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Review

Mammography screening and follow-up of breast cancer

Abstract

Breast cancer is the leading cause of cancer death among women worldwide. Imaging plays a key role in the early detection of breast cancer, and there is strong evidence that mammography screening has proven to be effective in reducing breast cancer mortality. Organized mammography screening programmes have been established around the globe, mostly in developed countries. Screening is important for an early diagnosis; however, the follow-up of patients with breast cancer is of importance, too. This review article is divided into two sections. The first section provides a general overview of mammography screening, including quality standards, controversial issues and aspects of high-risk screening. In the second section, we describe the potential uses of imaging modalities in the follow-up of breast cancer patients.

Mammography screening

Breast cancer is one of the leading causes of death among women in industrialized countries. In 2008, 1 383 500 new cases were diagnosed and 458 400 led to the death of the patient.1 Breast cancer mortality depends very much on tumour size and stage, as well as the presence and number of metastatic axillary lymph nodes and metastatic spread.2,3 Survival rates correlate strongly with early detection and diagnosis. There is strong evidence that mammography screening is effective in reducing breast cancer mortality.4–6 Thus, organized mammography screening programmes have been established around the globe, mostly in developed countries. Despite the positive aspects of screening, the problem of overdiagnosis, which results in unnecessary treatment interventions, should be considered as well. The first part of this review article provides a general overview of mammography screening, including quality standards, controversial issues and aspects of high-risk screening.

Historical overview

In the early to mid-twentieth century, public education programmes focused on breast self-examination (BSE) and systematic clinical breast examination (CBE) to detect breast cancer in its earliest phases.7 However BSE and CBE did not reduce breast cancer mortality to any significant degree. Experimental work with X-rays demonstrated that non-palpable breast cancer could be identified by mammography.8,9 Compared with BSE, the detection rate was much higher and mammography detected malignant breast lesions at earlier stages.5,10 This fact led to the first randomized controlled trial to detect early-stage breast cancer in the United States. The HIP Study (Health Insurance Plan of Greater New York) started in 1963 and ended in 1986. More than 60 000 women aged between 40 and 64 years were randomly assigned to either a study group or a control group. One group was subjected to screening examinations that consisted of screening mammography and CBE. The control group underwent CBE only. After 10 years, the mortality rate from breast cancer was reduced by 30% among the group who received mammography and CBE, whereas in the control group mortality rate was significantly higher. The greatest benefit was found in women over 50 years of age. In 1977, Sweden began randomized trials to test the efficacy of breast cancer screening with mammography.6 The results showed a mortality reduction of 31%. Other studies confirmed these results,11,12 and found an average mortality reduction of 25% for women between 50 and 69 years of age. Based on these findings, the WHO and the European Union recommend performing biannual mammography screening in women between 50 and 69 years of age.13

Quality-assured mammography screening in the EU

The first European Guidelines for Quality Assurance in Mammography Screening were released in 1992. The extended 4th edition was published in 2006, and became the standard reference for quality-assured mammography screening programmes, including the assessment and treatment of any breast disease within the EU. The main goals of this EU initiative are (a) the detection of breast carcinomas at an early and metastasis-free stage; (b) a 25–30% reduction in breast cancer mortality; (c) a significant reduction in the mastectomy rate (to less than 25%); and (d) improved outcomes and less harmful therapies. Below is an overview of the most important aspects of the guidelines, with regard to organization, medical specifications and quality assurance:13

Organization

  • Organized, written invitation to participate.
  • Screening examination in a special screening unit.
  • Women 50–69 years of age.
  • Two-year interval between screening examinations.
  • Participation of 70–75% of the population.
  • Technical quality assurance.

Medical specifications

  • Double reading by two independent radiologists.
  • If discordant reporting, a third radiologist consultant.
  • Five thousand mammograms per year for certification.
  • Double reporting by pathologists.
  • Special training for radiologists/radiographers at a European reference unit.
  • Special training for pathologists.

Quality assurance

  • QA in diagnostic, therapeutic and follow-up procedures
  • Interdisciplinary conferences pre- and post-interventional (radiologist, pathologist, surgeon, etc.).
  • Documentation
    • quality monitoring
    • central breast cancer administration.
  • Networking among different organizations
    • EUREF (European Reference Organization for Quality Assured Breast Screening and Diagnostic Services)
    • EBCN (European Breast Cancer Network).

