Breast magnetic resonance imaging (MRI) surveillance in breast cancer survivors

PURPOSE

As the breast cancer survivor population increases, the topic of screening these women for recurrences is increasingly relevant. In our institution, we use both breast MRI and mammography in the surveillance of breast cancer survivors, although little data exists on the use of MRI in this setting. We present a retrospective analysis of our experience and compare the sensitivity and specificity of MRI vs. mammography in this setting.

METHODS

We identified women under 65 with a history of breast cancer and at least one follow-up MRI performed along with a mammogram done within 6 months of the MRI. We compared the outcomes of MRI and mammography in terms of biopsies performed as well as in detection of new cancers.

RESULTS

Of 617 charts reviewed, 249 patients met inclusion criteria, with 571 paired MRI/mammogram results. There were 27 biopsies performed due to MRI findings alone, 10 done due to mammographic findings alone, and 15 done based on abnormalities seen on both imaging modalities. There were 8 malignancies identified based on an abnormal MRI, 3 detected on both MRI and mammography, and none identified via mammography alone. Overall, MRI had a sensitivity of 84.6% (the 95% CI 54.6-98.1) and a specificity of 95.3% (the 95% CI 93.3-96.9); mammography a sensitivity of 23.1% (the 95% CI 5.0-53.8), and a specificity of 96.4% (the 95% CI 94.5-97.8).

CONCLUSIONS

Breast MRI is a useful surveillance modality in breast cancer survivors and may be more sensitive at detecting recurrences than mammography alone in this population.

Treatment choices for patients with invasive lobular breast cancer: a doctor survey

RATIONALE, AIMS AND OBJECTIVES

Invasive lobular breast cancer (ILC) has distinct features that present challenges for management. We surveyed doctors regarding management approaches, opinions on quality of evidence supporting their practice, and future research needs.

METHODS

An online questionnaire was developed and circulated to breast cancer surgical, radiation and medical oncologists.

RESULTS

The questionnaire was completed by 88/428 doctors (20.6%); 22/56 (39.3%) surgeons, 21/64 (32.8%) radiation oncologists and 45/308 (14.6%) medical oncologists. The majority (65%) of surgeons were comfortable treating ILC patients using the same surgical management as patients with invasive ductal cancers (IDC). Furthermore, 25% would perform a similar surgery but would obtain larger gross margins. There was equipoise for radiation oncologists regarding whether or not ILC was an independent risk factor for local-regional recurrence after either breast-conserving surgery or mastectomy. Of those radiation oncologists who believe ILC is an independent risk factor for recurrence after mastectomy, 44.4% would offer radiation in the absence of usual indications. Medical oncologists approached systemic therapy for ILC patients similarly to those with comparable IDCs. Areas identified as most controversial and requiring future research were preoperative magnetic resonance imaging, radiotherapy post-mastectomy and the responsiveness of ILC to adjuvant chemotherapy compared with endocrine therapy.

CONCLUSIONS

There is a variation in doctors' beliefs, management and opinions regarding the quality of evidence for the management of ILC. Clinical trials specifically assessing the management of ILC are required to guide clinical practice.

The Right Treatment for the Right Patient - Personalised Treatment of Breast Cancer

The probability of healing breast cancer has been greatly improved in recent decades through the introduction and optimisation of multi-modal therapies and interdisciplinary treatments. Today, in addition to surgery or radiation, most patients receive a systemic treatment. To prevent excessive treatment, patients whose prognosis is so good that certain adjuvant therapies can be foregone or reduced must be identified. A lack of compliance with therapy, especially in the endocrine therapies stretching over years, is a further problem. As only treatments that are also carried out can improve chances of survival, efforts to improve compliance must be intensified. Studies show that lifestyle changes influence the efficiency of medication on the one hand, and on the other hand can also by themselves achieve a relevant improvement of the prognosis. Therefore, it is time not only to treat the tumour, but to also focus on the patient as a whole in therapeutic interventions.

Meta-analysis of the effect of preoperative breast MRI on the surgical management of ductal carcinoma in situ

Background

MRI has been used increasingly in the diagnosis and management of women with invasive breast cancer. However, its usefulness in the preoperative assessment of ductal carcinoma in situ (DCIS) remains questionable. A meta-analysis was conducted to examine the effects of MRI on surgical treatment of DCIS by analysing studies comparing preoperative MRI with conventional preoperative assessment.

Methods

Using random-effects modelling, the proportion of women with various outcomes in the MRI versus no-MRI groups was estimated, and the odds ratio (OR) and adjusted OR (adjusted for study-level median age) for each model were calculated.

Results

Nine eligible studies were identified that included 1077 women with DCIS who had preoperative MRI and 2175 who did not. MRI significantly increased the odds of having initial mastectomy (OR 1·72, P = 0·012; adjusted OR 1·76, P = 0·010). There were no significant differences in the proportion of women with positive margins following breast-conserving surgery (BCS) in the MRI and no-MRI groups (OR 0·80, P = 0·059; adjusted OR 1·10, P = 0·716), nor in the necessity of reoperation for positive margins after BCS (OR 1·06, P = 0·759; adjusted OR 1·04, P = 0·844). Overall mastectomy rates did not differ significantly according to whether or not MRI was performed (OR 1·23, P = 0·340; adjusted OR 0·97, P = 0·881).

