). How-

ever, 5-20% of cases are false negatives, mainly due to im-

proper technique for slide preparation. Thus, in cases of

suspected image but negative, unsatisfactory or inconsis-

tent FNAB compared to the clinical-imaging diagnosis,

investigation should continue.

Core needle biopsy (CNB) is done with a large needle

and an automated device that propels and retracts the nee-

dle that cuts the tissue. It is indicated for suggestive nod-

ules larger than 1.0 cm or extensive calcifications. Under

those conditions, sensitivity is 48 to 100% and specificity,

91 to 100%. On the other hand, it is contraindicated in case

of deep image alterations (risk of pneumothorax and he-

mothorax), fibro-glandular distortion, in suggestive asym-

metries, patients with hypomastia, or lesions adjacent to

breast implant.

Advantages include the fact that it is an outpatient

method, requiring local anesthesia. It allows evaluation

of invasion, histological type and immunohistochemical

expression, and the definition of a preoperative treatment

planning. Cost (moderate), fragmentation of the materi-

al, and the mobilization of the breast tissue simulating

invasion and/or embolization are the disadvantages. Anx-

ious patients may find the procedure uncomfortable.

Mammotomy with core needle biopsy (CNB) is per-

formed using a vacuum system with hollow

cannula

, which

rotates at high speed, cutting through the tissue that is

sucked out of the breast. It is also known as vacuum-as-

sisted CNB

It is especially indicated for nodules smaller

than 1.0 cm, unpronounced suspected calcifications, fi-

bro-glandular distortion and asymmetric densities. Sen-

sitivity reaches 93% and specificity, 98%.

As in the case of core biopsy, mammotomy has the

advantage of being an outpatient method, using only lo-

cal anesthetics. It makes it possible to evaluate invasion,

TABLE 2

Early detection and screening for breast cancer.

Brazilian Ministry of Health (2004)

Group without risk 40 – 49 years: Annual physical exam

50 – 69 years: Annual physical exam

Mammogram every two years

High-risk group

From the age of 35 years: Annual physical exam

Annual mammograms

Brazilian Society of Mastology (2002)

40 – 49 years: Annual mammograms

50 – 69 years: Mammogram every two years

≥ 70 years: Depending on life expectancy

American Society of Breast Diseases (2006)

From the age of 40 years: Annual mammograms

American Cancer Society (2015)

45 – 54 years: Annual mammograms

After 55 years: Mammogram every two years (provided that life

expectancy is greater than 10 years)