TUGAS EVIDENCE BASED MEDICINE

PRODI: Radiologi
JENIS STUDI: Diagnosis
KELOMPOK: 17 (sesuai yang sudah ditentukan)
Nama mahasiswa:
C125222001 DEWINSYA MEDISUJIANNISA MS IDRIS
C125222002 DHARMANADI SIDDHARTA WELLIANGAN
C125222003 ANDI WETENRI PADAULENG
C125222004 FARLINA MUNIRA AMIR

No Isi Nilai
max
1 Skenario Klinik 10
(mencakup karakteristik pasien, permasalahannya, dan apa yang ingin diinvestigasi).

Seorang pasien wanita berusia 29 tahun membawa surat pengantar dari Poli Bedah Tumor RSUP-
WS ke Radiologi Sentral RSUP-WS untuk melakukan pemeriksaan USG Mammae. Pasien
tersebut baru pertamakali datang untuk memeriksakan dirinya setelah mengalami benjolan pada
kedua payudaranya sejak 6 bulan yang lalu. Pasien tersebut ingin mengetahui apakah benjolan
pada payudaranya itu berbahaya (merupakan tumor ganas atau kanker) atau tidak (merupakan
tumor jinak) dengan memeriksakan dirinya ke rumah sakit. Terlebih pasien tersebut memiliki
riwayat keluarga (ibu kandung) dengan kanker payudara dan sudah wafat dua tahun yang lalu.
Namun demikian, pemeriksaan yang direkomendasikan pertamakali oleh dokter klinisi di Poli
Bedah Tumor adalah USG Mammae, bukan Mammography. Sementara berdasarkan pedoman
 terkini dari American College of Radiology (ACR) dan National Comprehensive Cancer Network,
pemeriksaan mammography merupakan pemeriksaan rutin dan gold standard dalam skrining dan
deteksi dini kanker payudara yang dapat dilakukan sekali setahun pada wanita yang berusia di atas
40 tahun atau berisiko tinggi mengalami kanker payudara secara genetik.

2 PICO 5

P: Wanita 29 tahun dengan benjolan pada payudara.

I: USG Mammae
C: Mammografi
O: Tumor jinak atau ganas
3 Pertanyaan klinik 5

Apakah pemeriksaan USG Mammae pada kasus benjolan pada payudara lebih baik daripada
Mammografi dalam menentukan benjolan tersebut merupakan tumor jinak atau ganas ?

