Ταχεία MRI (μαγνητική τομογραφία μαστού) – Λόγος και Αντίλογος

Επιμέλεια άρθρου: Αθηνά Βούρτση, Αρκάδιος Ρουσάκης

Η μαγνητική τομογραφία μαστού (MRI) είναι μία συμπληρωματική απεικονιστική εξέταση, γνωστή για τη χρησιμότητά της στην επίλυση διαγνωστικών προβλημάτων σε γυναίκες με αμφίβολα ευρήματα από τη Μαστογραφία ή το Υπερηχογράφημα. Έχει αποδειχθεί ιδιαίτερα χρήσιμη για τον έλεγχο των γυναικών που διατρέχουν αυξημένο κίνδυνο να εμφανίσουν καρκίνο του μαστού κατά τη διάρκεια της ζωής τους.

Ωστόσο μέχρι σήμερα η MRI μαστού δεν έχει εφαρμοσθεί για τον προληπτικό έλεγχο (screening) γυναικών για καρκίνο του μαστού. Οι παράμετροι που έχουν εμποδίσει την εφαρμογή της MRI μαστού ως εργαλείο πρώιμης διάγνωσης καρκίνου σε ασυμπτωματικές γυναίκες, είναι το υψηλό κόστος της εξέτασης, η έλλειψη ευρύτερης διαθεσιμότητας των μαγνητικών τομογράφων, ο σχετικά μακρύς χρόνος διεξαγωγής της εξέτασης (κατά μέσον όρο 20 λεπτά), ο ακόμα μεγαλύτερος χρόνος μελέτης της εξέτασης, η απαιτούμενη εξειδίκευση από τον Ακτινολόγο, η χορήγηση σκιαγραφικής ουσίας, η κλειστοφοβία και -το σημαντικότερο όλων- η έλλειψη πολυκεντρικών μελετών που να τεκμηριώνουν την αποτελεσματικότητα της συγκεκριμένης μεθόδου.

Η μελέτη για τη διαγνωστική ακρίβεια της MRI

Η καθηγήτρια Kuhl από το Πανεπιστήμιο του Aachen στη Γερμανία, γνωστή παγκοσμίως για την ερευνητική της δραστηριότητα στον τομέα της Μαγνητικής Μαστογραφίας, με σκοπό να αντιμετωπίσει μερικές από δυσκολίες που προαναφέρονται, εφάρμοσε για πρώτη φορά ένα σύντομο πρωτόκολλο εξέτασης, το οποίο ονόμασε «ταχεία μαγνητική μαστών» (Fast MRI). Στη μελέτη εξετάστηκαν 443 γυναίκες, οι οποίες υποβλήθηκαν στο πλήρες διαγνωστικό πρωτόκολλο της Μαγνητικής Μαστογραφίας και στη συνέχεια μελετήθηκε η αξιοπιστία της ταχείας Μαγνητικής Μαστογραφίας (Fast MRI T1 pre-contrast and post-contrast images and MIP). Σκοπός της μελέτης ήταν να συγκριθεί η διαγνωστική ακρίβεια στην ανίχνευση καρκίνου του μαστού ανάμεσα στην ταχεία Μαγνητική Μαστογραφία (Fast MRI) και στην πιο χρονοβόρα εξέταση που διενεργείται με το πλήρες διαγνωστικό πρωτόκολλο.

Το πρωτόκολλο της ταχείας MRI βασίστηκε στην αγγειοβρίθεια που αναπτύσσεται στους κακοήθεις όγκους. Μελετήθηκε η πρώιμη φάση από την χορήγηση παραμαγνητικής ουσίας διότι η φάση αυτή είναι η καταλληλότερη για τη διάγνωση του διηθητικού καρκίνου μαστού, καθώς και του ενδοπορικού καρκινώματος (DCIS). Θα πρέπει να σημειωθεί ότι η υψηλή ευαισθησία που ανέδειξε η ταχεία μαγνητική μαστογραφία (Fast MRI) είχε άμεση σχέση με την αξιολόγηση της από Ακτινολόγους εξαιρετικά εξειδικευμένους στη συγκεκριμένη εξέταση, με περισσότερες από 800 εξετάσεις ετησίως, κάτι το οποίο επισημάνθηκε και από την Καθηγήτρια Κuhl, κάτι που χαρακτηρίστηκε ως μειονέκτημα της μελέτης, καθώς η δυνατότητα αυτή δεν είναι εφικτή στα περισσότερα διαγνωστικά εργαστήρια.

