Ταχεία MRI (μαγνητική τομογραφία μαστού) – Λόγος και Αντίλογος

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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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