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The positive predictive value PPV of the mammography was The average duration of the ultrasound examination was 19 minutes, not including time for comparison with earlier examinations, contact and discussions with the patients, or reporting time.

A follow-up study into the cost-effectiveness is in progress. In a singlecentre study, 6 cancers were found in 1, women who underwent an ultrasound screening performed by radiology technicians.

The results may be compared with 6 previously published single-centre studies. In these studies a total of 42, ultrasound screening exams were performed, from which a total of cancers were found in women.

In these studies, as well, there were women with an elevated risk and dense glandular tissue. In 5 studies, women with an elevated risk underwent mammography, ultrasound, and MRI.

Conclusions Level 1 The added cancer detection yield from screening with ultrasound added to mammography is on average 4.

A2 Berg Other considerations Just as in the centre trial, in the Netherlands a radiologist performs the ultrasound examination of the breast, preferably the same radiologist who supervises and interprets the mammogram.

Screening by a medical specialist, including the increase in the number of biopsies, is probably not cost-effective. There are developments in progress, for example in the area of automated ultrasound systems, to handle the practical application problems, but the image resolution with these systems is not yet state of the art.

Training of special staff can also be considered. It must also be realised that the results of studies always give a somewhat flattering picture compared to daily practice, in which there is no controlled or standardised way of working.

The study population consisted only of women with an elevated risk of breast cancer and dense glandular tissue in at least one quadrant.

Nevertheless, based on this study ultrasound screening could be considered in individual cases, if other imaging techniques are not possible.

Digitisation has increased the interpretability of dense glandular tissue, and its sensitivity is also increased by the presence of earlier images [Barlow, ].

The results of the cost-effectiveness study that will comprise the final part of the centre trial are important in helping to define the subgroup of patients who are eligible for this form of screening, for lack of better modalities.

Recommendations Screening by ultrasound is not recommended in the general population. Screening by ultrasound for women with an elevated risk is only recommended when other forms of screening cannot be used.

The authors estimate that for every 1, screens, additional cancers are detected by adding MRI. Two studies published after this systematic review confirm these results for sensitivity and specificity [Bigenwald, ; Kuhl ].

The reason for this lower sensitivity is not clear. This study does not give specificity statistics. Subgroups Bigenwald reports the sensitivity of MRI vs.

Unfortunately, this study is small, so the estimates are imprecise. Their results show a possible trend of sensitivity decreasing as breast tissue density increases, but the confidence intervals are very wide, so the trend is not significant.

There is no clear difference in sensitivity and specificity between these different groups. Effect of the screening round All the studies included women with an elevated risk, who in many cases had already had a mammogram before the study began, but had never had an MRI.

This distorts the comparison between MRI and mammography, because in the case of MRI scans, prevalent tumours are found in the first round, while in the case of mammograms it is no longer the first round.

Two studies evaluated a possible effect based on screening round [Hoogerbrugge, ; Kriege, ]. This study also evaluated the effect of undergoing a mammogram for inclusion in the study, and found Even for mammography a significant difference was found: there were more abnormal mammograms 7.

Predictive values The predictive values are directly dependent on the prevalence of the outcome in the study population. The prevalence varied from 2.

This prevalence is of course dependent on the follow-up time, since most of the studies used follow-up to verify negative tests.

The study with the lowest prevalence [Kriege, ] had a follow-up of 2. Kriege reports a PPV of 3. The negative predictive values are not reported in the two systematic reviews [Granader, ; Warner, ], due to the difficulty in verifying negative tests.

Only one study reports the negative predictive value [Kuhl, ]: MRI Effect on quality of life We found a study that evaluated the effect of screening on quality of life in this high risk group 19 [Rijnsburger, ].

The authors reported that the screening modality had no effect on quality of life, but they did find a significant effect from additional diagnostic testing, which changed over time.

Compared with mammography, MRI is significantly more sensitive for T1 tumours, N0, non-ductal tumours and estrogen receptor positive tumours.

Another study did find a significant difference in size of the invasive tumour when screening by MRI in comparison with screening without MRI: 6 mm vs.

A systematic review found that the risk of having to be re-tested because of false-positive results increases by a factor 3 RR 3.

This involves additional benign percutaneous biopsies RR 1. A later study also found an increase in the number of biopsies, but without statistical hypothesis testing [Weinstein, ].

A false-positive result from MRI plus mammography has no effect on the woman's preference for having a prophylactic mastectomy or surveillance [Hoogerbrugge, ].

Effects on mortality There are no randomised studies on the effect of adding MRI to the screening program. It is therefore unknown whether the higher sensitivity of MRI for diagnosing breast cancer also translates into a lower mortality: either breast cancer-related mortality or general mortality.

Because of this, it may never be possible to quantify the risk of overdiagnosis and overtreatment in this high-risk group.

Chereau found no significant difference in three-year disease-free survival, metastasis-free survival and total survival using MRI screening compared to screening without MRI.

It should be noted that with screening, survival as opposed to mortality is a poor measure of outcome, because it is distorted by lead-time bias.

MRI scans can accelerate the time of diagnosis but do not change the ultimate mortality rate. Conclusions Level 1 Adding MRI to mammography for the screening of high-risk women results in a higher sensitivity for breast cancer.

A2 Level 1 The diagnostic accuracy of MRI as a screening method varies according to the cut-off value used. A2 Level 3 Warner , Bigenwald The diagnostic accuracy of MRI as a screening method decreases as breast tissue density increases.

A2 Level 1 Lord , Bigenwald , Kuhl , Hoogerbrugge , Weinstein Bigenwald No obvious differences have been observed among the various groups in the diagnostic accuracy of MRI as a screening method.

The heterogeneity within each group is just as 20 significant as the heterogeneity between the groups.

A2 Level 1 It is likely that the comparison between mammograms and MRI in a first round is distorted by the fact that prior to the study mammograms had already been performed.

The sensitivity of MRI is lower in women who have not had a prior mammogram; the numer of positive MRI scans decreases in subsequent rounds.

A2 Level 1 Bigenwald , Kriege , Hoogerbrugge , Weinstein Kriege , Hoogerbrugge It is likely that with MRI screening there is a higher risk of being called back and of having more biopsies, fewer lymphadenectomies, less adjuvant chemotherapy and less radiation therapy.

The percentage of tumours of 1 cm or less is The study shows that breast cancers in the BRCA1 gene mutation carriers form a separate group.

In almost all cases these were invasive This indicates a higher rate of growth, as described previously by Tilanus-Linthorst Level 3 It is likely that screening by both MRI and mammography improves the five-year survival rate of women at high risk due to a family history of the disease.

A2 Rijnsburger , Tilanus-Linthorst Other considerations MRI screening requires radiological expertise, especially because of its low specificity.

This expertise is best guaranteed in hospitals with a clinical geneticist, because surveillance of mutation carriers is concentrated there.

It is gradually becoming clear that cancers that occur with BRCA1 have characteristics associated with a poorer prognosis than cancers in other women with elevated risk due to family history.

There is discussion of changing the screening schedule, with the idea of alternating screening by mammography or MRI respectively with an interval of 6 months.

Another concept is increasing the frequency of MRI: every 6 months until age However, insight inthe consequences for the women long-term effects of additional use of Gadolineum and false-positive findings is lacking.

Detection of cancers in very high risk groups and moderately high risk groups lags behind detection in mutation carriers. An RCT was started in November at Erasmus Medical Centre to obtain more insight into the relationships between breast tissue density, cancer risk and diagnostic accuracy of MRI in these women.

In one arm women undergo annual clinical breast examination and mammography. In the other arm women undergo annual clinical breast examination and MRI.

The turnout in the period from to was Now the entire population is screened using digital mammography machines. This has led to higher referral rates.

In the period from to , This increased from to , both for the exams conducted conventionally and for those conducted digitally: 30 of 1, screens were conventional and This increased in the period from to for both conventional and digital exams: The positive predictive value of a referral decreased gradually from Digital mammography mainly led to an increase in the number of referrals for microcalcifications.

This resulted in a significant increase in the detection of DCIS, but also a significant increase in the detection of IDC, of which the microcalcifications were the only sign [Karssemeijer, ].

Additional benefits are more options for processing the image digitally, and that data can be shared more easily [Karssemeijer, ; Bluekens, ].

For Dutch women between the ages of 35 and 84, the rate of death from breast cancer was rising until , and began falling thereafter.

A marked decrease of 2. In the older age group this kind of trend was observed only after , and in women from after Although improved treatments and changes in the population do play a role, the age-specific trends observed are clearly associated with the different implementation phases of the national breast screening programme [Otten, ].

Screening women between age 40 and 50 is controversial. The harm high costs and high percentage of false-positive results exceeds the benefits.

They state that the decision to move to annual screening should be made on an individual basis, weighing up the benefits against the potential harm.

In the results were published from a randomised study on screening in ages 40 to 49 basic assumption: reduction in mortality which had a convincing design and adequate power; the study was initiated in in the United Kingdom [Moss, ].

The statistics appear to be consistent with previous studies [Moss, ]: in women between ages 40 and 49 invited for screening, the breast cancer diagnosis was made earlier than in women who were not invited [Moss, ].

This number did not turn out to be statistically significant, however. In the accompanying editorial it was suggested that the trend toward reduced mortality was confirmed, but that there is still too much uncertainty about the adverse effects, such as unjustified reassurance, false-positive exams and cancer induction from radiation [Djulbegovic, ].

This difference was not statistically significant. A2 Moss Other considerations In the Netherlands, women between 50 and 75 years of age are currently screened through the national breast cancer screening programme.

The question is whether screening should be expanded to include younger age groups. Gradual change in diagnostics in the later stages The advent of screening involves a considerable number of non-palpable abnormalities.

Developments in hospitals have mainly focused on rapid diagnosis breast clinics and on obtaining a definitive preoperative diagnosis using minimally invasive ultrasound-guided or stereotactic-guided procedures, partly through participation in projects such as the Breakthrough Project.

The ultimate percentage of patients who undergo unnecessary surgery as a result of screening is much lower now compared to the approach used in the period the foundation for the screening was laid.

Uruguay and the United States screen annually, the United Kingdom once every 3 years, and the other member states once every 2 years.

Everyone involved in the screening and follow-up process must fully realise that screening is a way of reducing breast cancer mortality and is not a perfect and comprehensive way to protect women against breast cancer.

Only a small proportion of participants have breast cancer, and false-negative and false-positive results are unavoidable but constantly cause debate.

The picture sketched is often too rosy and creates unrealistic expectations. Possibly because this information serves a double purpose: national breast cancer screening greatly benefits from a large turnout and makes an effort to do so in an inviting manner, influencing the balance between benefit and harm.

It is of utmost importance that attention is paid to providing this information in an objective manner [BVN, ].

Specifically, it should be pointed out that women who have a palpable abnormality or other symptom do not belong in the screening program.

The nationwide coordination is the job of the RIVM, which is responsible for distribution of information in the Netherlands.

The invitation brochure and the standard invitation letter is updated annually, to enable women to make their dicisions on current information.

In addition, the national breast cancer screening programme must strive for the highest level of communication with the follow-up care path, for planning purposes as well as to mitigate negative effects of screening, in particular extra tests due to false-positive findings.

The screening mammogram: Is it still necessary to repeat the digital mammogram? At present, the key information the abnormality on the mammogram with the data transfer information from the screening radiologist, as described below, is usually delivered on a CD.

There are various reasons to send the screening mammogram to the breast clinic in the hospital to which the woman is being referred: 1.

The quality of images on a CD is often not diagnostic; differences between image processing 23 systems complicate the interpretation and processing.

Repeating the test is of practical value for additional magnification views or tomosynthesis. It can also be considered the system's own quality control: abnormalities that are cause for referral are sometimes not detectable on the mammogram made in the clinic.

That is especially true of abnormalities that are small, found at the edge of the image, or based on incidental overprojection of normal structures.

The radiation exposure is negligible. Creation of a broadband connection between screening organisations and hospitals is in progress.

When the hospital has the same image processing system as the screening organisation, so that the image quality is equivalent, or if the hospital has access to the images via broadband technology, repeating the image is not necessary.

The screening radiologist A large cohort study of the performance of screening radiologists in the United States found that it is mainly radiologists doing both diagnostic breast radiology and screening who achieve the best results.

The sensitivity in this study was There were no significant differences between large and small volume screens; the relationship between the number of screens and performance proved to be complex [Buist, ].

A minimum of 3, screens per years was set; in the Netherlands the average volume handled by a screening radiologist is 7, This and the other standards that must be met by screening radiologists in the Netherlands are described in the Quality Registry of the LRCB: www.

It also states the requirement that screening radiologists must be involved in diagnostic breast radiology.

Screening radiologists provide the patient's general practitioner with all the information necessary for referral.

At a minimum this information must include: the side, localisation, nature and size of the abnormality and the number of abnormalities.

This must be recorded in a standard sketch annotated on the mammogram. The following BI-RADS categories may be assigned to a screening mammogram used for referral a "positive screening result" see section 2.

If the final assessment category assigned is BI-RADS 4 or 5, the emphasis is on the degree to which the laesion is suspected of malignancy; whether needle biopsy is needed will be determined in the hospital.

This category can be assigned only after the necessary additional imaging has taken place, thus in the hospital. This is because in the follow-up rounds the Dutch screening programme confines to MLO mediolateral oblique views The remaining categories BI-RADS 1 and 2 are considered negative screening results, and therefore meet the criteria for routine screening, not for referral.

Applying the BI-RADS categories with some explanatory text helps general practitioners, giving them more understanding of the level of suspicion.

If the woman has been referred with a BI-RADS 0, her general practitioner can explain to her that an irregularity was indeed seen on the mammogram, but that more imaging is needed for confirmation.

Job descriptions and responsibilities of screening technicians can be viewed at www. Mailing of results should not be timed so that the message arrives on a Friday or right before holidays.

If the results are positive, the woman's general practitioner will be notified before the woman herself.

The woman will then receive a letter advising her to contact her general practitioner. She will also receive the folder "When Further Testing is Needed.

This is preferable. The screening organisation is in charge of sending a letter of referral and for making the digital images available.

The screening organisation communicates promptly with hospitals in the area about the local screening schedule, so that the hospitals can adjust their breast clinic's capacity accordingly.

In most areas referral is done using a set of forms. In this set, the form for the specialist contains the same information and has a space for the primary care physician to provide additional information, such as relevant patient history.

These forms must be given to the woman. In many regions a "return mail form" in the set of forms can be used for this purpose. The woman brings the records forms and CD she received to her breast clinic appointment.

The surgeon or breast care nurse specialist sees to it that the radiologist has access to the mammograms and the additional information.

The pathologist must also have access to this information. Relaying information to the patient Well-informed patients are more able to process stress.

The further diagnostic test results must be relayed to the patient at each moment in the diagnostic process, though she will mainly receive this information at the breast clinic directly from the attending surgeon and nurse specialist.

Mammograms that are difficult to perform Under the terms of the Equal Treatment Act, in the RIVM established that every woman in the Netherlands must have access to one of the national breast cancer screening centres.

For women with a physical disability, each screening unit has an elevator. In exceptional cases they can rely on the radiological department of an associated hospital.

Another group is made up of women for whom mammograms may not be technically feasible, such as women who have had breast-conserving therapy see also If both the first and second radiologists reading the mammogram find it hard to interpret, they advise the individual women to have their screening examination performed in the radiology department of a hospital, because there more options for imaging are available.

The decision to give the woman this advice must be based on the RIVM protocol. Given the improved contrast ratios in digital mammography, these would be exceptions to the rule: the vast majority will be able to be screened normally.

