Search

Breast cancer among older women is a major and increasing public health issue. No clear recommendation has been established in France after 74 years, the age limit for state-organised screening program. A survey was performed among all regional agencies in charge of the breast screening to analyse which information is delivered to women reaching the age of 75 years. A postal survey sent to 91 French organised cancer screening agencies. Among the 89 agencies that answered, only 22 deliver a systematic written information. Twelve suggest that mammographic screening should be continued, and five mention clinical examination. Twenty agencies dispatch the screening to general practitioners or gynaecologists. Two information letters insist on the ongoing risk of breast cancer. Most of the written information is given with the last mammography report. No impact study has ever been performed. In our study, only 25% of the screening agencies give systematic information to women. The modalities and the substance of this information are heterogeneous. A better information seems to be a key-point for earlier clinical breast cancer diagnosis among older women, for whom there is little direct evidence of the benefit of systematic mammographic screening.

We described here the national breast cancer-screening program that is used, in France, today. First we depict official rules and regulations along with the organization needed to screen a whole population. Then, a technical assessment is made on the efficacy and limits on mammography analyses leading to tumor classification. Finally, an evaluation of the program is discussed.

Resume Objectifs Etudier, retrospectivement des carcinomes canalaires in situ (CCIS) bilateraux, traites a l'institut Bergonie et rechercher la relation entre les deux evenements. Materiel et methodes De 1971 a 2001, sur 812 patientes prises en charge pour un CCIS a l'institut Bergonie, 78 patientes ont presente un CCIS bilateral, parmi elles, 19 ont integralement ete traitees dans notre centre. Il s'agissait soit de lesions synchrones soit metachrone (> 6 mois). Nous avons realise une etude comparative des caracteristiques cliniques et histologiques des deux CCIS. Resultats En cas de lesion metachrone, les CCIS controlateraux surviennent apres un delai median de 75 mois et jusqu'a 22 ans apres le premier evenement. Pour l'ensemble de la serie, dans 31 % des cas, le grade est identique, la concordance est de 53 % si l'on regroupe les bas grades et grades intermediaires vs hauts grades. Dans 53 % des cas au moins un sous-type architectural est retrouve entre le CCIS droit et gauche. Il existe donc une concordance a la fois architecturale et de grade (bas/haut) dans 32 % des cas et une concordance architecturale ou de grade dans 63 % . Conclusion La concordance histologique entre les deux lesions nous fait envisager l'existence possible d'une maladie in situ bilaterale chez 30 % des patientes. Le taux de rechute locale est de 20 % quel que soit le traitement initial et les rechutes se font toutes sur un mode infiltrant. Le risque de rechute controlaterale impose une surveillance continue meme en cas de traitement radical.

The American College of Radiology Task Force on Breast Cancer published in 2003 the fourth edition of BI-RADS for Mammography. It is a lexicon of mammography terms including illustrations of each feature described, followed by a reporting format with assessment categories according to the degree of concern. The aim is to reduce inconsistencies in mammography reports and recommendations for assessment, to facilitate outcome monitoring and to allow each radiologist to audit his own mammography practice. In France, the Societe Francaise de Radiologie acquired the rights to translate BI-RADS, word for word and without adaptation or influence. The last edition was published in 2004. Simultaneously, French Haute Autorite de Sante and National Committee for Breast Cancer Screening proposed to all community practice mammography facilities a classification of detected abnormalities stating more clearly than BI-RADS do which feature has to be included in such and such assessment category and how to manage it. This "classification ACR" is adapted from BI-RADS but strongly influenced by the context of the French nationwide screening programme, and by European recommendations to limitate undesirable risks of screening such as false positive and overdiagnosis. The differences between the two systems are discussed.

Resume Objectif. – L'objectif de cette etude quasi prospective a ete d'apprecier de maniere differentielle le vecu psychologique des prelevements percutanes afin d'adapter le don d'information et la prise en charge des femmes. Patientes et methode. – L'etude a ete realisee du 1 er mars 2002 au 31 mars 2003. Un questionnaire sur le stress percu (Q1) a ete remis en fin de procedure (T1) a 73 femmes. A la suite de l'annonce des resultats histologiques (T2), un questionnaire (Q2) a ete remis a ces memes patientes. Resultats. – Ce questionnaire a ete valide grâce a une analyse en composantes principales suivie de rotation Varimax. Ceci a permis d'identifier trois facteurs : « procedure », « qualite de vie », « information et vecu postprelevement ». L'analyse quantitative a ete completee par une analyse qualitative (test de χ2) menee sur chacun des items du questionnaire. Deux sous-groupes, en fonction des resultats histologiques, ont ete etablis. Le premier sous-groupe (G1) correspondait aux femmes ayant un resultat histologique benin ( n = 32), le second sous-groupe (G2) aux femmes ayant un resultat histologique malin ( n = 32). Seul le facteur « procedure » a presente un vecu differentiel entre T1 et T2 ( p = 0,022). La compression mammaire est douloureuse : 11 % a T1 versus 21 % a T2. Les femmes etaient inquietes de l'anesthesie locale : 26 % a T1 versus 21 % a T2. Le prelevement etait percu comme douloureux : 6 % a T1 versus 13 % a T2. L'examen a paru long : 24 % a T1 versus 35 % a T2. La position etait inconfortable : 52 % a T1 versus 54 % a T2. L'information a ete consideree comme satisfaisante dans 90 % des cas. Il n'y a pas eu de difference significative entre les sous-groupes G1 et G2 dans le vecu differentiel de la procedure ( p = 0,357). Discussion et conclusion. – Une information adaptee et une empathie medicale sont le garant d'une bonne tolerance de ce type de procedure.