Quality is one of the most important aspects of any screening programme; thus, ‘key performance indicators for a quality-assured mammography screening programme’ have been developed and are summarized in Table 1. In addition, educational programmes, advertising, well-balanced communication strategies and the support of health professionals, politicians and industry are of the utmost importance in order to operate a successful programme.

TABLE 1 Summary table of key performance indicators (from Perry et al.13)

Performance indicator

Acceptable level

Desirable level

Target optical density

1.4–1.9

1.4–1.9

Spatial resolution

> 12 lp/mm

> 15 lp/mm

Glandular dose – PMMA thickness at 4.5 cm

< 2.5 mGy

< 2.0 mGy

Threshold contrast visibility

< 1.5%

< 1.5%

Proportion of women invited that attend for screening

> 70%

> 75%

Proportion of eligible women reinvited within the specified screening interval

> 95%

100%

Proportion of eligible women reinvited within the specified screening interval + 6 months

> 98%

100%

Proportion of women with a radiographically acceptable screening examination

97%

> 97%

Proportion of women informed of procedure and time scale of receiving results

100%

100%

Proportion of women undergoing a technical repeat screening examination

< 3%

< 1%

Proportion of women undergoing additional imaging at the time of the screening examination in order to further clarify the mammographic appearances

< 5%

< 1%

Proportion of women recalled for further assessment

Initial screening examinations

< 7%

< 5%

Subsequent screening examinations

< 5%

< 3%

Proportion of screened women subjected early recall following diagnostic assessment

< 1%

0%

Breast cancer detection rate, expressed as a multiple of the underlying, expected, breast cancer incidence rate in the absence of screening

Initial screening examinations

3 x IR

> 3 x IR

Subsequent-regular screening examinations

1.5 x IR

> 1.5 x IR

Interval cancer rate as a proportion of the underlying, expected, breast cancer incidence rate in the absence of screening

Within the first year (0–11 months)

30%

<30%

Within the second year (12–23 months)

50%

<50%

Proportion of screen-detected cancers that are invasive

90%

80–90%

Proportion of screen-detected cancers that are stage II

Initial screening examinations

NA

<30%

Subsequent regular screening examinations

25%

<25%

Proportion of invasive screen-detected cancers that are node negative

Initial screening examinations

NA

> 70%

Subsequent regular screening examinations

75%

> 75%

Proportion of invasive screen-detected cancers that are < 10 mm in size

Initial screening examinations

NA

>25%

Subsequent regular screening examinations

> 25%

> 30%

Proportion of invasive screen-detected cancers that are < 15 mm in size

50%

> 50%

Proportion of invasive screen-detected cancers < 10 mm in size for which there was no frozen section

95%

> 95%

Absolute sensitivity of FNAC

> 60%

> 70%

Complete sensitivity of FNAC

> 80%

> 90%

Specificity of FNAC

> 55%

> 65%

Absolute sensitivity of core biopsy

> 70%

> 80%

Complete sensitivity of core biopsy

> 80%

> 90%

Specificity of core biopsy

> 75%

> 85%

Proportion of localized impalpable lesions successfully excised at the first operation

> 90%

> 95%

Proportion of image-guided FNAC procedures with insufficient result

< 25%

< 15

Proportion of image-guided FNAC procedures from lesions subsequently proven to be malignant, with an insufficient result

< 10%

< 5%

Proportion of patients subsequently proven to have breast cancer with a preoperative FNAC or core biopsy at the diagnosis of cancer

90%

> 90%

Proportion of patients subsequently proven to have clinically occult breast cancer with a preoperative FNAC or core biopsy that is diagnostic for cancer

70%

> 70%

Proportion of image-guided core/vacuum procedures with an insufficient result

<20%

< 10%

Benign to malignant open surgical biopsy ratio in women at initial and subsequent examinations

<1 :2

< 1:4

Proportion of wires placed within 1 cm of an impalpable lesion prior to excision

90%

> 90%

Proportion of benign diagnostic biopsies on impalpable lesions weighing less than 30 g

90%

> 90%

Proportion of patients in whom a repeat operation is needed after incomplete excision

10%

< 10%

Time (in working days) between

Screening mammography and result

15

10

Symptomatic mammography and result

5

3

Result of screening mammography and offered assessment

5

3

Result of diagnostic mammography and offered assessment

5

3

Assessment and issuing of results

5

3

Decision to operate and date offered for surgery

15

10

Mammography screening programmes around the globe

Incidence rates vary greatly worldwide, with age-standardized rates as high as 99.4 per 100 000 in North America. Eastern Europe, South America and Western Asia have moderate incidence rates, but they are increasing. The lowest incidence rates are found in most African countries. Different countries have different resources for medical care. This includes funds, human resources and education. Thus, programme planners should consider WHO and EU criteria and local input data when implementing mammography screening programmes for the needs of their populations, and must ensure that such programmes are both tailored to, and evaluated by, each state individually. Table 2 gives an overview of different screening programmes around the world.