Conclusion Level 3 The screening radiologist's performance improves with a good balance between screening radiology and diagnostic radiology.

For a summary of the literature search, based on reviews, see appendices on Oncoline. The table below gives a global overview of the risk factors named in these reviews.

The decision was made to state the risks in terms of relative risks RR. It is not always possible to convert RR to lifetime risk LTR , since the information required for populations is not always known.

Regarding geographic region, note that for people from low-risk areas such as Asia , the difference decreases the longer they live in a high risk area such as North America.

In addition, there are several rare tumour syndromes caused by highly penetrant genes including breast cancer.

If one has a first-degree relative with breast cancer, the RR is 1 to 4, depending on one's age and other family history.

In women with breast cancer in the family, the RR depends greatly on the number of relatives, whether it is first- or second-degree kinship, and at what age the breast cancer occurred.

If there is only third-degree kinship with breast cancer, the RR is not elevated enough to justify screening outside the national breast cancer screening programme.

See the decision tree after section 1. Hormonal risk factors Risk factors with an RR of 2 or higher are present when the woman is over age 35 at the time of having her first child, and in postmenopausal women with high bone density.

Since estrogen can contribute to high bone density, estrogen use as a part of hormone replacement therapy can have a direct relationship as a risk factor in developing breast cancer.

As a result, it may not be the high bone density, but estrogen use that may be the risk factor that gives an RR of 2 or higher.

DES use during pregnancy gives an RR of 2, as does postmenopausal overweight. An RR of up to 2 has been published for menopause after age Menarche before the age of 11 gives an RR of Long-term hormone replacement therapy gives an RR of 1.

Use of oral contraceptives gives an RR of less than 2 in most studies. It is notable that there is currently no obvious evidence that in vitro fertilisation increases the risk of breast cancer.

Many other risk factors are indeed associated with a statistically significant increase in risk in large populations, but have little practical significance for an individual woman.

An exception are women who underwent chest or axillary radiation before the age of 40, usually as part of treatment for Hodgkin's Lymphoma.

There are no prospective studies on this group. In a retrospective study of 91 patients with an average age of 42, treated for Hodgkin's, 10 cancers were found in a period of 10 years; 4 by MRI only, 3 with mammography in addition to MRI, and 3 only with mammography based on microcalcifications [Sung, ].

Based on a risk estimate, beginning 8 years after the radiation therapy these women are offered the same screening program as gene mutation carriers.

See section 1. Another exception is women who receive radiation in the breast region for other forms of childhood cancer, including Wilms tumour, sarcoma, neuroblastoma or non-Hodgkin lymphoma.

For information on the definition of risk groups and the associated screening policy for breast cancer after treating childhood cancer, see the guideline "Follow-up after childhood cancer," sections 1, 2 en 3 www.

For women who underwent chest radiation therapy after the age of 40, screening may be started 10 27 years after radiation therapy.

This means that the national breast cancer screening programme is adequate for these women. There is no consensus on how to define the degree of increased risk.

Different risk factors are usually studied in different populations, so adding them together is not possible. However, there are models that combine some risk factors, such as menarche, age at the time of first child, and first-degree relative with breast cancer [Gail, ; Tyrer, ].

The epidemiologically proven relationship between density of glandular tissue and an increased risk of breast cancer applies to both premenopausal and postmenopausal populations [MacCormack, ].

It seems paradoxical that the percentage of glandular tissue reduces with age, while the cancer incidence increases. But this paradox can be explained: it is mainly a question of exposure to hormones, growth factors and effects of menarche, pregnancy and menopause on glandular tissue.

Dense glandular tissue is also associated with atypical benign breast laesions. The density of the breast tissue has a hereditary component.

Since evidence of the relationship between dense glandular tissue and breast cancer has mainly been found in screening populations, no recommendations can be made for other screening modalities [Boyd, ].

The increased incidence of breast cancer in general and the high frequency of mild risk factors, such as low number of pregnancies and late age at first child, increase the demand for screening outside the national breast cancer screening programme.

This calls for a good information campaign. If all women with mild risk factors would go to a hospital radiology department outside the national breast cancer screening centre, this would heavily overcrowd these departments.

Furthermore, it is questionable whether those departments are adequately equipped for this screening role, and whether this could be in conflict with the national breast cancer screening Act [Wet op het bevolkingsonderzoek WBO ] The following points are important in the information for women who are worried about their risk of breast cancer: most women will not get breast cancer.

Most of those who do get breast cancer have no family history of it. For most women older age is the main risk factor for getting breast cancer.

A woman with breast cancer due to a BRCA1 or 2 mutation is not only has a risk of recurrence, but also at increased risk of a second primary tumour, usually contralateral.

When urgent DNA testing is indicated, it is important to know: a. If a mutation is diagnosed, is a particular primary treatment preferred, in view of the chance of recurrence?

Could a simultaneous prophylactic contralateral mastectomy PCM have a clear survival 28 benefit?

Regarding a: Risk of ipsilateral recurrence In a systematic review, BRCA mutation carriers in 5 of the 17 studies had an elevated risk of an ipsilateral recurrence, and in 4 of the 14 studies poorer survival rates [Liebens, ].

In a study published later, breast cancer patients with a BRCA1 mutation, breast cancer patients with a BRCA2 mutation, breast cancer patients with a high familial risk but without gene mutation, and breast cancer patients with no family history, the risk of an ipsilateral recurrence did not differ between these 4 groups.

The studies done by Pierce and Kirova also report a slightly greater chance of ipsilateral recurrence, but it did not affect survival.

Metcalfe followed mutation carriers who had BCT; the risk of ipsilateral recurrence was 1. The risk was lower in women who were treated with radiation therapy, chemotherapy or oophorectomy.

Currently there are no strong arguments for treating diagnosed breast cancer in BRCA mutation carriers differently from non-mutation carriers.

Regarding b: Risk of contralateral breast cancer Various large studies have shown that there is a markedly increased risk of a second diagnosis of breast cancer in BRCA gene mutation carriers.

Liebens found this in 14 of the 16 studies [Liebens, ]. More recent studies confirmed the strongly increased risk of a contralateral tumour.

The studies of van der Kolk and Malone are also consistent with these results. Risk-reducing mastectomy was associated with a significantly lower risk of breast cancer.

No breast cancers were found in a group of women who had undergone risk-reducing mastectomy. There was no clear survival benefit after risk-reducing mastectomy.

After correcting for stage and therapy, Brekelmans found that a contralateral carcinoma did not affect survival.

In this study it was found that survival was determined by the characteristics of the primary carcinoma.

In a small study, Peralta did find better disease-free survival after PCM, but no difference in survival.

Heron showed, studying 1, patients, that survival was no worse after contralateral breast cancer. In Domchek's study, risk-reducing preventive bilateral salpingo-oophorectomy pBSO was associated with a significantly lower risk of ovarian cancer in both BRCA1 and BRCA 2 mutation carriers and in those with and without a history of breast cancer.

After pBSO in both BRCA1 and BRCA2 mutation carriers, there is a significantly lower risk of breast cancer, a decrease in mortality from all causes but also from breast cancer- and ovarian cancer-induced mortality.

Risk-reducing mastectomy significantly reduces the risk of a second diagnosis of breast cancer. Liebens , Domchek Risk-reducing contralateral mastectomy has been found to have no clear survival 29 benefit.

The survival is primarily determined by the prognosis and therapy of the primary breast carcinoma. B Domchek Recommendations Tumour treatment must be the priority in diagnosing breast cancer.

The women must be told that prophylactic contralateral mastectomy PCM will barely affect survival, but will strongly reduce their risk of contralateral breast cancer.

Up to the present there has been no evidence that routine screening for ovarian cancer results in diagnosing early stage ovarian cancer or in reducing mortality.

B Oei , Vasen , Meeuwissen , Stirling , Hermsen Other considerations Ovarian cancer has no detectable preliminary stage that is detectable with current diagnostic tests, and therefore does not meet the criteria for screening.

An alternative to screening for ovarian cancer at present is a preventive bilateral salpingo-oophorectomy pBSO.

Bilateral pBSO before the age of 45 is associated with higher mortality, especially if no hormone replacement therapy is given [Rivera, ].

Other drawbacks are menopausal symptoms and poorer sexual function [Madalinska, ; Madalinska, ].

The reported effects of early menopause include a higher risk of cardiovascular disease, neurological disease, osteoporosis and mood disorders, which can be partially mitigated by hormone replacement therapy [Sushter, ].

It is important to monitor these women in order to learn about the delayed effects of premenopausal pBSO. There is no consensus on the policy before pBSO.

There are gynaecologists who do annual screening until the patient has a pBSO. The disadvantage of such an approach is the risk of falsepositive results and the associated unnecessary additional diagnostic testing, which adds to the woman's distress.

Other gynaecologists support BRCA mutation carriers to decide for themselves what the best time is for a pBSO and do not offer any screening.

We therefore recommend informing women about the pros and cons of screening and pBSO. We have decided to present the risks in terms of RRs.

Section 1. For the risk factors with an RR between 2 and 4: Up to now, screening has been offered outside the national breast cancer screening programme when there is a moderate increased risk due to family history.

The lower limit for screening outside the national breast cancer screening programme due to a family history is therefore an RR of 2.

This limit is not based on scientific evidence, however, nor do we have data on the results of this approach.

Important points include the starting and ending ages of screening outside the national breast cancer screening programme, the value of clinical breast examinations and regular breast self-exams, and referral criteria for diagnostic DNA testing.

Also see flowcharts 1 and 2 for this. Considerations regarding the starting age of mammography screening outside the national breast cancer screening programme Increased risk due to family history Based on cost-effectiveness and on radiation exposure, there must be an RR of at least 3 in women under 40 to justify screening outside the national breast cancer screening programme.

Moderate increased risk due to family history An acceptable starting age for screening outside the national breast cancer screening programme for women with a moderate increased risk due to family history RR and negative DNA-testing is no longer age 35, but age High risk due to family history For women with a high risk and negative DNA testing RR , the starting age for screening outside the national breast cancer screening programme is We do not advise a starting age younger than 35 when familial breast cancer occurs at under age 35 in this group.

Neither is MRI screening advisable except as part of a study. At age 25 they can start MRI screening. Screening should take place annually [Rijnsburger, ; van der Kolk, ].

No data is available on the effectiveness in this small group of women. Other information: Regular breast self-exams With regard to regular breast self-exams it is concluded that this technique cannot be recommended as a method to reduce breast cancer mortality.

Knowledge of one's own body may well play a significant role in recognizing breast abnormalities, though.

Clinical breast examinations Clinical breast examinations as a screening method in the general population is not cost-effective.

Be aware of the limited value of clinical breast examinations as a screening method, even for women screened outside the national breast cancer screening programme, although it may play a greater role in young women at high and very high risk [Chiarelli, ; Barton, ].

Clinical Genetics The Clinical Genetics departments usually coordinate the multidisciplinary outpatient clinics for hereditary or familial tumours, and are located in teaching hospitals and unaffiliated cancer hospitals; see appendices for addresses.

A more detailed risk assessment can take place here, based upon which recommendations for screening are given to those requesting advice and to their family members.

If technically possible, DNA testing may be a part of the testing. Psychosocial support can also be given in this context. DNA testing for a hereditary predisposition to tumours should be requested by the clinical geneticist.

The reason for this policy is the clinical and genetic heterogeneity of many tumour syndromes and the psychological and social stress.

Advice may also be given if preventive bilateral mastectomy is being considered. See also section 1.

Recommendations Who is eligible for screening outside the national breast cancer screening programme? Screening schedules for women with no history of breast cancer but at increased risk.

The table below and both flow charts have been created as a tool to be used for patient management in the case of increased risk due to family history.

If applicable: read the table and flow charts in their entirety. Table 1. Information required for the family medical history When collecting information about the family history, it is important to gather information about at least first- and second-degree relatives in the paternal and maternal branch.

The physician should enquire about the occurrence of breast cancer, possible bilateral tumours, and other tumours in the same branch of the family, especially ovarian carcinoma, tubal carcinoma and prostate carcinoma.

The extent of the risk is estimated using the number of first-degree, second-degree or third-degree family members with breast cancer and the age of diagnosis.

The management plan for the healthy woman requesting screening is determined by her age and the life risk for breast cancer on the basis of family history see flow chart 1.

All affected relatives should be on the same side of the family and are family of the person requesting advice.

Third-degree relatives: great-grandparents, great-grandchildren, great-uncles and greataunts, cousins children of uncles and aunts.

Flow charts 1 and 2: indications for screening outside the national breast screening programme and reason for referral to a clinical geneticist.

Also see widget on www. Follow the below decision tree with data from her own medical history and family history. Screening for her and her relatives is determined there No reason for referral to clinical geneticist 36 13 Diagnostics 14 15 16 17 18 19 Diagnostics must focus on describing the nature, size and localisation of the laesion as precisely as possible, determining the the range of suspicion for malignancy is suspected and indicating the possibilities for further diagnostics and treatment.

If the diagnosis breast cancer has been determined based on pre-operative pathology, staging should be performed in relation to local extent, complemented by pre-operative staging of the axilla and distant metastases where necessary.

In first instance, women with breast complaints turn to the general practitioner. Given the frequent occurrence of a familial history in the case of breast cancer, each woman should be asked for possible occurrence of breast cancer in the maternal or paternal branch see 1.

The nature of complaints as well as the age of the woman plays a role in determining further steps to be taken. The urgency for additional examination and referral is therefore greater with older women than younger women.

In young women an ultrasound is sufficient, unless the abnormality has disappeared in another phase of the cycle.

If the palpable abnormality remains or increases in size: refer to the breast clinic - The woman feels a lump, the general practitioner does not: check after 2 weeks.

If the woman continues to feel something: perform a mammogram an ultrasound in women younger than If complaints persist: refer to the breast clinic - If there is local pain or sensitiveness in one breast: check after 2 weeks and, if complaints persist, after 3 months; if complaints persist: perform a mammogram.

If pain persist 3 months after a negative result in mammogram: refer to the breast clinic Diffuse complaints or abnormalities - Diffuse lumpy breast tissue often there are also complaints of pain usually indicates mastopathy.

Dense, firm, lumpy breast tissue may mask a carcinoma and is therefore an indication for a mammogram. Watch for women with dense breast tissue on a mammogram and repeat the mammogram if there are new complaints.

Nipple discharge - A malignancy should be suspected if there is brown or bloody nipple discharge. Another cause could be a milk duct fistula with a fistula opening on the edge of the areola.

Refer to a breast clinic if there is nipple discharge because a mammogram is insufficient. If a woman presents with new complaints, a recent mammogram without abnormalities e.

If additional imaging is indicated for women older than 30 years, this should consist of a mammogram, supplemented with an ultrasound if required.

In women younger than 30 years, ultrasound is the 37 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 method of choice due to the low positive predictive value of mammography in this group.

Obviously, evaluation on the basis of mammography is indicated if the ultrasound provides insufficient information.

When requesting imaging, the general practitioner provides adequate information to the radiologist about the indication in line with the above classification , the side s involved, nature and localisation of abnormalities found during the clinical breast examination, and important information from the medical history familial history, mastitis, any prior breast surgery etc.

Mammography is the basis of imaging in symptomatic women. Supplemental examination with Remaining considerations Mastopathy is a collective term for various complaints and disorders of one or both breasts in both men and women.

The definition used here is: dense, granular and lumpy breast tissue, sensitive on palpation and sometimes spontaneously painful, especially during the premenstrual phase.