Resume Le programme francais de depistage des cancers du sein est un systeme particulier qui s’inscrit dans les habitudes du systeme de soins francais : utilisation des structures de radiologie publiques et privees existantes, role des generalistes et des gynecologues dans la prescription et la prise en charge, deux incidences par sein tous les deux ans avec examen clinique, diagnostic immediat des anomalies detectees. Il repond cependant a la definition d’une action de sante publique programmee, par la formation prealable des intervenants, l’organisation, l’assurance de qualite a tous les niveaux, la double lecture et l’evaluation.Les avantages et les difficultes inherents a ce systeme inedit sont discutes.

Resume L’objectif de cette communication est de mettre en exergue les inadequations entre la classification radiologique d’une mammographie (elle traduit une Valeur Predictive Positive [VPP]), les perceptions et les representations des femmes. Cette etude est basee sur l’observation participante avec une analyse du corpus de donnees. Les resultats expriment une appropriation de cette nomenclature par les femmes. Il y a un « glissement semantique » du concept d’anomalie benigne vers celui de lesion. La mise en sens d’une probabilite (unite-objet statistique) et la realite de la personne humaine est difficilement comprehensible pour les patientes. Le cancer reste considere comme un processus mortifere nonobstant ce mot innommable peut etre nomme. Les praticiens doivent ajuster leur communication afin de rendre comprehensible un concept probabiliste.

The objective was to investigate women's perceptions and the perceived stress experience when undergoing surveillance mammography for benign lesions (ACR3, BI-RADS). A semi-prospective study was carried out on women with diagnosed "probably benign" breast abnormalities. It was a multicentric study from 1st March to 10th June 2002. The survey was performed at the first follow-up mammography and included questions about perceptions and perceived stress related to the follow-up experience. The response is analysed with chi-square test. Fifty women (35-75 years) answered the questionnaire. All women were satisfied with reception. The mammographies were painful (23 cases). Subsequent time seemed to be too long (seven cases) and they were anxious in 19 cases. Quality of life was spoiled (disturbed) (20 cases). Professional and social perturbations were not frequent (four cases). Speaking to a relative is frequent (39 cases), but patients were not satisfied with it (33 cases). Medical information was estimated (47 cases) but was not satisfactory (36 cases). The median of the stress scale is 4-5. There are two pickaxes, one at 2 (11 cases), the second at 5 (8 cases). "Low-stressed" women could have an avoidance coping. "High-stressed" women could use a helplessness- hopelessness coping strategy. Women reported a good and informative medical support and adequate comprehension of the short follow-up mammography. They were reassured by the medical care, but the evaluation of the stress level shows it to be high, probably due to the uncertainty of diagnosis.

Stereotactically-guided procedures for diagnosis of breast lesions can avoid a lot of surgical biopsies. Stereotactic guidance is used for vacuum-assisted core biopsies and for stereotactic breast biopsies. Technical details of the procedures are described, and the benefits and the limits of these methods are discussed. Indications for breast sampling are proposed according to the Breast Imaging Reporting and Data System (BI-RADS) assessment categories.

Six hundred seventy-six patients with ductal carcinoma in situ of the breast (DCIS) from 1971 to 1995 were included in the study. Computerized patient files were retrospectively analyzed. Clinical findings were less frequently reported to reveal DCIS after 1989. Positive mammographic findings were obtained in 87% of patients and were mainly represented by microcalcifications (79.4%). Treatment procedures were breast-conserving surgery (BCS) alone (37.5%), BCS followed by radiation (BCSR) (25.5%), or mastectomy (M) (37%). The actuarial local recurrence was 2.6% in the M group (94 months of follow-up), 14.5% in the BCS group (85,7 months of follow-up), and 7.5% in the BCSR group (78.8 months of follow-up). Predictive factors of recurrence in all patients were invaded margin status and age. In the BCS group, grade was also a predictive factor. The analysis per decade shows that the lesions currently diagnosed are less serious than those of the past. All the recurrence in patients with positive margins was in the same quadrant as the original lesion. This further emphasizes the need for clear margins.

Breast cancer among older women is a major and increasing public health issue. No clear recommendation has been established in France after 74 years, the age limit for state-organised screening program. A survey was performed among all regional agencies in charge of the breast screening to analyse which information is delivered to women reaching the age of 75 years. A postal survey sent to 91 French organised cancer screening agencies. Among the 89 agencies that answered, only 22 deliver a systematic written information. Twelve suggest that mammographic screening should be continued, and five mention clinical examination. Twenty agencies dispatch the screening to general practitioners or gynaecologists. Two information letters insist on the ongoing risk of breast cancer. Most of the written information is given with the last mammography report. No impact study has ever been performed. In our study, only 25% of the screening agencies give systematic information to women. The modalities and the substance of this information are heterogeneous. A better information seems to be a key-point for earlier clinical breast cancer diagnosis among older women, for whom there is little direct evidence of the benefit of systematic mammographic screening.