TABLE 2 Overview of mammography screening programmes around the world (modified from Smith40)

Country

Organizational level

Year initiated

Detection methods

Age (years)

Screening interval (years)

Europe

Austria

NS, O

2010

MM

40–69

1 (2)

Denmark

S

1991

MM, DM

50–69

2

Finland

N

1986

MM, DM

50–69

2

France

NS

1989

MM, CBE

50–74

2

Hungary

N

2002

MM

45–65

2

Ireland

N

2000

MM, DM

50–64

2

Italy

NS

2000

MM

50–69

2

Luxemburg

N

1992

MM

50–69

2

Netherlands

N

1989

MM

50–75

2

Norway

N

1996

MM, DM

50–69

2

Portugal

S

1990

MM, CBE

50–69

2

Spain

S

1990

MM

45–70

2

Sweden

NS

1986

MM, DM

40–74 (1)

40–54

1.5

55–74

2

Switzerland

S, O

1999

MM

50–69

2

United Kingdom

N

1988

N, MM, DM

50–70 (3)

3

North America

Canada

NS

1988

MM, DM, CBE

40–69

40–49

1

50–69

2

United States

MM, DM, CBE

40-

1–2

Latin America

Brazil

NS

2000

MM, CBE

40–49

2

Mexico

NS, O

2002

MM, CBE

40–69 (2)

1–2

Uruguay

N

1990

MM, CBE

40–69

40–49

2

50–69

1

Middle East

Israel

N

1997

MM

50–74

2

Jordan

O

2006

MM, CBE

40-

40–49

2

50-

1

Asia/Pacific

Australia

NS

1991

MM

50–69

2

Japan

N

2002

MM, DM, CBE

40–75

2

Korea

N

2002

MM

40–75

2

New Zealand

N

1998

MM, DM

45–69

2

Taiwan

N, O

2004

MM

45–69

2

Organizational level: N, national screening policy; NS, national screening policy with state/provincial/regional implementation; S, state/provincial/regional implementation; O, opportunistic screening.
Modality: MM, mammography; DM, digital mammography; CBE, clinical breast examination; BSE, breast self-examination .
(1) Countries determine whether to invite beginning at age 40 or 50. (2) Invitations and/or intervals vary by risk assessment. (3) Target population expanding to 47–73.

Controversial issues in mammography screening

Extension of age groups

There is strong evidence that mammography screening is effective in reducing breast cancer mortality, particularly in women aged 50–70. There is an on-going debate about whether screening in younger or elderly women is also effective (Table 3). Although no single randomized trial has clearly shown a reduction in mortality from mammography screening among women aged 40–49 years, several meta-analyses have demonstrated that mortality from breast cancer is reduced by 15–20% in this age group.14–17 A lower breast cancer risk, the lower sensitivity of mammography and a higher rate of false-positive findings among younger women than among older women, all of which lead to unnecessary breast biopsies, were considered to amount to a benefit-to-risk ratio that was too high to allow routine screening in women less than 50 years of age. However, this recommendation should be viewed with caution because of the greater number of years of life expectancy gained from preventing death from breast cancer in younger women. Screening initiated at the age of 40 years rather than 50 years would avert one additional death from breast cancer for every 1000 women screened, resulting in 33 life-years gained (Table 4).18 A recent study from Sweden, with an average of 16 years' follow-up, showed that the screening programme led to a reduction in mortality of 29%. This is why a newly initiated screening programme in Austria devised a compromise and begins inviting women > 45 years of age to be screened (http://www.bmg.gv.at).

