BACKGROUND:High-risk patients undergoing prophylactic mastectomy (PM) may have unsuspected cancers identified on pathology. The optimum way to identify and manage them is controversial. Magnetic resonance imaging (MRI) may identify occult cancer preoperatively. Sentinel lymph node biopsy (SLNB) allows intraoperative staging and axillary dissection during the same operation. We determined the efficacy and cost of MRI and/or SLNB in managing high-risk PM patients. METHODS:We reviewed 192 PMs in 173 patients from 1999 to 2005. Costs were estimated for MRI and SLNB during PM by the 2005 Medicare Resource-Based Relative Value Scale. We also estimated costs and procedures for the four strategies in a larger hypothetical cohort. RESULTS:A total of 19 (10%) of 192 PMs contained occult cancers, 14 ductal carcinoma-in-situ (DCIS) and 5 invasive ductal carcinoma (IDC). In 59 patients, MRI detected an IDC but missed two DCIS and an IDC. Positive MRIs generated an additional average cost of $1,207 per patient. In 56 PMs with SLNB, 6 occult cancers were found, 5 DCIS and 1 IDC, all with negative SLNBs. Adding a SLNB costs an additional average of $644. A theoretical analysis demonstrated that PM alone costs $808 per patient, PM with SLNB costs $1,420, PM with MRI and selective SLNB costs $1,774, and PM with routine MRI and SLNB costs $2,379. CONCLUSIONS:MRI adds great cost and misses most occult cancers in PMs. SLNB allows the rare patient with occult IDC to avoid axillary dissection but adds cost. Given the low rate of unsuspected invasive cancers and the costs of MRI and SLNB, neither is recommended as standard practice for PM patients.

译文

背景:进行预防性乳房切除术(PM)的高危患者可能在病理学上发现了未怀疑的癌症。识别和管理它们的最佳方法是有争议的。磁共振成像(MRI)可能会在术前识别隐匿性癌症。前哨淋巴结活检(SLNB)允许在同一手术过程中进行术中分期和腋窝淋巴结清扫术。我们确定了MRI和/或SLNB在治疗高危PM患者中的功效和成本。
方法:我们回顾了1999年至2005年间173例患者中的192例PM。根据2005年Medicare基于资源的相对价值量表,估算了PM期间MRI和SLNB的费用。我们还在更大的假设队列中估算了这四种策略的成本和程序。
结果:192例PM中共有19例(10%)包含隐匿性癌,14例原位导管癌和5例浸润性导管癌(IDC)。在59例患者中,MRI检测到一个IDC,但错过了两个DCIS和一个IDC。阳性MRI产生的平均额外费用为每位患者1,207美元。在56例SLNB患者中,发现了6例隐匿性癌症,其中5例DCIS和1例IDC均为SLNB阴性。添加SLNB的平均费用为644美元。理论分析表明,每人每人PM花费808美元,SLNB的PM花费1,420美元,MRI和选择性SLNB的PM花费1,774美元,常规MRI和SLNB的PM花费2,379美元。
结论:MRI增加了巨大的成本并且错过了PM中大多数隐匿性癌症。 SLNB可使罕见的隐匿性IDC患者避免腋窝淋巴结清扫术,但会增加成本。鉴于未预料到的浸润性癌症的发生率低以及MRI和SLNB的费用,均不建议将其作为PM患者的标准做法。

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