Τα αποτελέσματα της μελέτης

Τα αποτελέσματα της μελέτης απέδειξαν ότι η «ταχεία μαγνητική μαστογραφία» (Fast MRI) είχε παρόμοια ευαισθησία και ειδικότητα σε σύγκριση με το πλήρες διαγνωστικό πρωτόκολλο της κλασικής Μαγνητικής Μαστογραφίας για την ανίχνευση καρκίνου του μαστού. Το πλεονέκτημα της ταχείας MRI ήταν η μείωση τόσο του χρόνου διεξαγωγής της εξέτασης, όσο και του χρόνου ερμηνείας των ευρημάτων της.

Και ενώ στη χώρα μας, κατά την περασμένη άνοιξη, η ταχεία Μαγνητική Μαστογραφία γνώρισε μεγάλη δημοσιότητα από τα ΜΜΕ, είναι σημαντικό να τονίσουμε ότι έως σήμερα δεν υπάρχει ικανοποιητικός αριθμός μελετών που να τεκμηριώνει την αξιοπιστία της, ενώ ο αριθμός των ασθενών που έχουν εξεταστεί στη διεθνή βιβλιογραφία είναι εξαιρετικά περιορισμένος. Επιπλέον, για την εφαρμογή μιας νέας μεθόδου στον ευρύτερο πληθυσμό προϋπόθεση αποτελεί η διεξαγωγή πολυκεντρικών μελετών, που να τεκμηριώνουν υψηλή ευαισθησία και ειδικότητα της μεθόδου, αλλά και την ικανοποιητική θετική και αρνητική προγνωστική αξία, ώστε να τεκμηριώνεται η αποτελεσματικότητα της εξέτασης.

Συνεπώς προς το παρόν η ταχεία μαγνητική μαστογραφία (Fast MRI) είναι μία μέθοδος μη επαρκώς πιστοποιημένη για την ασφαλή εφαρμογή της ως εργαλείο προσυμπτωματικού ελέγχου (screening) στο γενικό γυναικείο πληθυσμό. Στο μέλλον αναμένεται η διεξαγωγή μελετών, τα αποτελέσματα των οποίων ενδεχομένως να μας κατατοπίσουν για την ορθή εφαρμογή της μεθόδου.

Οι εξετάσεις για τον προληπτικό έλεγχο του καρκίνου μαστού

Επιπλέον, οφείλουμε να τονίσουμε ότι η Μαγνητική Μαστογραφία δεν είναι μία εξέταση που αντικαθιστά τη μαστογραφία η οποία έως σήμερα παραμένει η μοναδική βασική εξέταση που, σύμφωνα με μεγάλες πολυκεντρικές μελέτες, έχει τεκμηριωθεί ότι είναι αποτελεσματική για την πρόληψη και τη μείωση της θνησιμότητας του καρκίνου του μαστού. Ενώ βεβαίως, δεν μπορούμε να παραβλέψουμε ότι το υπερηχογράφημα είναι απαραίτητο και ιδιαίτερα σημαντικό να γίνεται συμπληρωματικά της μαστογραφίας σε γυναίκες με πυκνούς μαστούς, ενώ στις γυναίκες που έχουν αυξημένο κίνδυνο ανάπτυξης καρκίνου του μαστού έχει αποδειχθεί αποτελεσματικός ο συμπληρωματικός τακτικός ετήσιος έλεγχος με τη γνωστή έως σήμερα σε όλους μας μαγνητική μαστογραφία (κλασικού τύπου).