TABLE 3 Age for inclusion in breast cancer screening programmes in different societies

Organization

Year

Mammography

National Health Service, United Kingdom

2011

47–73 years, every 3 years

NCCN (National Comprehensive Cancer Network)

2011

≥ 40 years, annually

ACS (American Cancer Society)

2010

≥ 40 years, annually

NCI (National Cancer Institute)

2010

≥40 years every 1–2 years

USPSTF (US Preventative Services Task Force)

2009

50–74 years, every 2 years

40–49/74+ years, individually

ACR (American College of Radiology)

2008

≥ 40 years, annually

WHO (World Health Organization)

2007

50–69 years, every 2 or 3 years

ACP (American College of Physicians)

2007

50–74 years, every 1–2 years

40–49 years, individualize the decision (every 1–2 years)

EU (European guidelines for mammography screening)

2006

50–69 years, every 2 or 3 years

American College of Obstetricians and Gynecologists

2003

40–49 years, every 1–2 years

≥ 50 years, annually

CTFPHC (Canadian Task Force on Preventative Health Care)

1998–01

50–69 years, every 1–2 years

40–49 years, individualize the decision (every 1–2 years)

Data are very rare for mammography screening in the age group > 70 years. The prognostic factors and the reduction in mortality have not been well evaluated in this age group. The Swedish mammography screening trial, which included women > 70 years, showed no significant benefit. The Cancer Intervention and Surveillance Modeling Network (CISNET) of the National Cancer Institute in the United States estimated that two deaths from breast cancer would be prevented per 1000 if women older than 70 were screened by mammography.19,20 Although there is a small benefit to extending screening beyond 70 years, there is agreement that screening is not indicated for women who have serious coexisting illnesses and a life expectancy of less than 5–10 years (Table 4).

TABLE 4 Number for screenings needed to prevent death from breast cancer (by age) (modified from Warner18)

Age (years)

No. of trials

Relative risk
(95% confidence interval)

No. of screenings to prevent one death

39–49

8

0.85 (0.75–0.96)

1904 (929 – 6378)

50–59

6

0.86 (0.75–0.99)

1339 (322 – 7455)

60–69

2

0.68 (0.54–0.87)

377 (230 –1050)

70–79

1

1.12 (0.73–1.72)

Not available

Data from meta-analyses of randomized breast cancer screening trials.6,12,41–47

Role of ultrasound of the breast

The sensitivity to detect breast carcinomas is reduced in women with dense breasts.21 Dense tissue is more common in younger women. Stomper et al.22 reported that about 62% of women in their 30s, 56% of women in their 40s and 27% of women in their 60s have dense breast tissue. Several studies have demonstrated that ultrasound of the breast can detect otherwise occult breast carcinomas in dense breast parenchyma. Adding ultrasound to mammography will yield an additional 1.1–7.2 cancers per 1000 women, but will also substantially increase the number of false-positives up to 16%.23–27 There is no doubt that breast ultrasound should be performed in women with a palpable lump, and to characterize lesions seen on mammography more precisely. However, a consensus statement published by the European Group for Breast Cancer Screening in 1998 concluded that there is no evidence to support the use of ultrasound for breast cancer screening at any age.28

Overdiagnosis

Overdiagnosis is the detection of breast cancer that would not have presented clinically during the woman’s lifetime, and, thus, would not have been diagnosed in the absence of screening. Cancers detected at screening that would not have presented clinically represent the major problem with mammography screening. Several studies have tried to quantify the problem of overdiagnosis. The estimation varies between 1% and 50%. Another problem has been whether the increasing detection of ductal carcinoma in situ (DCIS; cancers with an excellent prognosis) should also be considered as overdiagnosis. DCIS was an unusual diagnosis before the implementation of mammography screening, but today represents about 20–25% of screening-detected cancers. Thus, overdiagnosis estimates could also be influenced by the threshold for recall of subtle non-specific findings. In general, it is suggested that overdiagnosis, if any, is associated with the detection of DCIS and small invasive cancers and causes harm in less than 10%.29,30

Risk factors

Primary risk factors for breast cancer are female sex, age, lack of childbearing or breastfeeding, higher hormone levels, race, low economic status and dietary iodine deficiency.31–36 Approximately 38% of breast cancer cases in the USA are preventable through a reduction in alcohol intake, increasing physical activity levels and maintaining a healthy weight. It is also estimated that 42% of breast cancer cases in the UK could be prevented in this way, as well as 28% in Brazil and 20% in China. In addition, genetic mutations seem to play an important role. The cumulative risk for women with a genetic predisposition to develop breast cancer, up to the age of 70, is reported to be as high as 83%. In contrast to the average population, there is already a significant breast cancer risk at the age of 25 for individuals with a genetic predisposition, and, by the age of 50, 50% of the BRCA1 or BRCA2 mutation carriers have developed the disease. In addition to the BRCA genes, more as yet unknown breast cancer susceptibility genes are suspected. The high prevalence and early onset of breast cancer in women with a genetic predisposition necessitate an intensified surveillance protocol beginning at a young age. Until recently, mammography represented the only accepted and widely recommended breast cancer surveillance modality. However, mammography offers low sensitivity in young women because of their higher glandular breast density. In addition, the ionizing radiation that penetrates the breast tissue during mammography is presumed to carry an increased risk for women with a genetic predisposition for breast cancer due to impaired DNA repair mechanisms. In contrast, magnetic resonance imaging (MRI) of the breast is known to have a high sensitivity for breast cancer, independent of breast density, and bears no radiation risk. Recent guidelines recommend annual MRI breast cancer screening for high-risk patients beginning at the age of 30 years. MRI examinations and readings should be performed at an approved and quality-assured unit to improve sensitivity and specificity. Mammography should not be performed in women under the age of 35.37–39