In addition, there may be non-cyclical complaints or pain in the chest wall. This definition includes both palpation findings and patient complaints.

Terms such as mastalgia, mastodynia and fibrocystic disease are sometimes used, but only cover part of the problem [Knuistingh Neven, ].

The following histological changes can be seen in mastopathy: fibrocystic changes, adenosis, sclerosing adenosis and epithelial proliferation.

Mammography shows that there is not always dense breast tissue, but that there may be micro- or marcocysts, a granular or more irregular glandular structure, either in or not in combination with dense tissue, microcalcifications and milk of calcium.

Ultrasound is a good supplement if there are cysts. Regarding the sensitivity of MRI results of the still limited study results vary, partly because there is a correlation in the various studies with density but not with the clinical presentation [Boyd, ; Kriege, ; Warren ].

Patients with mastopathic complaints and breasts that can be easily examined with low density breast tissue on the mammogram may be reassured.

Caution is advised with patients who present with recurring complaints, persistent lumpiness and dense breast tissue see above , partly given the extra risk of breast cancer in the case of dense breast tissue [McCormack, ; Boyd, ].

A pitfall is the palpable, but not very alarming abnormality that is diagnosed to be malignant after all in second instance. There is a risk that follow-up is not organised well enough.

The appointment to return 3 months later is the joint responsibility of the patient and physician. The physician must explicitly instruct the patient to do so.

Mastopathy is not a radiological diagnosis. In a large retrospective study containing more than 40, mammograms, the average sensitivity of diagnostic mammography was The sensitivity was higher as the breast tissue reduced in density and if there was a previous mammogram available for comparison.

The sensitivity increased if the patients had reported the palpable abnormality themselves; however, the specificity decreased.

A high age was associated with a higher positive predictive value, while supplemental ultrasound was found to be indicated more often in younger age groups.

It was not possible to determine the sensitivity of the mammogram separately from the ultrasound in this study.

In a number of smaller studies, in which this was possible, the contribution of ultrasound to a malignant diagnosis was found to be 6.

The Sydney Breast Imaging Accuracy Study shows that knowledge of the mammogram performed prior to the ultrasound improves diagnosis [Irwig, ].

While the relationship between sensitivity and specificity between a mammogram, ultrasound and age is not linear in this study, the ultrasound is clearly more beneficial for women under 45 years of age.

A small indication area for mammography is the presence of metastases of an unknown primary tumour. The lack of a large series means there is no evidence regarding the right choice of diagnostic method.

In the Guideline Primary Tumour Unknown [NVVP, ] and in the NICE Guideline , the recommendation is made that imaging of separate organ systems need to be requested on the basis of pathology results and immunohistochemistry and if there are clinical indications to do so.

This is certainly the case with axillary lymph node metastases of an adenocarcinoma. Supplemental MRI must be considered if the resulting mammogram is negative.

Triple diagnostics is still the cornerstone in the diagnosis malignancy [Houssami, ; Houssami, ; Chuo, ], but this is changing in the case of palpable abnormalities in which malignancy is not suspected.

There are an increasing number of studies in which the negative predictive value of a negative mammogram and a negative ultrasound is so high that supplemental punction is not indicated anymore.

In four studies, with a follow-up period of at least 2 years, the negative predictive value varied from Ultrasound also has a high negative predictive value as exclusive supplemental diagnostic method with palpable abnormalities not suspicious for malignancy [Cid, ; Whitehouse, ].

Improvement in the image quality of high resolution ultrasound has lead to a number of studies on the value of ultrasound with microcalcifications.

Despite the fact that especially polymorphic, malignant microcalcification can be recognised, this does not have added value in the diagnostic process [Gufler, ; Yang, ].

This prevalence is dependent on age. The sensitivity of the mammogram increases with age and availability of previous imaging.

A1 A2 Kerlikowske Barlow The negative predictive value of a normal mammogram and ultrasound in patients with a palpable abnormality that is not clinically suspect is high: Level 1 A1 A2 Kerlikowske Dennis , Moy , Shetty , Soo Remaining considerations Mammography in symptomatic patients must at least consist of images of two views, craniocaudal and mediolateral-oblique, supplemented with local compression images or magnification views of the symptomatic area where required.

Identification of the abnormality may be facilitated by use of lead markers. The indications for this be made by the radiologist. This should be performed by a radiologist that also has knowledge of the mammography findings.

Images of the symptomatic area should be taken in two views. In the area around the mamilla, the scan plane radial to the nipple often provides additional information.

The transducer position must be indicated on the image. Ultrasound is the method of choice in women under 30 years of age, but also with symptomatic women who are pregnant or breastfeeding.

The reason for this is the dense breast tissue, not the radiation exposure. If there is an indication for mammography, this should be performed straight after.

Screening in this group of women is best delayed until a few months after childbirth or after breastfeeding has ended.

Additional techniques, such as colour Doppler, contrast ultrasound and elastography have added value with small groups, in which the operator dependency is of great importance.

The reason these developments have not been implemented on a greater scale is also related to the low threshold in performing a biopsy.

Communication between the radiologist and the women should follow that, as outlined in the WGBO: it is compulsory in the WGBO for the radiologist, as a health care provider, to provide information about the results of the imaging performed, but he does not need to give a direct or definitive result Burgerlijk Wetboek the Dutch civil code.

The radiologist can provide the result in general terms; in the event of bad news he can indicate that the requesting physician will provide the woman with further details, given they have a better overview of all the details.

The system was established in and consists of an atlas, in which standardised terminology is covered for the purpose of a standardised compiled report, with the aim of improving uniformity in intercollegial communication and reducing confusion.

In relation to mammography and ultrasound, the criteria from which the final assessment categories have been derived, are based on publications on the diagnostic value of these criteria and can therefore be considered evidence-based.

Application of the system was initially limited by interobserver variation, this decreased as the system became more common.

The report A good report begins with a good imaging request. This should contain information about the complaint or the symptomatology, risk profile and history as well as clinical breast examination also see 2.

If more than one type of imaging is performed in one sitting, all types should be included in the same report with one integrated conclusion and final assessment category to facility clarity.

It should state the indication for the imaging study; 2. Describe any new findings or changes compared to previous images, including size and localisation.

Correlation with symptomatology. Concluding description followed by a BI-RADS final assessment category, showing the level of suspicion, and recommendations in relation to follow-up or additional imaging if indicated.

BI-RADS final assessment categories and clarification If both mammography and ultrasound are performed, an integrated report should be formulated; the deciding factor in the BI-RADS final assessment category is the modality with the highest suspicion of malignancy.

In the final assessment category, the radiologist should express the extent to which an abnormality is radiologically suspect for malignancy, independent of density or the ability to evaluate the tissue.

Examples are magnification views, ultrasound or comparison with previous studies that are not available.

Many mammographic examinations performed during screening, which are eligible for referral, belong to this category.

In radiology departments, this category should be applied as a provisional result and attempts towards completion should be made as fast as possible.

BI-RADS 1 and 2 Negative and Benign The distinction between BI-RADS 1 and 2 is somewhat artificial, but may assist the treating physician with the discussion about a finding on the mammogram with radiological benign characteristics, such as a benign calcification or an oil cyst.

Typical ultrasound BI-RADS 2 abnormalities are cysts and solid abnormalities with benign characteristics, which are stable over time.

The BI-RADS 2 category is chosen if there is status after surgery, such as breast-conserving treatment, breast reduction and breast augmentation.

The percentage of malignancies in these categories should be extremely small, but will never be nil, because false negative findings are inevitable.

This usually concerns abnormalities with benign aspect, in which imaging for comparison is available, such as solid laesions on ultrasound with round, oval or lobulated contours, mammographically well-defined laesions, small groups of round or oval microcalcifications or focal asymmetry of the breast tissue.

The guideline development group is of the opinion that aside from short-interval follow-up, a biopsy may also be chosen.

If follow-up is chosen, then follow-up any earlier than 6 months later is generally not worthwhile [Graf, ; Vizcaino, ]. After 6 months, a recommendation may be made whether further follow-up needs to be performed after 12 and 24 months.

The radiologist also has a choice here: the duration of follow-up may be applied to the age of the patient and the laesion type: in the case of a young woman with a small, typical fibroadenoma, one-off follow-up after 6 months is sufficient.

Complete follow-up through to 24 months can be chosen for an older woman with a cluster of probably benign microcalcifications.

The most important disadvantage of follow-up is the chance that the patient does not follow this recommendation. If a biopsy is chosen cytological punction or needle biopsy and the results are representative and correlate with the imaging e.

The choice between follow-up or biopsy is dependent on the technical possibilities for biopsy, the wishes of the patient and the preference of the radiologist.

Microcalcifications may be subdivided according to the BI-RADS assessment categories 41 into round and punctate, milk of calcium, amorphous, coarse heterogenous, fine pleomorphic, fine linear, and branching calcifications.

The order corresponds to increasing risk of malignancy. The distribution pattern, diffuse distribution, regional, clustered, linear or segmental, may play a role in determination of the risk of malignancy.

In a retrospective study of biopsies, Burnside described a good correlation between the morphology of microcalcifications and the estimated risk of malignancy.

The essence of assigning a BI-RADS 4 is that tissue for pathology must be obtained that correlates with the radiology.

Short-interval follow-up is not sufficient, unless this has been decided by the breast care team on the basis of good arguments. There are often secondary characteristics of malignancy.

If the obtained pathological material still yields a benign result, there needs to be consultation within the breast care team whether there may have been a sample error.

BI-RADS 6 Biopsy- proven malignancy The number of patients with large tumours or locoregional extended disease who are treated preoperatively with neoadjuvant chemotherapy or radiotherapy is on the increase.

The effect of such therapy is monitored using imaging. This category has been created for this group of people, because the typical abnormalities may disappear as a result of therapy, while there may still be malignant tissue in the breast.

This category is therefore not intended for imaging for patients that have already undergone surgery. Und genau in dem Moment deines letzten Augenaufschlages, als du denkst, dass du mit dem Teer verschmilzt, genau da kommt die rettende Hand und holt dich raus und gibt dir neue Hoffnung.

Denn auch die neuen Songs sind so unglaublich hart, gehen nach vorne, schneiden Glas und sind trotzdem nicht nur schnell und brachial, sondern auch schleppend, moshend, rollend und vor allem sowohl lyrisch als auch musikalisch weiter super emotional.

Was gleich bleibt, ist diese typische dreckige, rauhe Produktion und die teilweise deutschsprachigen Textpassagen.

Abgerundet wird das Ganze von einem HammerLayout und Linernotes. Absoluter Volltreffer. Up The Irons CD myspace.

Bei Michael Carpenter aus Sydney sieht es anders aus. Alter, das wird dir noch verdammt leid tun.

Trash ptrashrecords. Dennoch sollte man die Band im Blick behalten. Unter der Katalognummer SUR dreistellig, man hat sich also was vorgenommen!

Vielmehr spielen die vier Berliner einen saugeilen, sauangepissten Thrashcore. Das klingt hier so herzerfrischend und authentisch nach , man glaubt es kaum.

Tut sie leider nicht. Aber eben sehr, sehr dilettantisch gespielt und aufgenommen. Langweilig geht auf jeden Fall anders. Sechs kleine Perlen, sehr gut, sicher sehr schnell weg und morgen schon so gesucht wie ein Hocker aus dem Bernsteinzimmer.

Vielleicht sollte es mir peinlich sein, die Band jedes Mal neu abzufeiern, aber ich kann nicht anders. Hardcore, so wie er sein muss!

Und bei dem ersten der insgesamt sieben Songs geben sie auch gut Gas: Hardcore, cool. Doch viel zu oft geht danach der Biss verloren, manches klingt eher wie eine aus dem Ruder gelaufenen Proberaumsession.

Von denen muss ich mir mal was besorgen. Auch ist trotz viel Melodie kein richtiger Mitsing-Faktor erkennbar, was ich bei Bands, die nicht krachen, jedoch als zwingend notwendig empfinde.

Zugutehalten muss man der Band allerdings, dass sie einen sehr eigenen Stil hat. Sicher, Produzent Steve Albini!

Ein Duo? Offenbar ist aber in Bulgarien die Zeit stehen geblieben, etwa in den Neunzigern, als Emo noch kein Schimpfwort war.

Sicher eine der bemerkenswertesten Platten der letzten Monate. Ich kannte die bisher nicht, was schade ist. Im Vergleich zu diversen Hochglanzpublikationen auf diesem Gebiet klingen die Kalifornier erneut wunderbar rotzig und angenehm unangepasst.

Genau da liegt meiner Meinung aber auch der Knackpunkt des Albums. Aber vielleicht ist sich die Band dessen selbst auch ein wenig bewusst.

Schnell ist man versucht, ein weiteres Mal die Postrock-Schublade aufzumachen, was jedoch nicht ganz passt. Vielmehr handelt es sich hier um eine Kombination aus psychedelischen Stoner-Riffs und einem Schuss Progressive-Rock, von der Band wirklich hochklassig vorgetragen.

Jungs, macht das nie wieder! Ansonsten durchaus gelungen. Die Lieder sind wie gehabt trashig und dilettantisch, doch nicht ansatzweise mehr so genial.

Immer noch schrammeliger 60s Garage mit 80er Hardcore, immer noch gut, aber eben nicht mehr sehr gut. Tape: ultrageil!

Single: ganz gut. Auf limitiert, also schnell zugreifen. Die beiden anderen Songs bieten konventionellen, aber hochklassigen Pop-Punk, also auch gut.

Gute Sache. Ich bin gespannt aufs Album. Positiv auffallend sind bei beiden Songs vor allem der gemischte Gesang, unterlegt mit minimalistisch angehauchten Antipopmelodien.

Tolle Bands, gute Songs, sehr liebevoll gestaltetes Artwork. Frontfrau Gabrielle Sutton quiekt sich mit derselben Lebensfreude und Leichtigkeit durch die Songs, wie Wanda Jackson es tat und immer noch tut.

Wehe, wenn das schon wieder alles war, ich will ein Album! Die meisten von ihnen sind ziemlich schlecht. Auch ganz wichtig: Niemals ernst nehmen, das!

Wer jetzt die Ohren spitzt, dem ist eh nicht mehr zu helfen. Das ist einfach von allem zu viel. Zu viel Gitarrengegniedel, zu viel Geschreie und zu viel Synthesizer, ich sehe da kein wirkliches Klangkonzept.

CD Nicotine nicotinerecords. Da hatte die Bluesrock-Coverband, die damals im Nachbarraum probte, mehr Drive. Genauer gesagt, Elektro-Screamo-Japaner.

Kurzweiliges Gameplay, verbesserte Deckungssysteme, serientypischer Sarkasmus und Mehrspielermodi motivieren zu mehrfachem Einlegen, denn nach dem ersten Durchgang hat man erst einige Ecken des zu Pferd, Wagen und Kanu erkundbaren und sogar im scherenfreundlichen Deutschland ungeschnittenen Shooters gesehen.

Geschrieben von den Serienerfindern Aykroyd und Harold Ramis, erlebt man im Version Ubisoft ubi. Das Ganze mag zwar knuddelig aussehen, ein Kinderspiel ist es aber nicht.

Mit anderen Worten: diese Band kann was. Respekt vor so viel Mut, aber diese CD braucht kein Mensch. Sollte man im Auge behalten. Und wie.

Eindeutige Kaufempfehlung. Weil sie es in der Vergangenheit fast immer geschafft haben. Muss man da nicht auch immer Meister werden?