4 Strategi pencarian literatur 10

Sumber Strategi penelusuran Didapat Diseleksi

Pubmed ((("29"[All Fields] AND "years"[All Fields] 41 0
AND "old"[All Fields] AND ("womans"[All
Fields] OR "women"[MeSH Terms] OR
"women"[All Fields] OR "woman"[All Fields]
OR "women s"[All Fields] OR "womens"[All
Fields])) AND ("medical subject
headings"[MeSH Terms] OR ("medical"[All
Fields] AND "subject"[All Fields] AND
"headings"[All Fields]) OR "medical subject
headings"[All Fields] OR "mesh"[All Fields]))
OR (("breast neoplasms"[MeSH Terms] OR
("breast"[All Fields] AND "neoplasms"[All
Fields]) OR "breast neoplasms"[All Fields] OR
("breast"[All Fields] AND "tumor"[All Fields])
OR "breast tumor"[All Fields]) AND ("medical
subject headings"[MeSH Terms] OR
("medical"[All Fields] AND "subject"[All
Fields] AND "headings"[All Fields]) OR
"medical subject headings"[All Fields] OR
"mesh"[All Fields]))) AND
((("ultrasonography, mammary"[MeSH Terms]
OR ("ultrasonography"[All Fields] AND
"mammary"[All Fields]) OR "mammary
ultrasonography"[All Fields] OR ("breast"[All
Fields] AND "ultrasound"[All Fields]) OR
"breast ultrasound"[All Fields]) AND ("medical
subject headings"[MeSH Terms] OR
("medical"[All Fields] AND "subject"[All
Fields] AND "headings"[All Fields]) OR
"medical subject headings"[All Fields] OR
"mesh"[All Fields])) OR
(("mammography"[MeSH Terms] OR
"mammography"[All Fields] OR
"mammographies"[All Fields] OR
"mammography s"[All Fields]) AND ("medical
subject headings"[MeSH Terms] OR
("medical"[All Fields] AND "subject"[All
Fields] AND "headings"[All Fields]) OR
"medical subject headings"[All Fields] OR
"mesh"[All Fields]))) AND (((("benign"[All
Fields] OR "benignancies"[All Fields] OR
"benignancy"[All Fields] OR "benignant"[All
Fields] OR "benigne"[All Fields] OR
"benignity"[All Fields] OR "benigns"[All
Fields]) AND ("breast neoplasms"[MeSH
Terms] OR ("breast"[All Fields] AND
"neoplasms"[All Fields]) OR "breast
 neoplasms"[All Fields] OR ("breast"[All
Fields] AND "tumor"[All Fields]) OR "breast
tumor"[All Fields])) AND ("medical subject
headings"[MeSH Terms] OR ("medical"[All
Fields] AND "subject"[All Fields] AND
"headings"[All Fields]) OR "medical subject
headings"[All Fields] OR "mesh"[All Fields]))
OR (("breast neoplasms"[MeSH Terms] OR
("breast"[All Fields] AND "neoplasms"[All
Fields]) OR "breast neoplasms"[All Fields] OR
("malignant"[All Fields] AND "breast"[All
Fields] AND "tumor"[All Fields]) OR
"malignant breast tumor"[All Fields]) AND
("medical subject headings"[MeSH Terms] OR
("medical"[All Fields] AND "subject"[All
Fields] AND "headings"[All Fields]) OR
"medical subject headings"[All Fields] OR
"mesh"[All Fields])))
Cochrane ( "Adult 19-44 years" OR "Neoplasm Of 3 1
Breast" ) AND Intervention ( "Breast
ultrasonography" OR "Mammography" ) AND
Outcome "Breast Cancer"'
Google scholar 29 years old woman with breast tumor 18.000 4
assessment of breast ultrasound for determining
benign or malignant breast lesions.

Lainnya

Total Inklusi 5

Total Eksklusi 17.995

Total seleksi 5
5 Eksklusi

Jumlah Alasan dikeluarkan Sisa 10

Dikeluarkan
4 Artikel ganda 18.040
18.040 Studi pada hewan 0
12.275 Pembanding bukan ultrasonografi 5765
1785 Bukan studi diagnostik 11.877
398 Fulltext tidak ditemukan 296
102 Buku/ prosiding 97
5
6 Karakteristik hasil pencarian 15

