Diagnostics & Imaging Week

VIENNA, Austria – Only a show business convention could offer more images of women’s breasts than a radiology conference.

There is no entertainment value, however, in the science of breast cancer — nor in the harsh statistics surrounding the disease. In Europe this year, 370,000 women will receive a diagnosis of breast cancer and 130,000 of them will die from it.

Not only is the rate of death shockingly high, the incidence of breast cancer has climbed over the past 20 years to reach 12% in Europe.

Beyond the images of breasts bared by dozens of exhibitors at the European Congress of Radiology, which ended here Tuesday, the message that came through is this no longer is your mother’s mammography.

Diagnostic imaging has moved beyond squishing breasts between plates of glass in the hunt for the second-deadliest disease among women.

And the science of diagnosing women’s diseases also has moved beyond breast cancer to include a vast range of gender-specific conditions.

Professor Gerhard Mostbeck, president of the Austrian Roentgen Society (Vienna, Austria), said imaging practices and newly acquired knowledge of diseases specific to mammary glands, female reproductive organs, pregnancy and systemic illnesses such as osteoporosis, rheumatism and atherosclerosis need to be included in general radiology training to prevent a separation of male and female practices.

“Women in Radiology,” the theme for this year’s event organized by the European Society for Radiology (ESR; Vienna), proved to be more than a Viennese gallantry.

In addition to the numerous scientific sessions and mini-courses dedicated to a range of women’s health issues, ESR took on professional barriers faced by women radiologists, from dealing with medical macho from male colleagues to the social stress of balancing a demanding career against domestic duties.

The headline discussions at ECR 2008 for gender-specific diseases where radiology plays a key role included advances in diagnostic imaging for breast cancer and a debate over acceptance of uterine fibroid embolization.

Professor Christiane Kuhl from the University of Bonn in Germany, whose studies of MRI in breast cancer have been published in the profession’s most prestigious publications, presented a series of findings to prove her case that while ultrasound is now the dominant imaging modality, it increasingly is being replaced by more powerful techniques.

Detection and treatment are key to survival and when the cancer is identified at a localized stage, there is a 90% survival rate today, she said.

“This is the mammography success story, but there is clearly room for improvement,” Kuhl said.

MRI is superior to mammography for all forms of diagnostics, she said, whether for primary or recurrent, invasive or intraductal and irrespective of a woman’s breast density.

The primary objection to using MRI is economic: that it is far too expensive to be used as a frontline screening tool. A breast MRI costs about €450 ($688), or about four times the cost of digital mammography.

Kuhl countered this challenge by presenting a study she led, published in August 2007 in The Lancet, where MRI detected more than double the number of cases of ductal carcinoma in situ (DCIS) than mammography.

Out of 167 women imaged and diagnosed with pure DCIS, 56% were diagnosed by mammography and 92% by MRI in the study.

The progress of MRI in breast cancer studies in recent years has been to move from a second-line modality for verification to the primary tool for staging of the cancer, whether during development or in follow up to surgery, and now to screening.

She said the American Cancer Society (Atlanta) last year recommended MRI over ultrasound as the first line of diagnostic imaging for women at high risk, for example with a family history of developing breast cancer.

Kuhl said mammography has had a substantial impact on the reduction of cancer and early treatment and she did not want to convey the message that ultrasound is ineffective, thus causing women to stop reporting for screenings.

Yet it has become increasingly evident “that breast MRI is by far the most powerful breast imaging technique that is currently available,” she said.

Meanwhile, a debate over uterine artery embolization (UAE) played out across scientific sessions and in the conference’s kick-off press conference.

On its face, a procedure based on a radiological intervention might be expected to receive a warm reception at a conference gathering thousands of practicing radiologists. But this alternative to hysterectomy, the traditional and long-dominant treatment for uterine fibroids, remains highly controversial.

Gynecologists openly resist even a patient’s insistence on the UAE procedure for medical reasons, in that it is considered a novel procedure, but also for the implicit threat it poses to an established surgery.

At stake is a woman’s ability to conceive and bear children.

Uterine fibroids are benign tumors that grow from the muscular wall of the uterus and are experienced during a woman’s childbearing years. The condition tends to disappear with menopause and the cessation of estrogen secretions that provoke fibroid growth.

Globally the condition can be experienced to some degree by one in three women, although it is most prevalent among black Africans.

The fibroids cause heavy menstrual bleeding and discomfort ranging from inconvenience to outright pain. In more extreme cases, fibroids can grow to a size that push against other organs and prevent their function, and can progressively shape deformations of the spine.

Uterine fibroid embolization was introduced in 1995 by Jean-Jacques Merland at Hôpital Lariboisiere (Paris).

For gynecologists, the findings of follow-up studies for UAE are not convincing. The procedure is not a guarantee, nor in many cases recommended for women who want to have children.

In January 2007, the New England Journal of Medicine published a study based on one-year follow-up of patients undergoing the procedure at 27 hospitals in the UK that showed equivalent quality-of-life benefit when compared to hysterectomy and myomectomy.

The study found that 12% of UAE patients experienced major adverse events against 20% for patients undergoing surgery. And 34% of UAE patients experienced minor complications, the majority of which were fever, pain and inflammation, as compared to 20% for hysterectomy or myomectomy.

While not a ringing medical endorsement, the study demonstrated more convincingly that UAE was more cost-effective than surgery, with 80% shorter hospital stays and a return-to-work rate double that of surgery.