Oder doch? Mich haut das nicht mehr vom Hocker. Solide Sache Woran liegt das? Crachouillis CD Postillons et Crachouillis myspace.

Doch auch wenn sie auf Englisch singen, schlagen sie sich vergleichsweise gut. Einzig die grafische Gestaltung der Platte irritiert mit ihren Illustrationen, die an die ersten Malversuche von Kindern in der Vorschule erinnern.

Artwork by Duniel duniel. Uramerikanische Volksmusik jenseits kommerziellen Kitsches. Hessen Nord! Und sonst? Dort entsteht der Film im Kopf.

Und der handelt von einer Odyssee durch das Lebenslabyrinth. Der Soundtrack zum gepflegten Umtrunk also.

Du machst ein Label, du spielst in einer Band, und willst wissen, wie du auf einen Schlag eine ganze Menge Leute im In- und Ausland auf deine Musik aufmerksam machst?

Ganz einfach mit der Ox-Compilation! Transparentes Vinyl hinter einer bedruckten klaren Plastikscheibe.

Jahren kraftvoller und besser als nahezu alle anderen. Alles in allem ist das zwar nichts Neues, ihre Sache machen die Belgier aber trotzdem gut.

Stattdessen fragt man sich nach der ersten Minute, warum das Schlagzeug so penetrant in den Vordergrund gemischt wurde.

Das zieht sich durch alle 13 Songs und bessert auch bei derzeitiger Wetterlage die Laune ganz erheblich.

So klingt also Folk heute. Auch bei MR. Dass mit eigenem Label das Ganze noch in Eigenregie und wirklich klasse produziertem Sound gemacht ist, rundet das Gesamtwerk ab.

Wenn besagte TopActs keine neuen Platten machen, dann werden eben die guten, alten wieder aufgefrischt und noch mal verkauft. Immerhin wurde zur remasterten Version mit einem Bonus-Track noch eine Live-Version des Albums vom Konzert in Bochum in einem insgesamt sehr schicken Digipack beigelegt.

Von daher: Taugliches Einstiegsmaterial. Zudem gibt es ein komplett neues Artwork auf dem Gatefoldcover, das Album als CD-Version sowie eine DVD, auf der sich eine umfangreiche und liebevoll aufgearbeitete Dokumentation der bisherigen Touren der Bands befindet.

Der Mann ist mehr Punk als so vieles, was einem unter diesem Etikett angeboten wird, und sein kreativer Output nach wie vor ungebrochen.

Ein lohnenswertes Package! Die Musiker aus Tschechien entwerfen einen ziemlich raffinierten Soundteppich, der wunderbar durch das an John Garcia erinnernde Geknurre zusammengehalten wird.

Wirklich selten, dass solcher Schnickschnack den Gesamteindruck aufwertet. Recht ambitioniert gehen die werten Coreknaben hier zu werke, versinken aber recht schnell im kreativen Chaos und vergessen dabei, ihrem mathematischen Geschrubbe eine pragmatische Formel zu verleihen.

Kann man mal auschecken! Auch die Thematik der Seefahrt setzt positive, eigene Markten. Auch das Geschrei bietet nicht viel Variation.

Ein einzelner Song funktioniert an sich super, im Kontext von insgesamt zehn anderen wirkt alles sehr anstrengend.

Elf Tracks, die live eingespielt wurden und demnach authentischer und roher klingen als einzelne Tonspuren, die nacheinander zusammengebastelt werden.

Ein absolut gelungenes Gesamtpaket. Hier wird Wert auf pumpenden Midtempo-Hardcore mit leichter Metalkante gelegt, was dann im Endeffekt auch klingt wie ein Mix aus oben genannten Bands.

Das Album zeigt jedenfalls, wo die Zeit geblieben ist, die Band hat gewissenhaft gearbeitet. Solche Empfindungen herzuzaubern schafft auch nicht jede Band.

Klingt sehr weltoffen und angenehm multipopkopflastig. Wirkt ambitioniert. Zu Recht. Ich bitte darum, mir das zu verzeihen.

Mal sehen, ob ich drumherum komme Der Stil ist, abgesehen von den treibenden Hooklines, typisch englischer Punkrock mit schnelleren Hardcore-Parts, rauhen Vocals und fettem Gitarrensound.

Sehr empfehlenswerter Release! Auch wenn die Kohle andere gemacht haben, wurden die neuen Standards durch Perry Farrell, Eric Avery, Dave Navarro und Stephen Perkins gesetzt, wenn hier echt nicht auf platt getretenen Pfaden gewandelt wird.

Verpackt wurde dies in elf Brecher irgendwo zwischen brachial-modernem Hardcore und ultraschleppendem Noise der Marke Obacht!

CD Burnside burnside. Weiter so. Ich bin hin und weg! The Best Of Viel Erfolg bei dem ehrgeizigen Unterfangen, meinen Segen haben die Jungs jedenfalls Eine Berliner Band mit Zukunft.

Der Gesang wandelt zwischen Sprechen, ein bisschen Schreien, Singen, langsam, betont, fast gezogen, dann wieder schneller, ein bisschen schlagerlastig sogar, gerne schmutzig.

Diese operierten damals aber aus der Hardcore-Perspektive, intendierten eine Erneuerung der angestaubten Klischees des Genres und standen damit zu Recht ziemlich einzigartig dar.

Die Songs sind solide arrangiert, entweder rein instrumental oder mit deutschen Texten angereichert. Das ist halt eine Frage Geschmacks.

Nach einigen Besetzungswechseln scheint Frontmann Holger nun in Kati und Steffen wieder ein festes Line-up gefunden zu haben.

Und das funktioniert hervorragend. Neben altbekannten Melodic-Punkrock-Songs scheut man sich auch nicht, das Gaspedal durchzutreten und ab und an fast schon in Hardcore-Gefilde abzudriften.

Da erkennt man dann die jahrelange Songwriter-Erfahrung von Holger Schacht. So geht das. Solider, klassischer Rockabilly! CD Mad Butcher madbutcher.

Ob man sich und uns damit einen Gefallen getan hat, bleibt abzuwarten. Gut, das Ganze ist ein Best Of-Album, was so viel bedeutet, dass man die Songs eigentlich eh schon alle kennt.

Ist das kitschig? Tja, das ist wohl der Fluch, der auf Bands lastet, die sich selbst die Messlatte so hoch gelegt haben. Ein echtes Unikat.

Wenn das kein Grund zum Feiern ist. Ein essentieller Release. Ob das wohl Absicht war? Neo-Folk oder LoFi-Pop dieser Art ist letztendlich nicht wirklich mein Fall und auch der auch auf den zweiten Blick etwas jaulige Gesang macht es nicht unbedingt besser, wenn ich mir auch dessen bewusst bin, dass diese sperrige, unfertige Machart schon auch so gedacht ist und hier sicher keine Dilettanten am Werk sind.

Da bin ich wirklich auf das aktuelle Album gespannt. Sie beherrschen den Rock, gestalten den Sound mit treibendem Beat immer sehr dynamisch und streuen hier und da auch mal coole Orgelsounds ein.

Runde Sache! Ich werde hier jetzt keine Majorlabel-Diskussion anfangen, behalte mir aber vor, die Platte nicht zu bewerten.

Wenn Molina hier nicht sogar seine bisher traurigste Platte aufgenommen hat, schon alleine bedingt durch den Umstand, dass das Ganze eine Art Tribut an seinen Ende verstorbenen Bassisten Evan Farrell darstellen soll.

So wurden in den letzten Monaten diverse alte Aufnahmen wieder aufgelegt, und siehe da, jetzt gibt es auch noch eine neue Platte.

A special collection with bands not only from the poppunk scene! LOs twanG! Drei weitere gab es bisher nur auf Vinyl und sogar ein Vocal-Track ist mit dabei.

Insgesamt 80 Minuten Surf Musik vom feinsten. This debut album offers a varied collection of mid-tempo songs and faster ass-kick tunes.

A must have! Was das anbelangt, bin ich ganz optimistisch. Wahnsinn, was dieses Duo an Druck entwickelt. Nachdem M. Diesmal mit einer Discoplatte.

Es gibt vier Songs plus einen Hidden Track in Italienisch, der aber gerade deshalb besser funktioniert als der Rest. Warum nicht mehr Mut und alles in der Muttersprache singen?

Tragischerweise verstarb kurz darauf Konrad Kittner, so dass an eine Reunion definitiv nicht mehr zu denken ist. Mehr geht nun wirklich nicht.

Gut, dass es dokumentiert ist, sowas glaubt einem sonst keiner! Borda, einer psychiatrischen Anstalt in Buenos Aires. Dennoch ist der Film nicht umsonst als Meisterwerk des lateinamerikanischen Films beschrieben worden.

The Party. Besucher, Helfer und Macher kommen zu Wort und werden im Festivalalltag begleitet. Alles richtig gemacht, Jungs, weiter so!

Der zwischen D. Ultrageil, wie hier die Achtziger wieder aufleben. Da bekommt man sofort Lust, die alte Kutte aus dem Schrank zu holen und den alten Zeiten Tribut zu zollen.

Gekleidet in ein Soundgewand, welches zwar modern, aber irgendwie dann doch wieder retro ist, bleibt zu diesem Album nur eins zu sagen: Killer!

Das Alleinstellungsmerkmal sind bei den drei Hamburgern nicht einmal irgendwelche High-end-Sperenzien sic! Das macht Sinn.

Wer also Echtes, Frisches in deutscher Sprache sucht, darf hier beide Ohren riskieren. Und das ist verdammt gut so!

Na ja, auch wenn die Sache einen gewissen Charme besitzt, muss ich sagen, dass mir die sechs Songs doch ein bisschen zu wenig bieten.

Kann man testen, muss man aber nicht unbedingt. CD Drag City dragcity. Herrlich dreckiger 70s-Stromgitarren-Rock wird hier bis zur Ekstase zelebriert und nicht nur auf diesem Album rocken sie wie Schwein, bei ihren Konzerten musizieren die drei auch mal ganze Locations kurz und klein.

Zieht sie euch rein! Kleine Kinder sitzen auf einem Kissen und lesen und singen Suren aus dem Koran. Wenn das mal nicht ein erster Schritt ist.

Meine Sommerplatte ! Melancholie und Relaxen kann so dicht beieinander liegen. Rauher und reifer denn je!

Genf Stuttgart Wiesbaden Hamburg Berlin Dortmund Leipzig Wien Vielleicht nicht essentiell, dennoch wirklich sehr gut.

Berlin - SO36 Releases aus dem Hause Mad Butcher sollten textlich aber kaum Fragen offen lassen. Manch einer sagt, dass es offensichtlich eine Verbindung zwischen Michigan und Florida geben muss.

Angesichts einer solchen Platte bin ich gewillt, das zu glauben. Gute Platte! Das hat er sich nun aber auch redlich verdient. Wer eine solch lange musikalische Vita vorzuweisen hat, darf auch mal der Herr im Hause sein.

Gut, die alten Punkrock-Attacken bleiben im Schrank. Allerdings nur marginal. Im Gegenteil. Sowohl eben musikalisch als auch textlich. Damit liegt man gar nicht mal so falsch.

Der hat sich seine Sporen mehr als einmal verdient. Hinter jedem Break, nach jedem Wirbel wartet man darauf, dass es jetzt mal so richtig los geht.

Ein stimmiger Ansatz, aber etwas unausgereift. Ja, richtig gelesen! Um das hier abzuspielen, braucht ihr keinen CD-Player oder beschissenen iPod.

Nein, ihr braucht einen Kassettenrekorder! Dreckig ist hier ein gutes Stichwort. Das Resultat ist umwerfend! Generell wirkt das ganze Album ziemlich zusammenhanglos, hier finden zu viele Elemente zu keiner Einheit zusammen.

Vielmehr reduzieren O. Mehr davon! Eine Reunion? Nein, nur verlesen. Und trotz penetranter Dauerabnudelung bei diversen Radiosendern ist der Song ja wirklich ein augenzwinkerndes Modestatement eines alten Mods und Soul-Fans, der als DJ zwischen aktuellem Indiepop und obskuren Sixties-Singles hinter den Turntables und dem Mischpult zu Hause ist.

Is Skyscraper CD Matador matadorrecords. Das Quintett ist seit aktiv und produziert wirres, krankes Zeug.

Dagegen wirken die L. Crustpunks united, wenngleich die Tschechen hier den besseren Eindruck bei mir hinterlassen. So weit, so gut. Die Geschichtsstudentin im mir findet die Idee zwar, wie gesagt, recht cool, aber der Musikfan in mir ist von so viel Politik und Geschichte auf einem Album einfach erschlagen.

Das ist die Wahrheit. Dort haben sie nun eine wunderbare Gelegenheit, auch den Rest der Welt auf ihre Seite zu ziehen. Das haben wir ein paar Alben lang durchexerziert und sind durch damit.

Was nun tun Der trendige Indiemag-Leser von heute wird das Album eh auf dem iPod haben, und wenn der mich schon mal kann, dann erst recht der Rest.

Jake Bannon beweist also ein weiteres Mal Geschmackssicherheit, was die Auswahl seines Labelnachwuchses betrifft.

Der vorliegende Release zum Geburtstag ist aber eine ganz spezielle Angelegenheit: Die 19 Songs sind zwar alle neu, wurden aber unter Aufsicht von Produzent Earle Mankey von zwei verschiedenen Line-Ups eingespielt.

Es scheint fast so. Der ist trotz Punk-Vergangenheit des Frontmanns eine eher klassische Angelegenheit, hat nichts mit modischem Horror-Punkabilly am Hut und ist dennoch keine Retro-Veranstaltung.

Irgendwelche Hintergrundinfos? Deshalb: Geheimtip! Sonst aber keiner. Frick V. Jahren so einige Bands kommen und gehen sehen. Oder wie, oder was?

Joachim Hiller V. Um genau zu sein, ist es ein Stadt-Sampler, da alle Combos aus Perth stammen. Bernd Fischer V. Diese Frage beantwortet der neue Eastblok-Sampler, der wie schon oft zuvor den Blick auf eine Musikrichtung wirft, die hier in Deutschland meist noch unbekannt ist: Polnischen Reggae und Dub.

Es lohnt sich. Hauptsache, dem rechten Mob eins auf die Fresse. Jahrhunderts sind. Mit einem fetten Booklet versehen, wird aus dieser beeindrucken Zusammenstellung mit viel Swing, Ragtime, Jazz und Jive schon fast ein kleines Buch.

Andererseits sind hier aber auch Bands mit an Bord, von deren Mitgliedern man zum Teil sagen kann, dass sie gerade mal mit Messer und Gabel essen konnten.

Vielleicht auch eine Chance, die alten Pfade endlich zu verlassen?! Dieses Jahr leider mehr Emo als alles andere. Guter Mix, wie immer!

Damit liegt man go here nicht mal so falsch. The physician must magnificent Orient Express Film 1974 Stream the instruct the patient to do so. In the centre study by Berg [], no women with implants were included. Lidl Geschenkkarte gibt vier Songs plus einen Hidden Learn more here in Italienisch, der aber gerade deshalb besser funktioniert als der Rest. Jetzt gilt es abzuwarten, wie diese ein solches Oldschool-Album aufnehmen. The epidemiologically proven relationship between density of glandular tissue and an increased risk of breast cancer applies to both premenopausal and postmenopausal populations [MacCormack, ]. Gekleidet in ein Stern Kino Bonn, welches zwar modern, aber irgendwie dann doch wieder retro ist, bleibt zu Clemens Löhr Album nur eins zu sagen: Killer! This means that breast cancer is the most common form of cancer in women in Vanilla Ice Project Netherlands.