Peneliti, jurnal dan Tipe Jenis Indeks test Comparison

tahun Penelitian/ spesimen
Jumlah
sampel
Anna Glechner et al, Random- The proportion High certainty Amongst 1000 women who
Mammography in effects meta- of women with evidence from do not have cancer, 37 more
combination with breast analysis/8 dense breast one trial received a false-positive
ultrasonography versus studi (1 ranged from
showed that result when they
mammography for breast RCT, 2 48% to 100%.
screening with participated in screening
cancer screening in women prospective Five studies used
at average risk, 2023. cohort digital a combination with a combination of
studies, 5 mammography, of mammography and
retrospective one study used mammograph ultrasonography than with
cohort breast y and mammography alone (RR
studies, tomosynthesis, ultrasonograph 1.43, 95% CI 1.37 to 1.50;
enrolling and two studies y detects more high certainty evidence).
209.207 used Automated breast cancer Compared to
women with Breast
than mammography alone, for
a follow-up Ultrasonography
mammograph every 1000 women
duration (ABUS) in
from 1 to 3 addition to y alone. The J- participating in screening
years mammography START (Japan with a combination of
screening. One Strategic Anti- mammography and
study used cancer ultrasonography, 27 more
digital Randomised women will have a biopsy
mammography Trial), (RR 2.49, 95% CI 2.28 to
alone or in enrolling 2.72; high certainty
combination
72,717 evidence). Results from
with breast
asymptomatic cohort studies with
tomosynthesis
and ABUS or women, had a methodological limitations
handheld low risk of confirmed these findings. A
ultrasonography. bias and found secondary analysis of the J-
that two START provided results
additional from 19,213 women with
breast cancers dense and non-dense
per 1000 breasts. In women with
women were dense breasts, the
detected over combination of
two years with mammography and
one additional ultrasonography detected
ultrasonograph three more cancer cases (0
y than with fewer to 7 more) per 1000
mammograph women screened than
y alone (5 mammography alone (RR
versus 3 per 1.65, 95% CI 1.0 to 2.72;
1000; RR 11,390 participants; high
1.54, 95% CI certainty evidence). A meta-
1.22 to 1.94). analysis of three cohort
Low certainty studies with data from
evidence 50,327 women with dense
showed that breasts supported this
the percentage finding, showing that
of invasive mammography and
tumours was ultrasonography combined
similar, with led to statistically
no statistically significantly more
significant diagnosed cancer cases
difference compared to mammography
between the alone (RR 1.78, 95% CI
two groups 1.23 to 2.56; 50,327
(69.6% (128 participants; moderate
of 184) versus certainty evidence). For
73.5% (86 of women with non-dense
117); RR 0.95, breasts, the secondary
95% CI 0.82 analysis of the J-START
to 1.09). study demonstrated that
However, more cancer cases were
positive lymph detected when adding
node status ultrasound to
was detected mammography screening
less frequently compared to mammography
in women with alone (RR 1.93, 95% CI
invasive 1.01 to 3.68; 7823
cancer who participants; moderate
underwent certainty evidence), whilst
mammograph two cohort studies with data
y screening in from 40,636 women found
combination no statistically significant
with difference between the two
ultrasonograph screening methods (RR
y than in 1.13, 95% CI 0.85 to 1.49;
women who low certainty evidence).
underwent Based on one study in
mammograph women at average risk of
y alone (18% breast cancer,
(23 of 128) ultrasonography in addition
versus 34% to mammography leads to
(29 of 86); RR more screening-detected
0.53, 95% CI breast cancer cases. For
0.33 to 0.86; women with dense breasts,
moderate cohort studies more in line
certainty with real-life clinical
evidence). practice confirmed this
Further, finding, whilst cohort
interval studies for women with
carcinomas non-dense breasts showed
occurred less no statistically significant
frequently in difference between the two
the group screening interventions.
screened by However, the number of
mammograph false-positive results and
y and biopsy rates were higher in
ultrasonograph women receiving additional
y compared ultrasonography for breast
with cancer screening.
mammograph
y alone (5
versus 10 in
10,000
women; RR
0.50, 95% CI
0.29 to 0.89;
72,717
participants;
high certainty
evidence).
False-negative
results were
less common
when
ultrasonograph
y was used in
addition to
mammograph
y than with
mammograph
 y alone: 9%
(18 of 202)
versus 23%
(35 of 152; RR
0.39, 95% CI
0.23 to 0.66;
moderate
certainty
evidence).
However, the
number of
false-positive
results and
necessary
biopsies were
higher in the
group with
additional
ultrasonograph
y screening.
Vikrant Kanagaraju et al, Prospective The diagnostic Mammograph In this prospective study,
Utility of Ultrasound study/ 50 performance of y of 14 we evaluated the diagnostic
Strain Elastography to palpable Ultrasound patients (28%) performance of SE in
predicting malignancy in
Diffrentiate Benign from breast Strain did not show
lesions of breast. Qualitative
Malignant Lesions of the masses in Elastography any SE with elasticity scoring
Breast, 2020. 50 patients demonstrable was found to
lesion due to have a superior sensitivity,
dense breast specificity, and diagnostic
with accuracy
predominantly compared to conventional
BIRADS assessment. In this
fibroglandular
initial study from India, we
tissue. conclude that real-time SE
41% of the of the breast, with its
malignant
lesions (12/29) superior sensitivity and
had spiculated specificity, could
appearance provide improved
characterization of benign
on
and malignant
mammograph breast masses compared
y, and with mammography and
microcalcificat conventional
ion was US. Due to greater
encountered in diagnostic accuracy, SE can
34% (10/29). be an effective
adjunctive tool to B-mode
14% (4/29)
US in predicting
showed malignancy of
architectural breast as well as decreasing
distortion. unnecessary biopsies in
Based on the clinical
BIRADS practice. However, SE is
assessment, one of advanced variant of
three were ultrasound.
assigned
BIRADS
category 3, 18
were assigned
category 4,
and 29
were assigned
category 5.
The
sensitivity,
specificity,
PPV,
NPV, and
accuracy of
BIRADS
assessment
were 96.5%,
9.5%,
59.5%, 66.6%,
and 60%,
respectively,
with
histopathology
as
the reference
standard.
Qualitative SE
using elasticity
scores had a
sensitivity of
100%
and specificity
of 76.1% in
detecting
malignancy.
The PPV
and NPV were
85.2% and
100%,
respectively,
with
diagnostic
accuracy of
90%. Higher
elasticity score
was
significantly
associated
with malignant
histopathology
 (P < 0.00001).
The
mean EI/B
ratio for
malignant
lesions was
1.36 ± 0.24
while
that of benign
lesions was
1.03 ± 0.30 (P
= 0.000).
Table 2
shows the
correlation
between
histopathology
, BIRADS
assessment,
and elasticity
scoring among
the lesions.
Bo Ra Kwon MD dkk, Prospective Asymptomatic Among 136 Supplemental ultrasound
Automated Breast study/ women with breasts, eight (US) is an effective imaging
Ultrasound System for Between small breast cases of breast method to detect
Breast Cancer March cancer were mammography-negative,
Evaluation : Diagnostic 2016 and detected by 2- early-stage invasive breast
Performance of the Two- May 2017, VST, and 10 cancer in women with dense
View Scan Technique in 136 cases of breast breasts. However,
Women with Small asymptoma cancer were performing supplemental
Breasts, 2020 tic women detected by 3- whole-breast US
with small VST. The with hand-held devices has
breasts (bra breast some limitations. Hand-held
coverage was
cup size A) satisfactory in US
suitable for 94.1% and system (HHUS) screening is
2-VST 91.9% of cases operator-dependent and
were under 2-VST time consuming,
enrolled. and 3-VST, and records only
Subsequent respectively representative images of the
ly, 272 (p = 0.318). detected lesions that cannot
breasts All HHUS- be easily compared with the
were detected results of past examinations.
subjected lesions were The automated breast
to bilateral visible on the US system (ABUS) has
whole- ABUS images capability to overcome
breast regardless of some of
ultrasound the scan those limitations by
examinatio technique. The allowing structured image
ns sensitivities acquisition,
using and which enables whole-breast
ABUS and specificities evaluation with multiplanar
the hand- were similar reformation (MPR) and
held between 2- temporal comparisons.
ultrasound VST and 3- Reports
system VST (100% have indicated that ABUS
(HHUS). [8/8] vs. 100% devices have similar
[10/10], and detection
97.7% ability for mammography-
[125/128] vs. negative invasive breast
95.2% cancers
[120/126], as compared to HHUS
respectively), Supplemental screening
with no with ABUS detected 1.9
significant more
difference (p > cancers per 1000 screens in
0.05). mammographically
 negative,
asymptomatic women, but
resulted in a high rate of
false
positives.
Peili An dkk; A Cross- Cross Hasil temuan Pada BI- Pada BI-RADS score 4,
Sectional Observational sectional/ ultrasonografi RADS score 0 sensitivitas diagnostik usg
mammae dan
Study to Compare the 1687 mammografi dan 2, tidak mammae dan mammografi
Role of Ultrasound with women ada perbedaan masing-masing adalah
Mammography in Women yang 0.989 dan 0.859. Pada BI-
Identified at High Risk for signifikan RADS score 5, sensitivitas
Breast Cancer in a antara hasil diagnostik usg mammae dan
Population in China; 2020 usg mammae mammografi masing-
dengan masing adalah 1 dan 0.984.
mammografi.
Pada BI-
RADS score 4
dan 5 di mana
secara
histopatologi
terkonfirmasi
kanker
payudara,
maka
sensitivitas
usg mammae
lebih besar
daripada
mammografi.
Paul B. Gordon; The Systematic Breast density The Avon- The choice of supplemental
Impact of Dense Breasts review of ACRIN screening should be based
on the Stage  of  Breast RCTs (American on an individual woman’s
Cancer at Diagnosis : A conducted College of risk
Review and Options for from the Radiology) profile. In 2010, Kuhl et al.
Supplemental Screening; early 1960s 6666 used data from the EVA
2022 to the mid multicenter trial to compare the cancer
1990s study recruited detection
2809 women rates of clinical breast
at 21 sites, examination,
who were at mammography, ultrasound,
increased risk and MRI, either alone
and who had or in various combinations,
dense breast for screening women at
tissue in at _20% lifetime risk for
least one
breast cancer,
quadrant, to
have three irrespective of breast
consecutive density. Cancer yields were:
screening mammography: 5.4/1000,
examinations US: 6/1000,
with mammography plus US:
mammograph 7.7/1000, MRI alone:
y
14.9/1000, MRI plus US:
and breast US.
The goal was 14.9/1000, and
to determine MRI plus mammography
the ICDR of 16/1000 (not statistically
annual breast significantly increased)
ultrasound
screening,
and all
participants
were offered
breast MRI at
the conclusion
of the study.
7 Validitas 5