Στόχος: Προληπτικός έλεγχος βάσει εξατομικευμένης προσέγγισης

Στο μέλλον, όραμα μας είναι να εφαρμοστεί ευρύτερα η εξατομικευμένη προσέγγιση με βάση το ιστορικό της κάθε γυναίκας, στο οποίο θα περιλαμβάνονται παράμετροι όπως η ηλικία, η πυκνότητα του μαστού, η λήψη ορμονικών σκευασμάτων, προηγηθείσες χειρουργικές βιοψίες και ο τύπος του αποτελέσματος, το οικογενειακό ιστορικό καρκίνου του μαστού και η υποβολή σε ακτινοβολίες. Οι παράμετροι αυτοί θα συνυπολογίζονται και η γυναίκα θα κατατάσσεται σε μεσαίο, μέτριο ή υψηλό κίνδυνο ανάπτυξης της νόσου και σύμφωνα με το βαθμό της επικινδυνότητας θα εφαρμόζουμε τα πιο κατάλληλα από τα εργαλεία που έχουμε στη διάθεσή μας για την έγκαιρη διάγνωση, τα οποία είναι η ψηφιακή μαστογραφία, η τομοσύνθεση -3D απεικόνιση- το υπερηχογράφημα και η μαγνητική μαστογραφία που έχει αποδειχθεί ότι είναι πραγματικά χρήσιμα γι’ αυτόν το σκοπό.

Βιβλιογραφία1. Christiane K. Kuhl, Simone Schrading, Kevin Strobel, et al. Abbreviated Breast Magnetic Resonance Imaging (MRI): First Postcontrast Subtracted Images and Maximum-Intensity Projection—A Novel Approach to Breast Cancer Screening With MRI JCO August 1, 2014 vol. 32 no. 22 2304-2310

2. Tabár L, Vitak B, Chen TH, et al. Swedish two-county trial: impact of mammographic screening on breast cancer mortality during 3 decades. Radiology. 2011;260(3):658–63

3. Wendie A. Berg, Jeffrey D. Blume, Jean B. Cormack, et al.Combined Screening With Ultrasound and Mammography vs Mammography Alone in Women at Elevated Risk of Breast Cancer for the ACRIN 6666 Investigators JAMA. 2008; 299(18):2151-2163.

4. Mann RM, Balleyguier C, Baltzer PA, Bick U, Colin C, Cornford E, Evans A, Fallenberg E, Forrai G, Fuchsjäger MH, Gilbert FJ, Helbich TH, Heywang-Köbrunner SH, Camps-Herrero J, Kuhl CK, Martincich L, Pediconi F, Panizza P, Pina LJ, Pijnappel RM, Pinker-Domenig K, Skaane P, Sardanelli F; European Society of Breast Imaging (EUSOBI), with language review by Europa Donna–The European Breast CancerCoalition. Breast MRI: EUSOBI recommendations for women‘s information. Eur Radiol. 2015 May 23.

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    Before you buy the thing, make guaranteed you check it out.
    This signifies performing an precise resolution check and see
    which resolution works ideal for you. These newer notebooks are capable of decent resolutions
    and it would be wise to consider your time and go as a result of them.

    You should open up up numerous packages, like
    Adobe Photoshop or Illustrator and see how the general layout
    of the software fits into the screen, how significant the enhancing place truly is and if the
    edited graphic is sharp sufficient for you to perform with.
    Just after a number of tries, you should really appear
    to a level the place you locate a notebook that’s just ideal for the work you
    intend to do.

    If there is a laptop computer you could like, like one particular
    of people MacBook Air which are alternatively small equally in resolution output and
    the screen measurement by itself, it can be a very good thought to get a keep an eye on which you can use to increase
    the existing laptop computer desktop, so you can keep
    all the toolbars and dockers on your laptop display screen and do the
    modifying operate on the significant observe where you can see it better.

    Program memory or RAM

    The method memory is an additional important variable to look for when you might be buying
    a laptop for graphic style and design operate. Graphic style systems
    are inclined to use a whole lot of RAM and that can lead to inadequate technique functionality if the laptop
    is not organized for this kind of a activity.
    The additional RAM your laptop has, the superior it will operate in the grand scheme of issues.
    A whole lot of RAM means the included capability to run quite a few style and
    design programs at once and quickly swap involving them.
    The amount of money of system memory set up will also affect fairly a great deal anything at all else you may possibly be jogging on your laptop, from films,
    video games, searching or real business office do the job.