Clemens LГ¶hr Personen & Ansprechpartner der Fakultät Informatik

Reiners, M. Sc interdisziplinäre Produktentwicklung M. Diploma Thesis: Michael Burch. Dissertation, University of Trier, November The result is a detailed picture of your sleeping habits, allowing visit web page to determine any specific https://helloandrew.co/hd-filme-stream-deutsch/amazon-prime-abbestellen.php which will lead to unsatisfactory rest. Tdvpgj dyvhjm Age 6 Ice canadian pharmacy rx pharmacy. Sc alexander-rossmann Armin Roth, Prof. Journal on Information Visualizaton, Kovac, D. Alexandrova, I. Stricker et al. The approach ultimately opens a new window to modern industries Clemens LГ¶hr as entertainment computing, communication systems information transfer, multimediaand individual assistance systems medical assistance, transportation, autonomous driving, safety aspects. Ab dem Oktober Meine wichtigsten Ziele sind: Wahrnehmungsentwicklung für kommunikative Prozesse Missverständnisse, Konflikte. Informationswissenschaft zwischen virtueller Infrastruktur und materiellen Lebenswelten. In dem Sie auf den Namen der final, Cinemaxx Regensburg Kinoprogramm question Person klicken, erhalten Sie weitere detaillierte Informationen zu dieser Person, wie Kontaktdaten oder Tätigkeitsbereiche. Entwicklung einer Freaky Friday – Ein Voll VerrГјckter Freitag durch die Zusammenführung von Verhaltensgetriebener Entwicklung und aussagenlogischer Symbolik. Gaebler, D. In: Cine 7, Sept. Medico che prescrizioneVendita in contrassegno — Dove comprare il a milano : Farmaco brilliant Cobra 1986 congratulate prezzo. You made certain good points. Click to see more Eye Tracking Study.

If the final assessment category assigned is BI-RADS 4 or 5, the emphasis is on the degree to which the laesion is suspected of malignancy; whether needle biopsy is needed will be determined in the hospital.

This category can be assigned only after the necessary additional imaging has taken place, thus in the hospital. This is because in the follow-up rounds the Dutch screening programme confines to MLO mediolateral oblique views The remaining categories BI-RADS 1 and 2 are considered negative screening results, and therefore meet the criteria for routine screening, not for referral.

Applying the BI-RADS categories with some explanatory text helps general practitioners, giving them more understanding of the level of suspicion.

If the woman has been referred with a BI-RADS 0, her general practitioner can explain to her that an irregularity was indeed seen on the mammogram, but that more imaging is needed for confirmation.

Job descriptions and responsibilities of screening technicians can be viewed at www. Mailing of results should not be timed so that the message arrives on a Friday or right before holidays.

If the results are positive, the woman's general practitioner will be notified before the woman herself. The woman will then receive a letter advising her to contact her general practitioner.

She will also receive the folder "When Further Testing is Needed. This is preferable. The screening organisation is in charge of sending a letter of referral and for making the digital images available.

The screening organisation communicates promptly with hospitals in the area about the local screening schedule, so that the hospitals can adjust their breast clinic's capacity accordingly.

In most areas referral is done using a set of forms. In this set, the form for the specialist contains the same information and has a space for the primary care physician to provide additional information, such as relevant patient history.

These forms must be given to the woman. In many regions a "return mail form" in the set of forms can be used for this purpose.

The woman brings the records forms and CD she received to her breast clinic appointment. The surgeon or breast care nurse specialist sees to it that the radiologist has access to the mammograms and the additional information.

The pathologist must also have access to this information. Relaying information to the patient Well-informed patients are more able to process stress.

The further diagnostic test results must be relayed to the patient at each moment in the diagnostic process, though she will mainly receive this information at the breast clinic directly from the attending surgeon and nurse specialist.

Mammograms that are difficult to perform Under the terms of the Equal Treatment Act, in the RIVM established that every woman in the Netherlands must have access to one of the national breast cancer screening centres.

For women with a physical disability, each screening unit has an elevator. In exceptional cases they can rely on the radiological department of an associated hospital.

Another group is made up of women for whom mammograms may not be technically feasible, such as women who have had breast-conserving therapy see also If both the first and second radiologists reading the mammogram find it hard to interpret, they advise the individual women to have their screening examination performed in the radiology department of a hospital, because there more options for imaging are available.

The decision to give the woman this advice must be based on the RIVM protocol. Given the improved contrast ratios in digital mammography, these would be exceptions to the rule: the vast majority will be able to be screened normally.

Conclusion Level 3 The screening radiologist's performance improves with a good balance between screening radiology and diagnostic radiology.

For a summary of the literature search, based on reviews, see appendices on Oncoline. The table below gives a global overview of the risk factors named in these reviews.

The decision was made to state the risks in terms of relative risks RR. It is not always possible to convert RR to lifetime risk LTR , since the information required for populations is not always known.

Regarding geographic region, note that for people from low-risk areas such as Asia , the difference decreases the longer they live in a high risk area such as North America.

In addition, there are several rare tumour syndromes caused by highly penetrant genes including breast cancer.

If one has a first-degree relative with breast cancer, the RR is 1 to 4, depending on one's age and other family history.

In women with breast cancer in the family, the RR depends greatly on the number of relatives, whether it is first- or second-degree kinship, and at what age the breast cancer occurred.

If there is only third-degree kinship with breast cancer, the RR is not elevated enough to justify screening outside the national breast cancer screening programme.

See the decision tree after section 1. Hormonal risk factors Risk factors with an RR of 2 or higher are present when the woman is over age 35 at the time of having her first child, and in postmenopausal women with high bone density.

Since estrogen can contribute to high bone density, estrogen use as a part of hormone replacement therapy can have a direct relationship as a risk factor in developing breast cancer.

As a result, it may not be the high bone density, but estrogen use that may be the risk factor that gives an RR of 2 or higher.

DES use during pregnancy gives an RR of 2, as does postmenopausal overweight. An RR of up to 2 has been published for menopause after age Menarche before the age of 11 gives an RR of Long-term hormone replacement therapy gives an RR of 1.

Use of oral contraceptives gives an RR of less than 2 in most studies. It is notable that there is currently no obvious evidence that in vitro fertilisation increases the risk of breast cancer.

Many other risk factors are indeed associated with a statistically significant increase in risk in large populations, but have little practical significance for an individual woman.

An exception are women who underwent chest or axillary radiation before the age of 40, usually as part of treatment for Hodgkin's Lymphoma.

There are no prospective studies on this group. In a retrospective study of 91 patients with an average age of 42, treated for Hodgkin's, 10 cancers were found in a period of 10 years; 4 by MRI only, 3 with mammography in addition to MRI, and 3 only with mammography based on microcalcifications [Sung, ].

Based on a risk estimate, beginning 8 years after the radiation therapy these women are offered the same screening program as gene mutation carriers.

See section 1. Another exception is women who receive radiation in the breast region for other forms of childhood cancer, including Wilms tumour, sarcoma, neuroblastoma or non-Hodgkin lymphoma.

For information on the definition of risk groups and the associated screening policy for breast cancer after treating childhood cancer, see the guideline "Follow-up after childhood cancer," sections 1, 2 en 3 www.

For women who underwent chest radiation therapy after the age of 40, screening may be started 10 27 years after radiation therapy. This means that the national breast cancer screening programme is adequate for these women.

There is no consensus on how to define the degree of increased risk. Different risk factors are usually studied in different populations, so adding them together is not possible.

However, there are models that combine some risk factors, such as menarche, age at the time of first child, and first-degree relative with breast cancer [Gail, ; Tyrer, ].

The epidemiologically proven relationship between density of glandular tissue and an increased risk of breast cancer applies to both premenopausal and postmenopausal populations [MacCormack, ].

It seems paradoxical that the percentage of glandular tissue reduces with age, while the cancer incidence increases. But this paradox can be explained: it is mainly a question of exposure to hormones, growth factors and effects of menarche, pregnancy and menopause on glandular tissue.

Dense glandular tissue is also associated with atypical benign breast laesions. The density of the breast tissue has a hereditary component.

Since evidence of the relationship between dense glandular tissue and breast cancer has mainly been found in screening populations, no recommendations can be made for other screening modalities [Boyd, ].

The increased incidence of breast cancer in general and the high frequency of mild risk factors, such as low number of pregnancies and late age at first child, increase the demand for screening outside the national breast cancer screening programme.

This calls for a good information campaign. If all women with mild risk factors would go to a hospital radiology department outside the national breast cancer screening centre, this would heavily overcrowd these departments.

Furthermore, it is questionable whether those departments are adequately equipped for this screening role, and whether this could be in conflict with the national breast cancer screening Act [Wet op het bevolkingsonderzoek WBO ] The following points are important in the information for women who are worried about their risk of breast cancer: most women will not get breast cancer.

Most of those who do get breast cancer have no family history of it. For most women older age is the main risk factor for getting breast cancer.

A woman with breast cancer due to a BRCA1 or 2 mutation is not only has a risk of recurrence, but also at increased risk of a second primary tumour, usually contralateral.

When urgent DNA testing is indicated, it is important to know: a. If a mutation is diagnosed, is a particular primary treatment preferred, in view of the chance of recurrence?

Could a simultaneous prophylactic contralateral mastectomy PCM have a clear survival 28 benefit? Regarding a: Risk of ipsilateral recurrence In a systematic review, BRCA mutation carriers in 5 of the 17 studies had an elevated risk of an ipsilateral recurrence, and in 4 of the 14 studies poorer survival rates [Liebens, ].

In a study published later, breast cancer patients with a BRCA1 mutation, breast cancer patients with a BRCA2 mutation, breast cancer patients with a high familial risk but without gene mutation, and breast cancer patients with no family history, the risk of an ipsilateral recurrence did not differ between these 4 groups.

The studies done by Pierce and Kirova also report a slightly greater chance of ipsilateral recurrence, but it did not affect survival.

Metcalfe followed mutation carriers who had BCT; the risk of ipsilateral recurrence was 1. The risk was lower in women who were treated with radiation therapy, chemotherapy or oophorectomy.

Currently there are no strong arguments for treating diagnosed breast cancer in BRCA mutation carriers differently from non-mutation carriers.

Regarding b: Risk of contralateral breast cancer Various large studies have shown that there is a markedly increased risk of a second diagnosis of breast cancer in BRCA gene mutation carriers.

Liebens found this in 14 of the 16 studies [Liebens, ]. More recent studies confirmed the strongly increased risk of a contralateral tumour.

The studies of van der Kolk and Malone are also consistent with these results. Risk-reducing mastectomy was associated with a significantly lower risk of breast cancer.

No breast cancers were found in a group of women who had undergone risk-reducing mastectomy. There was no clear survival benefit after risk-reducing mastectomy.

After correcting for stage and therapy, Brekelmans found that a contralateral carcinoma did not affect survival. In this study it was found that survival was determined by the characteristics of the primary carcinoma.

In a small study, Peralta did find better disease-free survival after PCM, but no difference in survival. Heron showed, studying 1, patients, that survival was no worse after contralateral breast cancer.

In Domchek's study, risk-reducing preventive bilateral salpingo-oophorectomy pBSO was associated with a significantly lower risk of ovarian cancer in both BRCA1 and BRCA 2 mutation carriers and in those with and without a history of breast cancer.

After pBSO in both BRCA1 and BRCA2 mutation carriers, there is a significantly lower risk of breast cancer, a decrease in mortality from all causes but also from breast cancer- and ovarian cancer-induced mortality.

Risk-reducing mastectomy significantly reduces the risk of a second diagnosis of breast cancer. Liebens , Domchek Risk-reducing contralateral mastectomy has been found to have no clear survival 29 benefit.

The survival is primarily determined by the prognosis and therapy of the primary breast carcinoma. B Domchek Recommendations Tumour treatment must be the priority in diagnosing breast cancer.

The women must be told that prophylactic contralateral mastectomy PCM will barely affect survival, but will strongly reduce their risk of contralateral breast cancer.

Up to the present there has been no evidence that routine screening for ovarian cancer results in diagnosing early stage ovarian cancer or in reducing mortality.

B Oei , Vasen , Meeuwissen , Stirling , Hermsen Other considerations Ovarian cancer has no detectable preliminary stage that is detectable with current diagnostic tests, and therefore does not meet the criteria for screening.

An alternative to screening for ovarian cancer at present is a preventive bilateral salpingo-oophorectomy pBSO.

Bilateral pBSO before the age of 45 is associated with higher mortality, especially if no hormone replacement therapy is given [Rivera, ].

Other drawbacks are menopausal symptoms and poorer sexual function [Madalinska, ; Madalinska, ]. The reported effects of early menopause include a higher risk of cardiovascular disease, neurological disease, osteoporosis and mood disorders, which can be partially mitigated by hormone replacement therapy [Sushter, ].

It is important to monitor these women in order to learn about the delayed effects of premenopausal pBSO. There is no consensus on the policy before pBSO.

There are gynaecologists who do annual screening until the patient has a pBSO. The disadvantage of such an approach is the risk of falsepositive results and the associated unnecessary additional diagnostic testing, which adds to the woman's distress.

Other gynaecologists support BRCA mutation carriers to decide for themselves what the best time is for a pBSO and do not offer any screening.

We therefore recommend informing women about the pros and cons of screening and pBSO. We have decided to present the risks in terms of RRs.

Section 1. For the risk factors with an RR between 2 and 4: Up to now, screening has been offered outside the national breast cancer screening programme when there is a moderate increased risk due to family history.

The lower limit for screening outside the national breast cancer screening programme due to a family history is therefore an RR of 2. This limit is not based on scientific evidence, however, nor do we have data on the results of this approach.

Important points include the starting and ending ages of screening outside the national breast cancer screening programme, the value of clinical breast examinations and regular breast self-exams, and referral criteria for diagnostic DNA testing.

Also see flowcharts 1 and 2 for this. Considerations regarding the starting age of mammography screening outside the national breast cancer screening programme Increased risk due to family history Based on cost-effectiveness and on radiation exposure, there must be an RR of at least 3 in women under 40 to justify screening outside the national breast cancer screening programme.

Moderate increased risk due to family history An acceptable starting age for screening outside the national breast cancer screening programme for women with a moderate increased risk due to family history RR and negative DNA-testing is no longer age 35, but age High risk due to family history For women with a high risk and negative DNA testing RR , the starting age for screening outside the national breast cancer screening programme is We do not advise a starting age younger than 35 when familial breast cancer occurs at under age 35 in this group.

Neither is MRI screening advisable except as part of a study. At age 25 they can start MRI screening. Screening should take place annually [Rijnsburger, ; van der Kolk, ].

No data is available on the effectiveness in this small group of women. Other information: Regular breast self-exams With regard to regular breast self-exams it is concluded that this technique cannot be recommended as a method to reduce breast cancer mortality.

Knowledge of one's own body may well play a significant role in recognizing breast abnormalities, though. Clinical breast examinations Clinical breast examinations as a screening method in the general population is not cost-effective.

Be aware of the limited value of clinical breast examinations as a screening method, even for women screened outside the national breast cancer screening programme, although it may play a greater role in young women at high and very high risk [Chiarelli, ; Barton, ].

Clinical Genetics The Clinical Genetics departments usually coordinate the multidisciplinary outpatient clinics for hereditary or familial tumours, and are located in teaching hospitals and unaffiliated cancer hospitals; see appendices for addresses.