Peneliti, jurnal dan tahun Jenis studi/ Level Apakah Apakah spektrum klinik
evidence perbandingan pasien bervariasi
dilakukan secara (dimana dijelaskan)
independent?
(dimana
dijelaskan)
Anna Glechner et al, Random-effects meta- Ya. Metode Ya. Metode Penelitian
Mammography in combination analysis/1 Penelitian
with breast ultrasonography
versus mammography for
breast cancer screening in
women at average risk, 2023.
Vikrant Kanagaraju et al, Prospective study/2 Ya. Metode Ya. Metode Penelitian
Utility of Ultrasound Strain Penelitian
Elastography to Diffrentiate
Benign from Malignant
Lesions of the Breast, 2020.
Bo Ra Kwon MD dkk, Prospective study/2 Ya. Metode Ya. Metode Penelitian
Automated Breast Penelitian
Ultrasound System for
Breast Cancer Evaluation :
Diagnostic Performance of
the Two-View Scan
Technique in Women with
Small Breasts, 2020
Peili An dkk; A Cross- Cross sectional/3 Ya. Metode Ya. Metode Penelitian
Sectional Observational Penelitian
Study to Compare the Role
of Ultrasound with
Mammography in Women
Identified at High Risk for
Breast Cancer in a
 Population in China; 2020
Paul B. Gordon; The Impact Systematic review/1 Ya. Metode Ya. Metode Penelitian
of Dense Breasts on the Penelitian
Stage  of  Breast Cancer at
Diagnosis : A Review and
Options for Supplemental
Screening; 2022
8 Importance 15

