Mathelin C, Molière S
Service de chirurgie, Institut de cancérologie Strasbourg Europe (ICANS), 17, rue Albert-Calmette, 67033 Strasbourg cedex, France; CHRU, Hôpitaux universitaires de Strasbourg, 1, place de l'hôpital, 67091 Strasbourg, France; IGBMC, Institut de génétique et de biologie moléculaire et cellulaire, biologie du cancer, CNRS UMR 7104, INSERM U964, Université de Strasbourg, Illkirch, France.
CHRU, Hôpitaux universitaires de Strasbourg, 1, place de l'hôpital, 67091 Strasbourg, France; Unité d'imagerie mammaire, Institut de cancérologie Strasbourg Europe (ICANS), 17, rue Albert-Calmette. 67033 Strasbourg cedex, France.
Gynecol Obstet Fertil Senol. 2021 May;49(5):485-492. doi: 10.1016/j.gofs.2021.03.026. Epub 2021 Mar 20.
The objective was to evaluate the diagnostic value of clinical examination and complementary imaging in the exploration of a breast lump or microcalcifications occurring in a postmenopausal woman taking hormonal replacement therapy (HRT), based on a systematic review of the literature in order to make recommendations for HRT management.
A literature review was conducted using Medline, Cochrane Library data and international recommendations in French and English until 2020.
In the presence of a clinical breast mass in postmenopausal women, there is no clinical evidence to rule out cancer. A double evaluation by mammography and ultrasound is recommended and allows the imaging to be classified into 5 BI-RADS categories. The diagnostic management of masses classified BI-RADS 4 and 5 should be based on percutaneous sampling, with microbiopsy being the first step. A total of four situations may arise: 1. Clinical examination has detected a breast mass, but there is no imaging abnormality. In this case, the imaging NPV is high (>96%). If the clinical lesion increases in size, a tissue biopsy should be performed, while continued routine breast screening is recommended if the lesion remains stable and HRT can be continued. 2. Clinical examination, mammography, and ultrasound are in favour of a cyst. Simple cysts can be punctured if painful. There is no contraindication to continuing HRT in the case of simple cysts. Management options for complicated and complex cysts are no different from those offered to women without HRT. Continuation of HRT must consider their histological nature. 3. Clinical examination, mammography, and ultrasonography suggest a benign solid tumour. The management of these benign breast lesions (fibroadenoma…) is not different in women taking an HRT and there is no contraindication to continue the HRT. 4: Clinical examination, imaging and microbiopsy diagnose a malignant tumour. It is imperative that the HRT be stopped, whatever the hormonal dependence of the tumour and whether it is invasive or in situ. The management of the cancerous tumour must consider the updated breast cancer treatment guidelines. In the presence of microcalcifications, the course of action to be taken depends on the BI-RADS classification, established according to the morphology and arrangement of the calcifications. In case of suspicious microcalcifications (BI-RADS 4 or 5), a guided macrobiopsy should be performed. Diagnostic and therapeutic management in these patients is no different from that offered to women without HRT. Discontinuation of HRT is necessary in cases of malignancy (in situ or invasive cancer).
A rigorous multidisciplinary approach is necessary for the exploration of a breast mass or microcalcifications in a postmenopausal woman.
基于对文献的系统综述，评估临床检查及辅助成像在探索接受激素替代疗法（HRT）的绝经后女性出现的乳腺肿块或微钙化中的诊断价值，以便为HRT管理提供建议。
利用Medline、Cochrane图书馆数据以及法语和英语的国际推荐进行文献综述，直至2020年。
对于绝经后女性出现临床乳腺肿块的情况，尚无临床证据排除癌症。建议进行乳腺钼靶和超声双重评估，并可将成像分为5个BI-RADS类别。对分类为BI-RADS 4和5的肿块的诊断管理应基于经皮取样，细针穿刺活检是第一步。总共可能出现四种情况：1. 临床检查发现乳腺肿块，但成像无异常。在这种情况下，成像的阴性预测值很高（>96%）。如果临床病变增大，应进行组织活检；如果病变保持稳定且可继续HRT，则建议继续进行常规乳腺筛查。2. 临床检查、乳腺钼靶和超声均支持为囊肿。如果疼痛，单纯性囊肿可进行穿刺。对于单纯性囊肿，继续HRT没有禁忌证。复杂性囊肿和复合性囊肿的管理选项与未接受HRT的女性相同。继续HRT必须考虑其组织学性质。3. 临床检查、乳腺钼靶和超声提示为良性实性肿瘤。这些良性乳腺病变（纤维腺瘤等）在接受HRT的女性中的管理并无不同，继续HRT也没有禁忌证。4. 临床检查、成像和细针穿刺活检诊断为恶性肿瘤。无论肿瘤的激素依赖性如何以及是浸润性还是原位癌，都必须停止HRT。癌性肿瘤的管理必须考虑最新的乳腺癌治疗指南。对于微钙化，应采取的行动方案取决于根据钙化的形态和排列确定的BI-RADS分类。对于可疑微钙化（BI-RADS 4或5），应进行引导下粗针穿刺活检。这些患者的诊断和治疗管理与未接受HRT的女性相同。在恶性肿瘤（原位癌或浸润性癌）的情况下，必须停止HRT。
对于绝经后女性乳腺肿块或微钙化的探索，需要严格的多学科方法。