Follow-up of breast carcinomas

Breast cancer recurrence is a widespread problem. It is commonly accepted that recurrence is adversely correlated with survival in cancer patients.48–55 Although most patients are subject to follow-up examination after the end of therapy, diagnosis of recurrence is often difficult, especially in the early stages. Early detection of recurrence is, however, vital for the patient’s outcome.56,57 Multiple follow-up strategies, often combining a multitude of different examination techniques, such as physical examinations, lab tests and/or different imaging modalities, have been developed and implemented into the clinical routine. An example of the Austrian annual follow-up protocol for the first 5 years after therapy is given in Table 5. However, to date, there is no consensus about an internationally accepted common follow-up protocol.

In the second section of this review article, we describe the potential uses of imaging modalities in the follow-up of breast cancer patients.

TABLE 5 Annual follow-up protocol for breast cancer patients in Austria for the first 5 years after disease

Low risk

High risk, triple-negative, Her2-positive

Tumour markers

1

1

Alkaline phosphatase

1

1

Bone scan

1*

1*

CT thorax/abdomen

1

1

MRI neurocranium

0

1

Mammography

1

1

0, no exams; 1, exams. *Only in case of elevated alkaline phosphatase.

Locoregional recurrence

Locoregional recurrence occurs in the same region as the primary tumour, namely the ipsilateral breast, the adjacent chest wall or the ipsilateral axillary lymph nodes.

Rates of locoregional recurrence have been reported to range from around 0.5% to 1.5% per year after diagnosis, with a peak after 2–7 years, depending on treatment strategy and extent of primary disease.58–62 A long-term follow-up study published by Fisher et al.63 reported 20-year locoregional recurrence rates of 8.1% after lumpectomy and irradiation, 14.8% after total mastectomy and 17.5% after lumpectomy alone. In that study, 76% of all locoregional recurrences occurred in the first 5 years of follow-up, about 16% between 5 and 10 years, and 8% after more than 10 years.

Various imaging modalities can be used to detect locoregional recurrence. The standard imaging tools for follow-up are mammography and ultrasound, both of which are fast, cheap and widely available. Imaging after breast-conserving surgery (BCS) poses a severe challenge because of the limited compressibility of the breast and overlapping features of benign post-treatment findings and tumour recurrence. After BCS and radiation therapy, mammographic findings, such as breast oedema, skin thickening, fluid collections, architectural distortion and calcifications, have characteristic sequences of evolution towards stability. Changes in the imaging appearance after stability have been observed, including increasing asymmetry, an enlarging mass, increasing oedema or skin thickening, and the development of pleomorphic calcifications within or near the operative bed, all of which hint at possible tumour recurrence.64 However, the diagnostic accuracy of mammography in the detection of locally recurrent breast cancer is limited, with sensitivities as low as 55–68% reported.65–67 Apart from its generally accepted weakness in very dense breasts, it is often hard to discriminate between scar tissue and recurrent tumour formations with mammography. Other disadvantages include the exposure to ionizing radiation and compression of the breast, which can be painful for the patient.68–75

Ultrasound has shown better results than mammography in diagnosing locoregional recurrence, especially in lymph nodes and the chest wall.76–79 However, its accuracy in the differentiation between scar and recurrence is still limited.80,81 A problem is the lack of reproducibility and the fact that ultrasound is heavily dependent on the experience of the examiner.