Penulis Sensiti- Specifi PPV NPV LLR LLR neg Pre-test Post-test
vity (%) - city (%) (%) pos Prob,% Probab. %
(%)
Anna
Glechner - - - - - - - -
dkk
Vikrant
Kanagar - - - - - - - -
aju dkk
Bo Ra
Kwon - - - - - - - -
MD dkk
Peili An
100 0 9 0 100 0 9 90
dkk
Paul B.
- - - - - - - -
Gordon
Pemeriksaan USG Mammae merupakan pemeriksaan diagnostik yang memiliki sensitivitas yang lebih
tinggi daripada pemeriksaan mammografi, namun sebaliknya memiliki spesifisitas yang lebih rendah
daripada mammografi. Hal ini berdampak kepada peningkatan angka false-positive, dilakukannya prosedur
biopsi yang tidak perlu dan juga meningkatkan kecemasan pasien. Namun demikian, untuk mengatasi hal
tersebut, pasien direkomendasikan untuk mammografi terlebih dahulu sebelum biopsi jika saja hasil skrining
dengan USG Mammae menunjukkan lesi yang mengarah kepada malignansi (misalnya hasil USG Mammae
menunjukkan skor BIRADS 4 atau 5).
Berdasarkan hasil penelitian di atas juga diperoleh informasi bahwa sensitivitas mammografi meningkat
seiring dengan bertambahnya usia yang disebabkan oleh adanya penurunan densitas payudara, sehingga
pasien wanita yang lebih tua atau lansia di mana densitas payudaranya sudah berkurang, maka lebih
disarankan untuk melakukan mammografi daripada USG Mammae. Selain itu, spesifisitas USG Mammae
 juga menurun pada wanita obese dikarenakan adanya lapisan lemak yang tebal di bawah kulit sehingga
dapat menimbulkan fat attenuation yang menurunkan kualitas citra USG Mammae. Oleh karena itu, wanita
obese juga lebih direkomendasikan untuk melakukan skrining dengan mammografi daripada USG
Mammae.
Perbedaan USG Mammae dan Mammografi lainnya dalam mendeteksi kanker payudara adalah USG
Mammae lebih akurat dalam mendeteksi karsinoma invasif sedangkan Mammografi lebih akurat dalam
mendeteksi karsinoma in situ. Di sisi lain, sebagian besar kanker payudara merupakan karsinoma invasif
yang diawali dengan adanya massa pada payudara. Oleh karena itu, kemampuan USG Mammae dalam
mendeteksi massa lebih baik daripada Mammografi.Hal inilah yang menyebabkan sensitivitas USG
Mammae lebih baik daripada Mammografi.