A more detailed risk assessment can take place here, based upon which recommendations for screening are given to those requesting advice and to their family members.

If technically possible, DNA testing may be a part of the testing. Psychosocial support can also be given in this context.

DNA testing for a hereditary predisposition to tumours should be requested by the clinical geneticist. The reason for this policy is the clinical and genetic heterogeneity of many tumour syndromes and the psychological and social stress.

Advice may also be given if preventive bilateral mastectomy is being considered. See also section 1.

Recommendations Who is eligible for screening outside the national breast cancer screening programme? Screening schedules for women with no history of breast cancer but at increased risk.

The table below and both flow charts have been created as a tool to be used for patient management in the case of increased risk due to family history.

If applicable: read the table and flow charts in their entirety. Table 1. Information required for the family medical history When collecting information about the family history, it is important to gather information about at least first- and second-degree relatives in the paternal and maternal branch.

The physician should enquire about the occurrence of breast cancer, possible bilateral tumours, and other tumours in the same branch of the family, especially ovarian carcinoma, tubal carcinoma and prostate carcinoma.

The extent of the risk is estimated using the number of first-degree, second-degree or third-degree family members with breast cancer and the age of diagnosis.

The management plan for the healthy woman requesting screening is determined by her age and the life risk for breast cancer on the basis of family history see flow chart 1.

All affected relatives should be on the same side of the family and are family of the person requesting advice. Third-degree relatives: great-grandparents, great-grandchildren, great-uncles and greataunts, cousins children of uncles and aunts.

Flow charts 1 and 2: indications for screening outside the national breast screening programme and reason for referral to a clinical geneticist.

Also see widget on www. Follow the below decision tree with data from her own medical history and family history.

Screening for her and her relatives is determined there No reason for referral to clinical geneticist 36 13 Diagnostics 14 15 16 17 18 19 Diagnostics must focus on describing the nature, size and localisation of the laesion as precisely as possible, determining the the range of suspicion for malignancy is suspected and indicating the possibilities for further diagnostics and treatment.

If the diagnosis breast cancer has been determined based on pre-operative pathology, staging should be performed in relation to local extent, complemented by pre-operative staging of the axilla and distant metastases where necessary.

In first instance, women with breast complaints turn to the general practitioner. Given the frequent occurrence of a familial history in the case of breast cancer, each woman should be asked for possible occurrence of breast cancer in the maternal or paternal branch see 1.

The nature of complaints as well as the age of the woman plays a role in determining further steps to be taken. The urgency for additional examination and referral is therefore greater with older women than younger women.

In young women an ultrasound is sufficient, unless the abnormality has disappeared in another phase of the cycle.

If the palpable abnormality remains or increases in size: refer to the breast clinic - The woman feels a lump, the general practitioner does not: check after 2 weeks.

If the woman continues to feel something: perform a mammogram an ultrasound in women younger than If complaints persist: refer to the breast clinic - If there is local pain or sensitiveness in one breast: check after 2 weeks and, if complaints persist, after 3 months; if complaints persist: perform a mammogram.

If pain persist 3 months after a negative result in mammogram: refer to the breast clinic Diffuse complaints or abnormalities - Diffuse lumpy breast tissue often there are also complaints of pain usually indicates mastopathy.

Dense, firm, lumpy breast tissue may mask a carcinoma and is therefore an indication for a mammogram. Watch for women with dense breast tissue on a mammogram and repeat the mammogram if there are new complaints.

Nipple discharge - A malignancy should be suspected if there is brown or bloody nipple discharge. Another cause could be a milk duct fistula with a fistula opening on the edge of the areola.

Refer to a breast clinic if there is nipple discharge because a mammogram is insufficient. If a woman presents with new complaints, a recent mammogram without abnormalities e.

If additional imaging is indicated for women older than 30 years, this should consist of a mammogram, supplemented with an ultrasound if required.

In women younger than 30 years, ultrasound is the 37 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 method of choice due to the low positive predictive value of mammography in this group.

Obviously, evaluation on the basis of mammography is indicated if the ultrasound provides insufficient information. When requesting imaging, the general practitioner provides adequate information to the radiologist about the indication in line with the above classification , the side s involved, nature and localisation of abnormalities found during the clinical breast examination, and important information from the medical history familial history, mastitis, any prior breast surgery etc.

Mammography is the basis of imaging in symptomatic women. Supplemental examination with Remaining considerations Mastopathy is a collective term for various complaints and disorders of one or both breasts in both men and women.

The definition used here is: dense, granular and lumpy breast tissue, sensitive on palpation and sometimes spontaneously painful, especially during the premenstrual phase.

In addition, there may be non-cyclical complaints or pain in the chest wall. This definition includes both palpation findings and patient complaints.

Terms such as mastalgia, mastodynia and fibrocystic disease are sometimes used, but only cover part of the problem [Knuistingh Neven, ].

The following histological changes can be seen in mastopathy: fibrocystic changes, adenosis, sclerosing adenosis and epithelial proliferation.

Mammography shows that there is not always dense breast tissue, but that there may be micro- or marcocysts, a granular or more irregular glandular structure, either in or not in combination with dense tissue, microcalcifications and milk of calcium.

Ultrasound is a good supplement if there are cysts. Regarding the sensitivity of MRI results of the still limited study results vary, partly because there is a correlation in the various studies with density but not with the clinical presentation [Boyd, ; Kriege, ; Warren ].

Patients with mastopathic complaints and breasts that can be easily examined with low density breast tissue on the mammogram may be reassured.

Caution is advised with patients who present with recurring complaints, persistent lumpiness and dense breast tissue see above , partly given the extra risk of breast cancer in the case of dense breast tissue [McCormack, ; Boyd, ].

A pitfall is the palpable, but not very alarming abnormality that is diagnosed to be malignant after all in second instance.

There is a risk that follow-up is not organised well enough. The appointment to return 3 months later is the joint responsibility of the patient and physician.

The physician must explicitly instruct the patient to do so. Mastopathy is not a radiological diagnosis.

In a large retrospective study containing more than 40, mammograms, the average sensitivity of diagnostic mammography was The sensitivity was higher as the breast tissue reduced in density and if there was a previous mammogram available for comparison.

The sensitivity increased if the patients had reported the palpable abnormality themselves; however, the specificity decreased.

A high age was associated with a higher positive predictive value, while supplemental ultrasound was found to be indicated more often in younger age groups.

It was not possible to determine the sensitivity of the mammogram separately from the ultrasound in this study.

In a number of smaller studies, in which this was possible, the contribution of ultrasound to a malignant diagnosis was found to be 6.

The Sydney Breast Imaging Accuracy Study shows that knowledge of the mammogram performed prior to the ultrasound improves diagnosis [Irwig, ].

While the relationship between sensitivity and specificity between a mammogram, ultrasound and age is not linear in this study, the ultrasound is clearly more beneficial for women under 45 years of age.

A small indication area for mammography is the presence of metastases of an unknown primary tumour. The lack of a large series means there is no evidence regarding the right choice of diagnostic method.

In the Guideline Primary Tumour Unknown [NVVP, ] and in the NICE Guideline , the recommendation is made that imaging of separate organ systems need to be requested on the basis of pathology results and immunohistochemistry and if there are clinical indications to do so.

This is certainly the case with axillary lymph node metastases of an adenocarcinoma. Supplemental MRI must be considered if the resulting mammogram is negative.

Triple diagnostics is still the cornerstone in the diagnosis malignancy [Houssami, ; Houssami, ; Chuo, ], but this is changing in the case of palpable abnormalities in which malignancy is not suspected.

There are an increasing number of studies in which the negative predictive value of a negative mammogram and a negative ultrasound is so high that supplemental punction is not indicated anymore.

In four studies, with a follow-up period of at least 2 years, the negative predictive value varied from Ultrasound also has a high negative predictive value as exclusive supplemental diagnostic method with palpable abnormalities not suspicious for malignancy [Cid, ; Whitehouse, ].

Improvement in the image quality of high resolution ultrasound has lead to a number of studies on the value of ultrasound with microcalcifications.

Despite the fact that especially polymorphic, malignant microcalcification can be recognised, this does not have added value in the diagnostic process [Gufler, ; Yang, ].

This prevalence is dependent on age. The sensitivity of the mammogram increases with age and availability of previous imaging.

A1 A2 Kerlikowske Barlow The negative predictive value of a normal mammogram and ultrasound in patients with a palpable abnormality that is not clinically suspect is high: Level 1 A1 A2 Kerlikowske Dennis , Moy , Shetty , Soo Remaining considerations Mammography in symptomatic patients must at least consist of images of two views, craniocaudal and mediolateral-oblique, supplemented with local compression images or magnification views of the symptomatic area where required.

Identification of the abnormality may be facilitated by use of lead markers. The indications for this be made by the radiologist.

This should be performed by a radiologist that also has knowledge of the mammography findings. Images of the symptomatic area should be taken in two views.

In the area around the mamilla, the scan plane radial to the nipple often provides additional information. The transducer position must be indicated on the image.

Ultrasound is the method of choice in women under 30 years of age, but also with symptomatic women who are pregnant or breastfeeding.

The reason for this is the dense breast tissue, not the radiation exposure. If there is an indication for mammography, this should be performed straight after.

Screening in this group of women is best delayed until a few months after childbirth or after breastfeeding has ended. Additional techniques, such as colour Doppler, contrast ultrasound and elastography have added value with small groups, in which the operator dependency is of great importance.

The reason these developments have not been implemented on a greater scale is also related to the low threshold in performing a biopsy.

Communication between the radiologist and the women should follow that, as outlined in the WGBO: it is compulsory in the WGBO for the radiologist, as a health care provider, to provide information about the results of the imaging performed, but he does not need to give a direct or definitive result Burgerlijk Wetboek the Dutch civil code.

The radiologist can provide the result in general terms; in the event of bad news he can indicate that the requesting physician will provide the woman with further details, given they have a better overview of all the details.

The system was established in and consists of an atlas, in which standardised terminology is covered for the purpose of a standardised compiled report, with the aim of improving uniformity in intercollegial communication and reducing confusion.

In relation to mammography and ultrasound, the criteria from which the final assessment categories have been derived, are based on publications on the diagnostic value of these criteria and can therefore be considered evidence-based.

Application of the system was initially limited by interobserver variation, this decreased as the system became more common.

The report A good report begins with a good imaging request. This should contain information about the complaint or the symptomatology, risk profile and history as well as clinical breast examination also see 2.

If more than one type of imaging is performed in one sitting, all types should be included in the same report with one integrated conclusion and final assessment category to facility clarity.

It should state the indication for the imaging study; 2. Describe any new findings or changes compared to previous images, including size and localisation.

Correlation with symptomatology. Concluding description followed by a BI-RADS final assessment category, showing the level of suspicion, and recommendations in relation to follow-up or additional imaging if indicated.

BI-RADS final assessment categories and clarification If both mammography and ultrasound are performed, an integrated report should be formulated; the deciding factor in the BI-RADS final assessment category is the modality with the highest suspicion of malignancy.

In the final assessment category, the radiologist should express the extent to which an abnormality is radiologically suspect for malignancy, independent of density or the ability to evaluate the tissue.

Examples are magnification views, ultrasound or comparison with previous studies that are not available.

Many mammographic examinations performed during screening, which are eligible for referral, belong to this category. In radiology departments, this category should be applied as a provisional result and attempts towards completion should be made as fast as possible.

BI-RADS 1 and 2 Negative and Benign The distinction between BI-RADS 1 and 2 is somewhat artificial, but may assist the treating physician with the discussion about a finding on the mammogram with radiological benign characteristics, such as a benign calcification or an oil cyst.

Typical ultrasound BI-RADS 2 abnormalities are cysts and solid abnormalities with benign characteristics, which are stable over time. The BI-RADS 2 category is chosen if there is status after surgery, such as breast-conserving treatment, breast reduction and breast augmentation.

The percentage of malignancies in these categories should be extremely small, but will never be nil, because false negative findings are inevitable.

This usually concerns abnormalities with benign aspect, in which imaging for comparison is available, such as solid laesions on ultrasound with round, oval or lobulated contours, mammographically well-defined laesions, small groups of round or oval microcalcifications or focal asymmetry of the breast tissue.

The guideline development group is of the opinion that aside from short-interval follow-up, a biopsy may also be chosen. If follow-up is chosen, then follow-up any earlier than 6 months later is generally not worthwhile [Graf, ; Vizcaino, ].

After 6 months, a recommendation may be made whether further follow-up needs to be performed after 12 and 24 months. The radiologist also has a choice here: the duration of follow-up may be applied to the age of the patient and the laesion type: in the case of a young woman with a small, typical fibroadenoma, one-off follow-up after 6 months is sufficient.

Complete follow-up through to 24 months can be chosen for an older woman with a cluster of probably benign microcalcifications. The most important disadvantage of follow-up is the chance that the patient does not follow this recommendation.

If a biopsy is chosen cytological punction or needle biopsy and the results are representative and correlate with the imaging e.

The choice between follow-up or biopsy is dependent on the technical possibilities for biopsy, the wishes of the patient and the preference of the radiologist.

Microcalcifications may be subdivided according to the BI-RADS assessment categories 41 into round and punctate, milk of calcium, amorphous, coarse heterogenous, fine pleomorphic, fine linear, and branching calcifications.

The order corresponds to increasing risk of malignancy. The distribution pattern, diffuse distribution, regional, clustered, linear or segmental, may play a role in determination of the risk of malignancy.

In a retrospective study of biopsies, Burnside described a good correlation between the morphology of microcalcifications and the estimated risk of malignancy.

The essence of assigning a BI-RADS 4 is that tissue for pathology must be obtained that correlates with the radiology. Short-interval follow-up is not sufficient, unless this has been decided by the breast care team on the basis of good arguments.

There are often secondary characteristics of malignancy. If the obtained pathological material still yields a benign result, there needs to be consultation within the breast care team whether there may have been a sample error.

BI-RADS 6 Biopsy- proven malignancy The number of patients with large tumours or locoregional extended disease who are treated preoperatively with neoadjuvant chemotherapy or radiotherapy is on the increase.

The effect of such therapy is monitored using imaging. This category has been created for this group of people, because the typical abnormalities may disappear as a result of therapy, while there may still be malignant tissue in the breast.

This category is therefore not intended for imaging for patients that have already undergone surgery. A1 A2 ACR Caplan , Lehman , Monticciolo Remaining considerations Patients referred by the national breast screening programme form a separate group.

They usually do not have any symptoms, but an abnormality on the screening mammogram. For most patients, the mammogram and ultrasound can be used to explain the referral indication and assign a definitive, diagnostic BI-RADS final assessment category.

For a small proportion, the abnormalilities that are cause for referral are not detected on the 42 mammogram in the hospital and can at the most be interpreted as fibroglandular tissue.

In a few cases, e. Given this concerns asymptomatic women from the general population with low suspicion of malignancy, an MRI is also not indicated in this group.

There must not be more than two working days between performing the examination and reporting. Requesting mammograms that have been taken elsewhere must also not delay reports, any comparisons performed at a later point in time may be mentioned in an appendix.

Assigning a BIRADS 0 may only be applied if the comparison with previous mammograms is absolutely necessary for the conclusion.

Each radiology unit should consider striving for a comprehensive system in relation to requesting previous mammograms from elsewhere and follow-up recommendations.

Recommendations by a radiologist are not binding, although it is adviced that a multidisciplinary decision for a change in patient management is also recorded in an appendix.

Finally, it remains important to also communicate personally unexpected findings with the requesting physician. On this basis, a choice should be made between a punction or short-term follow-up 6 months.