In recent years, magnetic resonance imaging (MRI), which provides excellent tissue contrast and does not use ionizing radiation, has been established as a valuable tool for the detection and staging of recurrence when findings are indeterminate on mammography or ultrasound (Figure 1). Local recurrence can be detected at rates of around 90% with dynamic contrast-enhanced MRI,82,83 and the differentiation of scar tissue from recurrent malignancy is possible with high accuracy.84,85 Recently, additional MR techniques, such as diffusion-weighted imaging or MR spectroscopic imaging (MRSI), have been developed, and studies have indicated their potential to further improve the diagnostic accuracy in the detection of breast cancer recurrence.86,87 One limitation is that early examinations with MRI can lead to false-positive results. Follow-up MRI should not be performed within the first 6 months after surgery or within the first 12–18 months after combined surgery and radiation therapy.88 Another limitation is that not all patients are suitable for MRI follow-up, for example those with metallic implants or devices such as some orthopaedic prostheses or pacemakers.

FIGURE 1 A 54-year-old woman with a history of invasive lobular breast cancer (ILC G3) of the right breast treated with skin-sparing mastectomy and reconstructive surgery as well as adjuvant chemotherapy presented with a palpable lump of the right breast. Ultrasound (A) reveals a suspicious, spiculated, irregular mass (1 cm) in the upper outer quadrant of the breast (bold arrow). Contrast-enhanced T1-weighted MRI (B) and subtractions (C) demonstrate suspicious enhancement of the lesion, also hinting at recurrence. Additionally, MRI revealed an extensive, enhancing mass in the thoracic wall (arrow) indicative of a local recurrence. Ultrasound-guided biopsy of the masses in the breast and in the thoracic wall revealed a local recurrence of an invasive lobular cancer.

   

Positron emission tomography (PET) has demonstrated good sensitivity (87%) and specificity (83%) in the detection of breast cancer recurrence.89 At present, 18-fluorodeoxyglucose (18-FDG) is the most common tracer. In contrast to scar tissue or most benign changes, recurrence is FDG avid.89 However, the limitations of this method are its relatively low spatial resolution and the fact that other benign processes, such as inflammation, can mimic cancer and thus lead to false-positive results.90,91 It can be expected that with the introduction of new tracers, such as specific, radiolabelled antibodies, the specificity of detection of recurrence will be increased. By adding CT, which on its own is of limited value in the diagnosis of local recurrence, the advantages of PET and CT, which provide metabolic and morphological information, respectively, are combined. Studies have demonstrated that PET–CT has excellent sensitivity and specificity of up to 97% and 92%, respectively, in suspected locoregional recurrence92 and, in the case of full body images, also very good rates in distal recurrence.90,93,94

An emerging imaging modality for improved assessment of recurrence is PET–MRI. Preliminary studies have shown promising results.62 Multiparametric molecular imaging with PET–MRI, which compared with PET-CT involves hardly any ionizing radiation, has the potential to substantially increase sensitivity and specificity in the diagnosis of recurrence, as well as to provide optimal information on tumour localization and extent, which is essential for further therapy planning

Distant recurrence

Distant recurrence occurs in organs which are not directly adjacent to the location of the primary tumour. Distant recurrence is much more common than locoregional recurrence. Large, long-term studies have found overall rates of distant recurrence of about 25–40%.62,95

The organs that are mostly affected by breast cancer metastases are the bones (in 30–80% of patients with distant recurrence), the liver (up to 60%) and the central nervous system (10–30%). Recurrence in other locations is very rare.96 In general, the imaging modalities employed for the detection of distant recurrence are ultrasound, bone scans, CT, PET–CT and MRI. The decision as to which modality is utilized depends on the organ of interest.

Bones

Bone scanning using 99Tc-methylene disphosphonate is still the standard imaging modality for the detection of bone metastasis. Recent reviews97 of imaging of bone metastasis in breast cancer have reported that this method has good sensitivity and specificity of around 80%, but the results are highly variable (62–100%). Although conventional radiography performed much worse, providing sensitivities of only about 40–50%,98–102 detection rates of 71–100% for CT and 82–100% for contrast-enhanced MRI have been described.103–105

Liver

Metastases are the most common malignant tumours found in the liver.106 For practical and economic reasons, they are usually diagnosed using sonography, even though CT and MRI provide better diagnostic accuracy.107–110 The performance of CT and MRI for detection of liver metastasis varies greatly in different studies, from around 60% to 97% for CT and from 68% to 92% for MRI.111–113

CNS

The gold standard for the imaging of brain metastases in breast cancer is MRI. Sensitivities and specificities of around 76% and 77% have been reported for contrast-enhanced MRI,114 far superior to contrast-enhanced CT.115–119 Combined PET–MRI increases sensitivity to up to 86%.120

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