9 Applicability 15
Perbandingan biaya pemeriksaan USG Mammae dan Mammografi.

Jenis
Ekspertise
pemeriksaan Harga per pemeriksaan
Khusus*
diagnostik
USG - 75±7 ¥ Lower cost
- - Perlu
Mammae
Mammografi 210±15 ¥
- - - Higher cost Perlu
*Harga yang tertera belum ditambahkan dengan jasa expert yang memeriksa.

Dari sisi analisis biaya, pemeriksaan USG Mammae relatif lebih murah daripada Mammografi. Pemeriksaan
USG Mammae dapat dilakukan berulangkali untuk mengevaluasi perkembangan lesi atau massa tumor
karena lebih praktis dan memiliki potensi radiasi yang minimal.
Selain itu, masa tunggu untuk memperoleh hasil pemeriksaan USG Mammae juga relatif lebih cepat dan
singkat daripada pemeriksaan Mammografi.
10 Kesimpulan 10
Pemeriksaan USG Mammae lebih direkomendasikan untuk skrining awal benjolan pada payudara daripada
Mammografi pada wanita usia muda yang memiliki densitas payudara yang padat dan tidak obese.
Pemeriksaan USG Mammae ini terdiri dari USG konvensional dan USG dengan strain elastography, di
mana pemeriksaan USG dengan strain elastography dapat memberikan nilai lebih baik dalam membedakan
lesi tumor jinak (benign) dengan ganas (malignant).
 Jika hasil pemeriksaan USG Mammae menunjukkan skor BIRADS 4 atau 5, maka dapat dilanjutkan dengan
Mammografi dan atau Biopsi Histopatologi untuk menentukan jenis lesi atau tumor.

Referensi :

Glechner A, Wagner G, Mitus JW, Teufer B, Klerings I, Böck N, Grillich L, Berzaczy D, Helbich TH, Gartlehner G. Mammography in
combination with breast ultrasonography versus mammography for breast cancer screening in women at average risk. Cochrane Database Syst
Rev. 2023 Mar 31;3(3):CD009632. doi: 10.1002/14651858.CD009632.pub3. PMID: 36999589; PMCID: PMC10065327.

Kanagaraju V, Dhivya B, Devanand B, Maheswaran V. Utility of Ultrasound Strain Elastography to Differentiate Benign from Malignant
Lesions of the Breast. J Med Ultrasound. 2020 Sep 5;29(2):89-93. doi: 10.4103/JMU.JMU_32_20. PMID: 34377638; PMCID: PMC8330691.

Kwon BR, Chang JM, Kim SY, Lee SH, Kim SY, Lee SM, Cho N, Moon WK. Automated Breast Ultrasound System for Breast Cancer
Evaluation: Diagnostic Performance of the Two-View Scan Technique in Women with Small Breasts. Korean J Radiol. 2020 Jan;21(1):25-32.
doi: 10.3348/kjr.2019.0275. PMID: 31920026; PMCID: PMC6960315.

An P, Zhong S, Zhang R, Hou X, Xi R, Wang Y. A Cross-Sectional Observational Study to Compare the Role of Ultrasound with
Mammography in Women Identified at High Risk for Breast Cancer in a Population in China. Med Sci Monit. 2020 Jun 24;26:e919777. doi:
10.12659/MSM.919777. PMID: 32576809; PMCID: PMC7334879.

Gordon PB. The Impact of Dense Breasts on the Stage of Breast Cancer at Diagnosis: A Review and Options for Supplemental Screening. Curr
Oncol. 2022 May 17;29(5):3595-3636. doi: 10.3390/curroncol29050291. PMID: 35621681; PMCID: PMC9140155.