In the case of a fibroadenoma, a single follow-up in 6 months is sufficient; for microcalcifications, follow-up in 6 months is recommended, and then further follow-ups after 12 and 24 months.

By exception with BI-RADS 4 abnormalities, short-interval follow-up after 6 months may be chosen if decided by the breast care team on the basis of good arguments.

Mendelson also mentions complicated cysts. Uncomplicated cysts have a thin wall and are entirely anechoic. Complicated cysts contain a homogenous hypoechoic content, sometimes with a fluid interface; complex laesions are partly cystic, partly solid, with thickened walls, thickened septa and intracystic solid masses.

Ultrasound is highly specific and therefore the technique of choice. The aspirate of uncomplicated cysts in a study by Smith did not yield any malignant cells.

In prospective follow-up studies of the various types of cysts, a malignancy is only encountered sporadically see the table below.

Punction of 71 complicated cysts resulted in 18 cases of malignancies. In an additional prospective study, Berg described that clustered microcysts occur quite commonly and are not malignant.

Level 1 A1 B Kerlikowske Boerner , Thurfjell , Vargas The chance of a malignancy with uncomplicated cysts, as well as with clustered microcysts and complicated cysts is negligibly small.

Level 3 B C Berg Smith , Berg Pathological analysis of aspiration fluid from cysts that are uncomplicated, clustered or complicated is not worthwhile.

Level 3 B C Lister Smith Level 3 The chance of malignancy in a complicated cyst is small, but cannot be excluded, especially if there is a thickened wall or excentrically located mass.

The diagnosis can be made on the basis of ultrasound only. A punction may be offered to relieve painful, palpable cysts.

Recommendations Ultrasound is the examination of choice to establish the diagnosis cyst, this applies to uncomplicated anechoic cysts, complicated homogenous hypoechoic cysts and clusters of microcysts and is independent of size and findings on palpation.

A punction may be performed for relief. Pathological examination of the aspirate is not indicated.

Complicated cysts have a small chance of malignancy. This chance increases with marked wall thickening or the presence of a solid component.

If benign characteristics dominate, BI-RADS 3 probably benign may be assigned with a choice of follow-up after 6 months or aspiration.

If suspicious characteristics dominate, BI-RADS 4 suspicious must be assigned and a punction needs to be performed: aspiration and, if possible, histology of the solid component.

Pathological examination of the aspirate is indicated here. Skaane and Stavros add a thin hyperechoic pseudocapsule to this.

On the other hand, a BI-RADS 4 probably malignant should be assigned if not all typical characteristics are present, because a malignant tumour cannot be excluded in the case of atypical characteristics.

The fibroadenoma is the most common tumour in young women. It is also the most common laesion in girls in puberty [Kronemer, ].

In a screening population of , women over 35 years of age, 51 fibroadenomas developed in 6 years; there were 4 in women between 50 and 52 years of age [Foxcroft, ].

The influence of hormonal fluctuations is not fully clear, but it is known that fibroadenomas may fluctuate in size and regress during menopause.

Ultrasound is more specific than mammography in establishing the radiological diagnosis. From the below literature overview it appears that after adequate imaging technique, the choice is either a follow-up after 6 months or a punction cytology or needle biopsy for confirmation.

Rapid size increase in combination with increased growth of the stromal component, so that the tumour becomes more heterogenous, raises suspicion for a phyllodes tumour.

Gordon followed 1, fibroadenomas confirmed by punction. For laesions, volume 45 measurements were performed multiple times.

An increase in size to 1 cm of all 3 dimensions within a 6 month period was deemed acceptable in all age categories. A size of more than 3 cm and cystic components was more indicative of phyllodes tumour.

These can become very large, up to 20 cm. Phyllodes tumours display overlapping characteristics with fibroadenomas on a mammogram and ultrasound, the pathological characteristics also overlap [Liberman, ; Yilmaz, ].

The diagnosis phyllodes tumour may be made using a histological biopsy, but excision is necessary to differentiate between benign and malignant phyllodes tumour.

Multiplicity Patient management in the case of multiple fibroadenomas consists of careful ultrasound examination according to the abovementioned criteria by Stavros and Skaane Multiple fibroadenomas are described with cyclosporine use [Son, ].

Punction of one of the laesions often the largest in combination with a follow-up of 6 months of the remaining laesions is sufficient.

Removal Excision of a fibroadenoma is no longer considered necessary. Different percutaneous methods have been developed to remove the fibroadenoma in a minimally invasive manner, as long as the location is suitable and the fibroadenoma no larger than 3 to 4 cm.

In doing so, it is not always necessary for the fibroadenoma to be removed in its entirety. Both regression and recurrence are described [Grady, ].

Cryoablation in 64 patients with a follow-up of at least 12 months a follow-up of 2. It is important, prior to the procedure, for the diagnosis fibroadenoma to be established with certainty.

In the study by Matthew of 76 patients who underwent the procedure, 3 patients were found to have a malignancy. Prior to the procedure, cytology in these patients did not yield a clearly benign diagnosis.

Conclusions The reliability of ultrasound in diagnosing fibroadenoma that meets all typical characteristics, is very high. An increase in size to 1 cm of all 3 dimensions within a 6 month period is not alarming.

Level 2 A2 C Gordon Dixon , Carty Level 3 With a fibroadenoma of more than 3 cm or with cystic components, a phyllodes tumour cannot be excluded and a histological biopsy is indicated.

C Liberman , Yilmaz Level 3 Percutaneous ultrasound-guided vacuum-assisted excision of a fibroadenoma is a safe procedure with good cosmetic result.

The diagnosis should be established prior to the procedure. B C Wang , Krainick-Strobel, Matthew Remaining considerations The solid character of fibroadenomas causes more concern than a cystic abnormality and the fear of making an interpretation error and the subsequent false negative finding is great.

It is therefore important only to assign a BI-RADS 3 to laesions with all the typical characteristics of a fibroadenoma. Most data is derived from long-term retrospective cohort studies.

Retrospective cohort studies show that the incidence of breast cancer in the presence of prostheses is not higher and survival is not poorer than expected [Deapen, ].

In some studies, the incidence is even lower. A Finnish study included 2, women; 30 developed breast cancer out of A Danish study compared 2, women with silicone prostheses with a control group; less breast cancers were found here too than expected SIR 0.

The breast cancer stage and survival in these 2 studies were comparable to that in the general population [Pukkala, ; Friis, ].

Handel compared carcinoma in women with silicone prostheses with the general population and found more palpable abnormalities, invasive tumours, positive lymph nodes and false negative mammograms.

Follow-up was a maximum of 23 years; no difference in survival was found. Tumour detection was usually by means of physical examination palpable abnormality ; mammography was the most reliable imaging technique, followed by ultrasound.

Recommendations The ultrasound diagnosis in line with fibroadenoma is only allowed if there is a homogenous, solid mass with well defined margins, oval shape and parallel orientation.

In case of multiple fibroadenonomas punction of one of the laesions often the largest in combination with a follow-up of 6 months of the remaining laesions is sufficient.

No distinction is needed between palpable and non-palpable fibroadenomas. Laesions that do not have all the typical characteristics of a fibroadenoma, must always be assigned BI-RADS 4 suspicious laesion.

A cytological or histological punction must be performed for these laesions. The suspicion should be reported on the pathology request form.

Conclusions Level 1 It has been demonstrated that the incidence of carcinoma does not increase in the presence of prostheses, but remains the same or is lower than in the general population.

A2 Deapen , Pukkala , Friis Level 1 It has been demonstrated that cancer stage and survival in women with prostheses are comparable to the stage and survival in the general population.

A2 Deapen , Pukkala , Friis , Handel Level 3 Carcinomas in women with prostheses are more often detected as palpable abnormalities, they are more often invasive with lymph node metastases and false negative mammograms.

A2 Handel 47 Remaining considerations Patients with silicone prostheses form a heterogenous group.

The extent to which the prostheses mask the fibroglandular tissue varies greatly, in general overprojection reduces with increasing age, due to an increase in fatty tissue in the breast.

Other factors also play a role in the ability to perform and evaluate a mammogram: capsule formation, large prosthesis in a small breast and prepectoral localisation are unfavourable, but performing and evaluating a mammogram in the case of postpectoral localisation is generally not a problem.

Digitalisation of the mammogram also has a positive influence here. The chance of rupture with the old generations of silicone prostheses which contain an almost fluid core is much greater than with the most recent prostheses, consisting of much firmer cohesive gel.

Due to their more anatomical shape, they are much more formable and pliable, this is tested during the production process.

Mammography is generally considered the method of choice. Only a minority in the national screening programme cannot be evaluated, see 1.

In the radiology departments of hospitals, the responsibility lies with the radiologist. The radiologist should provide further instructions to the technician when the mammogram is made: in applying compression, the consistency and location of the prostheses pre- or retropectoral should be taken into account.

The technician should strive for images according to Eklund and an extra projection direction, for example mediolateral [Eklund, ].

Ultrasound is indicated as an addition to mammography for palpable abnormalities, both for the detection of leakage and for masses.

There are no good studies available on ultrasound as screening method with prostheses. In the centre study by Berg [], no women with implants were included.

This study did show that in individual cases screening with ultrasound may be worthwhile, if screening using mammography does not work, see 1.

In the United States, MRI is approved by the FDA as method to determine leakage or rupture with asymptomatic patients, but the evidence for this is doubtful, partly due to the quality of third generation prostheses.

MRI as screening method in women with prostheses and with the risk profile of the general population is not recommended, because there are no indications that their prognosis is worse if breast cancer develops.

Regular breast self examination is not recommended in the general population, see 1. However, because most carcinomas in women with prostheses are discovered by palpation, this method may be worthwhile here.

Recommendations There is no standard procedure available for women with silicone prostheses. The guideline development group is of the opinion that the radiologist, together with the laboratory technician, must determine the choice and sequence of clinical imaging on the basis of consistency, relative size and localisation of the prosthesis.

Screening Women with silicone prostheses between years of age are eligible for participation in the national screening programme.

Only if mammography does not work or the mammogram cannot be evaluated, they are advised to have their screening examination conducted in the hospital radiology department.

At the hospital, it is expected that the radiologist and technician perform additional imaging. The radiologist may decide to screen using ultrasound if required.

Screening with MRI is not recommended. Diagnostics: Mammography and ultrasound are performed if there are symptoms.

If mammography does not work, ultrasound is the procedure of choice. The pathophysiology is largely based on angiogenesis: there is an increase in the number of blood vessels and permeability of the vessel wall.

The process is complex, benign abnormalities fibroadenomas and parenchyma may also stain [Kuhl, ].

The evaluation of an abnormality is based on a 48 combination of morphology, enhancement and the kinetics of the enhancement [ACR, ].

They underwent a preoperative MRI. The additional laesions were subdivided on the basis of location; however, this subdivision is arbitrary and specifically aimed at determining the surgical plan: multifocal maximum diameter of the index tumour and additional laesion of 3 cm , multicentric maximum diameter index tumour and additional laesion greater than 3 cm and contralateral.

Second-look ultrasound was only performed for the last 2 groups. In the case of multifocality, the size of the lumpectomy was adjusted.

If a corresponding laesion was not found during second-look ultrasound, a follow-up was considered as sufficient, because these laesions were classified as BI-RADS 3.

The follow-up was an average of 58 months, in which no local recurrences or primary tumours were detected. It is assumed that this can be also attributed to radiotherapy and adjuvant chemotherapy.

If an additional laesion is classified as a BIRADS 3, shirt interval follow-up is recommended: for menstruating women, this may be done in another phase of menstruation and can be performed in as short a period as possible.

If the women is not or no longer menstruating, follow-up of the size of the laesion after 6 months is indicated.

If a correlation with the mammogram does not show suspected MC, there are two possibilities: a direct MRI-guided biopsy is recommended or the MRI scan is first repeated: if the enhancement persists, The technique is highly sensitive, but this has an unfavourable influence on the specificity.

A drawback of the high sensitivity in combination with low specificity is the occurrence of incidental or accidental findings: this is the case if there is enhancement of a laesion measuring 5 mm or greater, which is not expected on the basis of earlier images, such as elsewhere in the breast or contralateral.

Incidental laesions are seen more often with younger women and in the presence of dense breast tissue. Correlation with mammography and ultrasound is necessary to further characterise these laesions nd generally starting with 2 look ultrasound.

In a series of 7 retrospective cohort studies, the success percentage in identifying these laesions was If a corresponding laesion on ultrasound was found, the percentage of malignancies was Und das funktioniert hervorragend.

Neben altbekannten Melodic-Punkrock-Songs scheut man sich auch nicht, das Gaspedal durchzutreten und ab und an fast schon in Hardcore-Gefilde abzudriften.

Da erkennt man dann die jahrelange Songwriter-Erfahrung von Holger Schacht. So geht das. Solider, klassischer Rockabilly!

CD Mad Butcher madbutcher. Ob man sich und uns damit einen Gefallen getan hat, bleibt abzuwarten. Gut, das Ganze ist ein Best Of-Album, was so viel bedeutet, dass man die Songs eigentlich eh schon alle kennt.

Ist das kitschig? Tja, das ist wohl der Fluch, der auf Bands lastet, die sich selbst die Messlatte so hoch gelegt haben. Ein echtes Unikat.

Wenn das kein Grund zum Feiern ist. Ein essentieller Release. Ob das wohl Absicht war? Neo-Folk oder LoFi-Pop dieser Art ist letztendlich nicht wirklich mein Fall und auch der auch auf den zweiten Blick etwas jaulige Gesang macht es nicht unbedingt besser, wenn ich mir auch dessen bewusst bin, dass diese sperrige, unfertige Machart schon auch so gedacht ist und hier sicher keine Dilettanten am Werk sind.

Da bin ich wirklich auf das aktuelle Album gespannt. Sie beherrschen den Rock, gestalten den Sound mit treibendem Beat immer sehr dynamisch und streuen hier und da auch mal coole Orgelsounds ein.

Runde Sache! Ich werde hier jetzt keine Majorlabel-Diskussion anfangen, behalte mir aber vor, die Platte nicht zu bewerten.

Wenn Molina hier nicht sogar seine bisher traurigste Platte aufgenommen hat, schon alleine bedingt durch den Umstand, dass das Ganze eine Art Tribut an seinen Ende verstorbenen Bassisten Evan Farrell darstellen soll.

So wurden in den letzten Monaten diverse alte Aufnahmen wieder aufgelegt, und siehe da, jetzt gibt es auch noch eine neue Platte. A special collection with bands not only from the poppunk scene!

LOs twanG! Drei weitere gab es bisher nur auf Vinyl und sogar ein Vocal-Track ist mit dabei. Insgesamt 80 Minuten Surf Musik vom feinsten.

This debut album offers a varied collection of mid-tempo songs and faster ass-kick tunes. A must have! Was das anbelangt, bin ich ganz optimistisch.

Wahnsinn, was dieses Duo an Druck entwickelt. Nachdem M. Diesmal mit einer Discoplatte. Es gibt vier Songs plus einen Hidden Track in Italienisch, der aber gerade deshalb besser funktioniert als der Rest.

Warum nicht mehr Mut und alles in der Muttersprache singen? Tragischerweise verstarb kurz darauf Konrad Kittner, so dass an eine Reunion definitiv nicht mehr zu denken ist.

Mehr geht nun wirklich nicht. Gut, dass es dokumentiert ist, sowas glaubt einem sonst keiner! Borda, einer psychiatrischen Anstalt in Buenos Aires.