    Now I know a large amount of graphic designers and they tend to operate a good deal of courses all at the moment.
    Of study course, their pcs are configured with a ton of process memory which helps make it a lot easier for the computer system to manage running Photoshop,
    Illustrator and other vector graphic design and style systems
    all at when. The matter to recall right here is that the
    sum of method memory immediately impacts all round program general performance.

    Your intention must be in the 4GB selection bare minimum, and that
    is just for starters. If you are on a finances, this is your starting stage and you should
    really system to include far more memory modules in the upcoming.

    If you want to closely multitask and operate quite a few
    programs aside from the graphic design and style types, you need to assume about
    laptops with about 8GB of RAM set up. Various laptops out
    there in the present-day sector make it possible for you to obtain the common design, with about 4GB
    of RAM but they include things like the risk of adding far more by way of the open up memory slots accessible.

    Now if you go for an Apple laptop, you could want to choose into
    account the more cost you may arrive throughout if you
    intend to update your present product with a lot more RAM.
    Some distributors do this, and they cost excess if you want to up grade
    your laptop computer. If you will not thoughts having your arms filthy, you should really test to get the
    RAM modules on the net and put in them by yourself, fairly than spend extra for genuinely simple screwdriver work.

    Laptop computer CPU – Central Processing Unit – Processor

    The CPU, or processor in the laptop computer is the aspect that helps make all the calculations.

    It’s an important piece of vector based mostly structure plans,
    in which there are a whole lot of parameters to choose into account.
    A respectable CPU really should be a further issue on your record of matters which
    make up the best notebook for graphic design and style.

    There are several achievable alternatives to be built in this
    article. A fantastic starting up position is to goal
    for laptops carrying at least a dual-main processor.
    This will permit you to run programs a large amount better so
    you would not put up with from technique halts or sloppy operation.

    If you choose for a laptop with a quad-core processor, you really should have no difficulty jogging pretty considerably any graphic layout program out there.

    Just keep in mind – much more cores implies much
    better notebook efficiency.

    Graphics or Online video Card

    If you genuinely want the greatest laptop for graphic style, you will most probably hardly ever pick one
    which will come with an built-in graphics card.

    This is mainly because integrated GPUs (Graphics Processing Unit) takes
    advantage of the obtainable RAM to output the graphic on the
    screen, whilst a devoted graphics card has its personal RAM, or VRAM.

    You can get rid of a lot of RAM if your laptop has an built-in GPU, and method memory
    is incredibly crucial in graphic design and style laptops.

    This kind of units will operate slower considering the fact that they will split up the out there RAM for working the precise courses and the built-in graphics card.
    This should really be another merchandise on your record – get a notebook which
    has a dedicated graphics card.

    Now if you had been a gamer, you would be involved with the style of graphics card set up, since this is an crucial factor in gaming laptops.

    But considering that the notebook will be applied for graphic structure do
    the job, a mid-assortment video clip card will do just high-quality.

    If your do the job indicates performing 3D graphics function as nicely,
    then a superior-conclude graphics card is required as nicely.

    Recent laptops in this area of interest have fantastic graphics playing cards
    with about 1-2GB of dedicated memory. These are fantastic for both of those graphics
    style and a bit of gaming as effectively when you might be not in the temper for function.

    If you do intend to engage in a ton of online games, or start off accomplishing 3D modelling and renders,
    then you must choose a glimpse at Alienware laptops or the Republic of Players collection from Asus, considering the
    fact that these are configured to participate in the hottest video games at the
    greatest doable visual configurations.

    Laptops for graphic design and style will have a devoted graphics
    card which has its very own memory or VRAM.

    Portability – This is what you sacrifice

    If you believe you’ll be getting a quite transportable notebook then you could possibly
    be mistaken.

    The ideal laptops for graphic design have
    a ton of impressive components installed and this might make it a little bit difficult for the
    notebook battery to previous a lot more than a couple of several hours.

    You sacrifice portability for functionality when you select a notebook for this
    kind of operate, but it really is very well value it.

    In conclusion

    The greatest laptops for graphic layout are configured with a decent-sized screen which lets a very good indigenous resolution so you can match in all
    those people toolbars, dockers and however have sufficient display screen left for the impression that’s becoming edited.
    Also, you can find a significant sum of RAM put
    in, a devoted graphics card and at minimum a dual-main processor, if not a quad-core.

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