The American College of Radiology Task Force on Breast Cancer published in 2003 the fourth edition of BI-RADS for Mammography. It is a lexicon of mammography terms including illustrations of each feature described, followed by a reporting format with assessment categories according to the degree of concern. The aim is to reduce inconsistencies in mammography reports and recommendations for assessment, to facilitate outcome monitoring and to allow each radiologist to audit his own mammography practice. In France, the Société Française de Radiologie acquired the rights to translate BI-RADS, word for word and without adaptation or influence. The last edition was published in 2004. Simultaneously, French Haute Autorité de Santé and National Committee for Breast Cancer Screening proposed to all community practice mammography facilities a classification of detected abnormalities stating more clearly than BI-RADS do which feature has to be included in such and such assessment category and how to manage it. This "classification ACR" is adapted from BI-RADS but strongly influenced by the context of the French nationwide screening programme, and by European recommendations to limitate undesirable risks of screening such as false positive and overdiagnosis. The differences between the two systems are discussed.

We retrospectively analysed mammographies of 909 ductal carcinoma in situ (DCIS) (1980-1999) and compared our results to those of literature. Microcalcifications were present in 75% of the cases, and soft-tissue abnormalities in 27% cases with association with calcifications in 14% of cases. Palpable masses were found in 12% of the cases and nipple discharge was present in 12% of the cases. The radiographic-pathologic correlation allowed to suspect the DCIS "aggressiveness" on radiologic signs. Granular, linear, branching and/or galactophoric topography of the microcalcifications were correlated with necrosis, grade 3, comedocarcinoma type. A number of microcalcifications higher than 20 was correlated with necrosis and grade 3. Mammographic size was correlated to histologic size. Masses were correlated with grade 1. A diagnosis strategy can be proposed with a multidisciplinar approach.

Information takes a large part of patient's perceptions of the procedure. If the information is adapted, patients tolerate the procedure well. We point out indications and explain the different types of procedure. For infraclinical masses, sonographically guided automated core needle biopsy removes samples. Sonographically guided vacuum-assisted large-core biopsy is only used for diagnosis generally on second purpose for masses. Stereotaxic vacuum-assisted large-core biopsy is used for microcalcifications (needle 8 or 11 gauge). Haematoma and bleeding are rare (4%), but care is necessary to avoid complications. Information is executed before the procedure and a booklet is giving to the women. This information has to be adapted because lot of informations could increase patient's anxiety if they don't want more informations and "not enough information" could also increase anxiety if they want more informations. The practitioner, by hearing, his formation and his experience, is able to adapt informations.

Breast papillary lesions are difficult to interpret and include a large variety of benign, atypical and malignant lesions. We report the case of a 41-Year-old woman presenting with an intracystic papillary carcinoma, in order to illustrate our pragmatic diagnostic approach, which includes the use of a decision tree, useful for differentiating the different types of breast papillary lesions.

The purpose of this pictorial essay is to describe the different mammographic aspects of residual Lipiodol ultra fluid (LUF) after galactography, and to define some specific patterns, because it may in some cases mimic microcalcifications and give diagnostic problems. The mammograms of 14 patients, aged 32–63 years, presenting LUF residues related to previous galactography, were analyzed retrospectively. In 12 cases the diagnosis was easy because the patients presented a typical pattern on mammography and came with their initial galactography. In 2 cases the diagnosis was more difficult because the patients did not remember the previous injection and the progressive resorption mimicked perfectly intraductal calcification. Benign duct ectasia with inflammatory reaction to foreign bodies were found in 3 cases in which surgery was performed. Lipiodol ultra fluid is no longer used for galactography, but it may persist in breast ducts or cysts for years and seems to still be used in some countries. There are in most cases specific signs enabling the diagnosis.

We are doing research on computerized techniques for classifying mammograms as dense or fatty. The hypothesis is that areas of dense tissues are the major factor making certain mammograms harder for both radiologists and computers to interpret. Automatic identification of dense mammograms might therefore permit better use of the time and skills of expert radiologists. Concentrating on the fatty mammograms could also improve the scope for computer-aided detection of abnormalities. Mammograms were independently classified by two radiologists, with a high level of inter-observer agreement. A number of local statistical and texture measures were compared, initially on manually-placed patches of the digitized images. Two strategies for automating the procedure were then compared. The most successful measure (based on grey-level skewness in small tiles) and strategy (automatic patch placement) yield an almost automatic procedure which produces a promising separation between the classes. Evaluation of a fully-automated procedure is in progress.

Objectifs pedagogiques Mise au point sur le contexte reglementaire du programme national. Retour d’information sur le deroulement des programmes. Recommandations pour le respect des cahiers des charges. Etat des lieux de l’activite globale de la mammographie en France.