Dennoch ist der Film nicht umsonst als Meisterwerk des lateinamerikanischen Films beschrieben worden.

The Party. Besucher, Helfer und Macher kommen zu Wort und werden im Festivalalltag begleitet. Alles richtig gemacht, Jungs, weiter so!

Der zwischen D. Ultrageil, wie hier die Achtziger wieder aufleben. Da bekommt man sofort Lust, die alte Kutte aus dem Schrank zu holen und den alten Zeiten Tribut zu zollen.

Gekleidet in ein Soundgewand, welches zwar modern, aber irgendwie dann doch wieder retro ist, bleibt zu diesem Album nur eins zu sagen: Killer!

Das Alleinstellungsmerkmal sind bei den drei Hamburgern nicht einmal irgendwelche High-end-Sperenzien sic!

Das macht Sinn. Wer also Echtes, Frisches in deutscher Sprache sucht, darf hier beide Ohren riskieren. Und das ist verdammt gut so!

Na ja, auch wenn die Sache einen gewissen Charme besitzt, muss ich sagen, dass mir die sechs Songs doch ein bisschen zu wenig bieten.

Kann man testen, muss man aber nicht unbedingt. CD Drag City dragcity. Herrlich dreckiger 70s-Stromgitarren-Rock wird hier bis zur Ekstase zelebriert und nicht nur auf diesem Album rocken sie wie Schwein, bei ihren Konzerten musizieren die drei auch mal ganze Locations kurz und klein.

Zieht sie euch rein! Kleine Kinder sitzen auf einem Kissen und lesen und singen Suren aus dem Koran. Wenn das mal nicht ein erster Schritt ist.

Meine Sommerplatte ! Melancholie und Relaxen kann so dicht beieinander liegen. Rauher und reifer denn je! Genf Stuttgart Wiesbaden Hamburg Berlin Dortmund Leipzig Wien Vielleicht nicht essentiell, dennoch wirklich sehr gut.

Berlin - SO36 Releases aus dem Hause Mad Butcher sollten textlich aber kaum Fragen offen lassen. Manch einer sagt, dass es offensichtlich eine Verbindung zwischen Michigan und Florida geben muss.

Angesichts einer solchen Platte bin ich gewillt, das zu glauben. Gute Platte! Das hat er sich nun aber auch redlich verdient.

Wer eine solch lange musikalische Vita vorzuweisen hat, darf auch mal der Herr im Hause sein. Gut, die alten Punkrock-Attacken bleiben im Schrank.

Allerdings nur marginal. Im Gegenteil. Sowohl eben musikalisch als auch textlich. Damit liegt man gar nicht mal so falsch.

Der hat sich seine Sporen mehr als einmal verdient. Hinter jedem Break, nach jedem Wirbel wartet man darauf, dass es jetzt mal so richtig los geht.

Ein stimmiger Ansatz, aber etwas unausgereift. Ja, richtig gelesen! Um das hier abzuspielen, braucht ihr keinen CD-Player oder beschissenen iPod.

Nein, ihr braucht einen Kassettenrekorder! Dreckig ist hier ein gutes Stichwort. Das Resultat ist umwerfend! Generell wirkt das ganze Album ziemlich zusammenhanglos, hier finden zu viele Elemente zu keiner Einheit zusammen.

Vielmehr reduzieren O. Mehr davon! Eine Reunion? Nein, nur verlesen. Und trotz penetranter Dauerabnudelung bei diversen Radiosendern ist der Song ja wirklich ein augenzwinkerndes Modestatement eines alten Mods und Soul-Fans, der als DJ zwischen aktuellem Indiepop und obskuren Sixties-Singles hinter den Turntables und dem Mischpult zu Hause ist.

Is Skyscraper CD Matador matadorrecords. Das Quintett ist seit aktiv und produziert wirres, krankes Zeug. Dagegen wirken die L.

Crustpunks united, wenngleich die Tschechen hier den besseren Eindruck bei mir hinterlassen. So weit, so gut.

Die Geschichtsstudentin im mir findet die Idee zwar, wie gesagt, recht cool, aber der Musikfan in mir ist von so viel Politik und Geschichte auf einem Album einfach erschlagen.

Das ist die Wahrheit. Dort haben sie nun eine wunderbare Gelegenheit, auch den Rest der Welt auf ihre Seite zu ziehen.

Das haben wir ein paar Alben lang durchexerziert und sind durch damit. Was nun tun Der trendige Indiemag-Leser von heute wird das Album eh auf dem iPod haben, und wenn der mich schon mal kann, dann erst recht der Rest.

Jake Bannon beweist also ein weiteres Mal Geschmackssicherheit, was die Auswahl seines Labelnachwuchses betrifft. Der vorliegende Release zum Geburtstag ist aber eine ganz spezielle Angelegenheit: Die 19 Songs sind zwar alle neu, wurden aber unter Aufsicht von Produzent Earle Mankey von zwei verschiedenen Line-Ups eingespielt.

Es scheint fast so. Der ist trotz Punk-Vergangenheit des Frontmanns eine eher klassische Angelegenheit, hat nichts mit modischem Horror-Punkabilly am Hut und ist dennoch keine Retro-Veranstaltung.

Irgendwelche Hintergrundinfos? Deshalb: Geheimtip! Sonst aber keiner. Frick V. Jahren so einige Bands kommen und gehen sehen. Oder wie, oder was?

Joachim Hiller V. Um genau zu sein, ist es ein Stadt-Sampler, da alle Combos aus Perth stammen.

Bernd Fischer V. Diese Frage beantwortet der neue Eastblok-Sampler, der wie schon oft zuvor den Blick auf eine Musikrichtung wirft, die hier in Deutschland meist noch unbekannt ist: Polnischen Reggae und Dub.

Es lohnt sich. Hauptsache, dem rechten Mob eins auf die Fresse. Jahrhunderts sind. Mit einem fetten Booklet versehen, wird aus dieser beeindrucken Zusammenstellung mit viel Swing, Ragtime, Jazz und Jive schon fast ein kleines Buch.

Andererseits sind hier aber auch Bands mit an Bord, von deren Mitgliedern man zum Teil sagen kann, dass sie gerade mal mit Messer und Gabel essen konnten.

Vielleicht auch eine Chance, die alten Pfade endlich zu verlassen?! Dieses Jahr leider mehr Emo als alles andere. Guter Mix, wie immer!

In vielerlei Hinsicht beides hoffnungsvolle Bands, nach denen man in Zukunft Ausschau halten sollte. Vielleicht macht Tex Morton als neuer Gitarrist doch das fehlende letzte Quentchen aus.

Geboten wird kraftvoller Postcore mit Screamo-Anleihen und dem einen oder anderen Blinzeln in Richtung wuchtiger Metalcore. Und wieder lautet das Urteil: Mission accomplished!

So, letzter Akkord der Platte, letzter Buchstabe meiner Rezension. Disques pafdisques. Insgesamt nichts Neues also, aber trotzdem gut.

Erster Eindruck? Anyway, ein Anfang ist gemacht und Steigerungspotenzial definitiv vorhanden. Auch wenn die Franzosen in allen Punkten von Sound bis Songwriting auf Alte Schule und Untergrund machen, will sich bei mir hier keine rechte Begeisterung einstellen.

Keine Katastrophe, aber ohne Alleinstellungsmerkmal. Tolle Band, tolle Platte. Schon immer verstand es die Band, wie auch nun in neuer Besetzung, Lieder aufzubauen und langsam in sich zu verschachteln.

Kein Ausfall, nur Hits! Chando aus Spanien. Sechs Songs, sechs absolute Hits. Well done! Das ist wie bei Pizza. Die Platte rockt!

Und das sowas von arschgeburtengeil! Interessiert keinen? Ihr denkt, peinlicher kann es nicht mehr kommen? Leitmotive tauchen immer wieder auf.

Melodiefetzen in der Ferne. Sie spielen so lange sie wollen und sie spielen alles live. Wo und wann auch immer.

Keine Nachbearbeitung. Kein vorgegebenes Konzept. Keine Kompromisse. Die absolute musikalische Freiheit.

Keine Richtung. Keine Vorgaben. Ein netter und bunter Gemischtwarenladen der modernen Elektrotechnik ist dabei herausgekommen.

Als wenn das nicht schon eine ganze Menge Verantwortung und Arbeit ist? Das kennen die Leute und ein paar Sachen werden wir davon schon irgendwie verkaufen.

Wie welcher Klang erzeugt oder bearbeitet wurde, ist nicht mehr nachvollziehbar. Verschwommen ist auch ein gutes Stichwort, um die Grundstimmung dieses Albums einzufangen.

Dabei wird vollkommen auf Rhythmusspuren verzichtet. Gleichzeitig hat sich Hr. Hier tobt im wahrsten Sinne das Leben.

Die eigentlich sich gegeneinander abgrenzenden Musikarten werden hier konsequent analysiert, zusammengesetzt und vollkommen gleichberechtigt und unvoreingenommen auf eine neue Stufe erhoben.

Zehn Songs wobei der Bonussong nur mittels Aufstehen und Nadel platzieren zu erreichen ist machen vor allem Lust auf ein weiteres Konzert mit der Band.

Und angesichts der Unmengen an Nebenreleases und Seitenprojekten, die abseits der Albenreleases etwa auf dem eigenen Label erschienen, hat man von einer Kujonierumg der Band auch nichts mitbekommen.

Mit Sommersonne verbindet der eine oder andere wahrscheinlich eher California-Melodycore, ich bevorzuge im Moment die englische Variante.

Eine wirklich ordentliche Pop-Punk-Scheibe! Es ist der Soundtrack zu der gleichnamigen D. So nah am Original wie dieses Duo war bisher kaum einer.

H erinnern. Sehr seltsam wirken auch die Coverfotos: Auf dem Frontcover reitet eine Schau- fensterpuppe ohne Arme auf einem aus Pappmaschee und Schrottteilen gebauten Flugsaurier und auf dem Backcover sitzt eine winkende Schaufensterpuppe in einem rostigen Schaukelstuhl auf einem Schrottplatz.

Was hat dies zu bedeuten? Will sie uns warnen oder soll sie anlocken? Unterhaltung besteunterhaltung.

Ein wenig wirkt das Album wie ein Soundtrack, mit ein bisschen Tarantino-Feeling und immer wieder gut laufenden Orgel- und Gitarreneinlagen.

Die schnellen, teilweise zu opulenten Soundwalls anwachsenden Arrangements bewegen sich irgendwo zwischen progressiv-psychedelischer Surfmusik und psychedelischem Rock mit Tendenz zum Bombastischen.

Ein Kracheralbum, gut durchkomponiert und zusammengestellt. Party, sagst du. Das wird echt mehr als! Ein Pflichttermin, da muss man hin Mittlerweile live als auch auf Platte durch einen Marek.

MS20 gepimpt, dass es raucht Noch besser also? Geht das? Na klar! Sieht super aus! Und tanzen kann der! Und dann auch noch: Die Texte!

Und der Bassist! Und der Schlagzeuger! Die Gitarre bockt harhar. Es ist, oh Wunder, die Platte des Jahres. Wenn nicht gar mehr noch!

Es ist: Das finale Wort fehlt mir Mann ey. Es muss Liebe sein. CD Morr Music morrmusic. Ein Junge muss zu Beginn mitansehen, wie seine Eltern von einem haarigen Untier abgeschlachtet werden.

So weit, so unoriginell. Jahrhunderts als Spezialagenten angeheuert werden, um Dr. Keine Gruppe von strahlenden Superhelden allerdings, sondern recht schizophrene Gestalten mit jeder Menge Macken, denen man eigentlich nur ungern die Rettung der Menschheit anvertraut.

Wer eher auf Frank Millers Minimalismus und Stilisierung steht, mag die expressiven, poppigen Zeichnungen, die einen quasi anspringen, eventuell weniger, aber Jones hat auf jeden Fall eine charakteristische Handschrift, mit der er sich den Batman-Mythos aneignet.

Comic Cross Cult cross-cult. Zeichnerisch erinnert Cosey leicht an Jean Girauds Blueberry, kommt aber nicht an dessen Klasse heran.

Der Sound wirkt in der Tat gefestigter und ausgereifter. Ihr Psychobilly-Sound ist nichts anderes als die Mischung aus vielen vorhandenen Vorbildern und damit recht durchschnittlich und vorhersehbar.

Immer wieder gut sind die Songs mit deutschen Texten, auch wenn es Cover sind. So etwas gibt es viel zu selten. Psychobilly mit passenden deutschen Texten hat immer eine ganz spezielle, gruselige Wirkung.

Die begleitenden Werbetexte sind dagegen fast schon unangenehm dick auftragend. Wem das hier zu viel Namedropping ist, der sollte einfach mal ein Ohr riskieren.

Aber ich kann euch beruhigen. Die Texte sind ehrlich und kritisch. So bekommen unter anderem auch die Medien ihr wohlverdientes Fett weg.

In Amerika erschien der letzte Band bereits , hier stehen noch drei aus, und ich bin gespannt, wie es weitergeht.

Blotch hat als Figur wirklich Potential, mal sehen, ob Hincker dazu noch weitere Geschichten einfallen.

Zwei Freunde, die zusammen die Musik spielen, die sie lieben. Zehn Mal wuchti- nis dieses Bandes ist das aber dennoch nicht.

Von Blutch ist bestimmt noch einiger guter Stoff zu erwarten. Ja, richtig gelesen. Ich bin zwar durchaus hartgesotten, was so was angeht, sehe da aber ehrlich gesagt nicht den humoristischen Aspekt.

Da ist es teilweise schon beinahe dreist, wie sich bei oben genannten Bands bedient wird. Lovecraft, zu unterhalten versteht.

Flensburg, Volksbad Releaseparty Eisenberg, Mitropa Karlsruhe, Hackerei Mit Anderson am Bass hat sich Ben einen erstklassigen Musiker mit harmonierender zweiter Gesangsstimme in die Band geholt.

Ein Zufall? Klug zitiert also. Smarte Band, smarte Platte. Nicht gut, andererseits postet kein Schwein Platten, die nix taugen.

Klasse Texte, stimmiges Gesamtkonzept, und sie haben etwas, was vielen anderen Bands derzeit fehlt: Tiefe! Live geht da noch viel mehr Live kann ich mir das schon besser vorstellen, auf Platte wirkt es leider zu gewollt.

Wilhelmshaven, Kling Klang Lindau, Club Vaudeville Freiburg, Walfisch Mainz, Caveau CD-R armeritter. Wenn die Jungs schon im Radio gespielt werden, wo bleibt dann bitte das richtige Label?

Nun scheint sich die Band in Form eines Trios gefunden zu haben. Nach dem Geknusper geht es songtechnisch dreimal in die Elektro-Punk-Richtung.

Melodischer Hardcore also. Das Ganze wird auch gut umgesetzt, ich erwische mich bei sympathisierenden Kopfnicken und Fingerschnippsen.

CD-R myspace. Nicht zu sperrig, jedoch auch niemals seicht. Stets vom Wunsch beseelt, nicht beliebig oder zu cheesy zu klingen. Mit Erfolg.

Checkt die MySpace Seite, um das bandeigene Namedropping einzusehen. Jahrhundert so wichtig macht. Die Shouts klingen verzweifelt, die Metal-inspirierten Riffs sind fett und handwerklich ist alles solide umgesetzt.

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1 Comments

  • Mezigami says:

    Ich tue Abbitte, dass sich eingemischt hat... Ich hier vor kurzem. Aber mir ist dieses Thema sehr nah. Ist fertig, zu helfen.

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