Zusammenfassung
Die Aussagekraft der Mammographie (MG) als Screeninguntersuchung zum Ausschluss eines
Mammakarzinoms ist unter einer Hormonsubstitutionstherapie (HST) vermindert. In den
zu dieser Fragestellung vorliegenden Untersuchungen werden signifikante Reduktionen
der Sensitivität und Spezifität zwischen 7 und 21 %, bzw. 0,6 und 12 % angegeben.
Mehrere Ursachen werden für diesen Effekt verantwortlich gemacht. Einerseits ist anzuführen,
dass unter HST die Dichte des Brustdrüsenkörpers zunimmt. Dies führt zu einer erhöhten
Röntgendichte der Brust, wodurch die Unterscheidung zwischen Parenchym und Tumoren
erschwert wird. Dieser Effekt ist von der Art der durchgeführten HST abhängig, wobei
eine kontinuierlich kombinierte HST mit dem stärksten Dichtezuwachs vergesellschaftet
ist. Weiterhin könnte die unter HST auftretende höhere Schmerzhaftigkeit des Drüsengewebes
zu einer Verminderung der diagnostischen Treffsicherheit beitragen, da die Brustdrüse
zur MG komprimiert werden muss, um eine optimale Bildqualität zu erhalten.
Schließlich scheint es auch Unterschiede in den histologischen Charakteristika der
Tumoren zu geben, die sich unter HST entwickeln. Im Vergleich zu Mammakarzinomen,
die unabhängig von einer HST auftreten, findet sich unter HST ein höherer Anteil lobulärer
Karzinome. Lobuläre Karzinome sind in der MG schwieriger zu diagnostizieren als duktale
Karzinome.
Ein kurzfristiges Aussetzen der HST führt zu einer signifikanten Aufhellung des Mammographiebildes.
Es ist jedoch unklar, ob und in welchem Ausmaß dadurch der HST-bedingte Sensitivitäts-
und Spezifitätsverlust der MG ausgeglichen werden kann. Die Einnahme von Tibolon ist
mit einer signifikanten Abnahme der Brustdichte assoziiert. Daten zur Sensitivität
und Spezifität der MG unter Tibolon liegen derzeit nicht vor.
Angesichts der vorliegenden Daten erscheint vor allem bei Patientinnen mit primär
röntgendichter Brust der Verzicht auf eine kontinuierlich kombinierte HST, das Aussetzen
der HST 2 - 4 Wochen vor der MG und die Verwendung von Tibolon als Alternativtherapie
empfehlenswert. Es sollte jedoch darauf hingewiesen werden, dass kein direkter Nachweis
einer qualitativen Verbesserung der Sensitivität und Spezifität der MG durch derartige
Maßnahmen vorliegt.
Abstract
Hormone replacement therapy (HRT) is associated with reduced sensitivity and specificity
of mammography, probably due to increased breast density. The increase in breast density
depends on the particular HRT regimen, with continuous combined HRT associated with
the largest increase. In addition, women on HRT have a higher incidence of mastalgia
compared with women not using HRT. This may also contribute to the reduced sensitivity
and specificity of mammography, because adequate compression of the breast may be
less likely in these women. There is also evidence that women with HRT develop a higher
proportion of lobular carcinomas, which are less likely to be detected by mammography
than ductal carcinomas. Short-term cessation of HRT before mammography can reduce
breast density, but whether cessation can compensate for the HRT-mediated loss of
sensitivity and specificity is unclear. Tibolone, as an alternative to estrogen-containing
HRT, is associated with reduced breast density but there are as yet no data on the
sensitivity and specificity of mammography in women taking tibolone. In summary, these
data support the omission of continuous combined HRT, the cessation of HRT 2 - 4 weeks
before mammography, and the use of tibolone, especially in women with dense breasts.
However, the effect of these interventions on the sensitivity and specificity of mammography
are unproven.
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PD Dr. C. Keck
Univ.-Frauenklinik
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