Conclusion

Preoperative MRI in women with DCIS is not associated with improvement in surgical outcomes.

Magnetic resonance imaging improves breast screening sensitivity in BRCA mutation carriers age ≥ 50 years: evidence from an individual patient data meta-analysis

PURPOSE

There is no consensus on whether magnetic resonance imaging (MRI) should be included in breast screening protocols for women with BRCA1/2 mutations age ≥ 50 years. Therefore, we investigated the evidence on age-related screening accuracy in women with BRCA1/2 mutations using individual patient data (IPD) meta-analysis.

PATIENTS AND METHODS

IPD were pooled from six high-risk screening trials including women with BRCA1/2 mutations who had completed at least one screening round with both MRI and mammography. A generalized linear mixed model with repeated measurements and a random effect of studies estimated sensitivity and specificity of MRI, mammography, and the combination in all women and specifically in those age ≥ 50 years.

RESULTS

Pooled analysis showed that in women age ≥ 50 years, screening sensitivity was not different from that in women age < 50 years, whereas screening specificity was. In women age ≥ 50 years, combining MRI and mammography significantly increased screening sensitivity compared with mammography alone (94.1%; 95% CI, 77.7% to 98.7% v 38.1%; 95% CI, 22.4% to 56.7%; P < .001). The combination was not significantly more sensitive than MRI alone (94.1%; 95% CI, 77.7% to 98.7% v 84.4%; 95% CI, 61.8% to 94.8%; P = .28). Combining MRI and mammography in women age ≥ 50 years resulted in sensitivity similar to that in women age < 50 years (94.1%; 95% CI, 77.7% to 98.7% v 93.2%; 95% CI, 79.3% to 98%; P = .79).

CONCLUSION

Addition of MRI to mammography for screening BRCA1/2 mutation carriers age ≥ 50 years improves screening sensitivity by a magnitude similar to that observed in younger women. Limiting screening MRI in BRCA1/2 carriers age ≥ 50 years should be reconsidered.

Breast magnetic resonance imaging indications

The use of breast magnetic resonance imaging (MRI) has grown for the past decade and, along with the increase in use, there has been a progression in the indications for use. Breast MRI has been shown to be a valuable additional tool for breast imagers to use to provide optimal patient care. Because of the benefit that MRI can provide, the technology is now being used for a wide variety of indications, from evaluation of the extent of disease to evaluation of the high-risk patient, evaluation of tumor response to chemotherapy, and search for occult primary tumor. This review will cover the various indications for breast MRI, discuss research to date, as well as provide case examples.

Association between rim enhancement of breast cancer on dynamic contrast-enhanced MRI and patient outcome: impact of subtype

The heterogeneous nature of breast cancer is represented by three breast cancer subtypes associated with different patient outcome. However, within subtypes, variations still exist. Additional stratification is necessary for more individualized therapy. Functional tumor characteristics on dynamic contrast-enhanced (DCE)-MRI may play a role. Rim enhancement of breast cancers has been associated with unfavorable pathology characteristics in the context of outcome. However, existence of a direct link is unknown. The purpose was to retrospectively determine the association between rim enhancement on DCE-MRI and long-term patient outcome, and whether it has complementary value to subtype. Preoperative DCE-MRI was performed in 556 consecutive female patients who were eligible for breast-conserving therapy. Presence of rim enhancement was assessed. Tumor characteristics were derived from resection specimens. Patients were stratified according to subtype. Association was assessed between rim enhancement and patient, pathology and treatment characteristics, recurrence-free interval and invasive disease-free survival. Median follow-up was 84 months. Patients were stratified into ER-positive/HER2-negative (N = 416), HER2-positive (N = 75), or triple-negative (N = 65) subtypes. Rim enhancement was seen in 29.0% (N = 161/556) of tumors and was associated with higher histologic grade, negative ER-status, and triple-negative subtype. Only within triple-negative tumors, an association was seen with outcome. Recurrence was lower in non-rim-enhancing tumors (N = 1/36; 2.8%) compared to rim-enhancing tumors (N = 9/28; 32.1%) (p = 0.001). Survival was higher in non-rim-enhancing tumors (N = 34/36; 94.4%) compared to rim-enhancing tumors (N = 18/28; 64.3%) (p = 0.001). Rim enhancement on DCE-MRI is associated with long-term outcome of patients with triple-negative breast cancer and may potentially serve as a prognostic biomarker in these patients.

Can breast cancer molecular subtype help to select patients for preoperative MR imaging?

PURPOSE

To assess whether breast cancer molecular subtype classified by surrogate markers can be used to predict the extent of clinically relevant disease with preoperative breast magnetic resonance (MR) imaging.

MATERIALS AND METHODS

In this HIPAA-compliant, institutional review board-approved study, informed consent was waived. Preoperative breast MR imaging reports from 441 patients were reviewed for multicentric and/or multifocal disease, lymph node involvement, skin and/or nipple invasion, chest wall and/or pectoralis muscle invasion, or contralateral disease. Pathologic reports were reviewed to confirm the MR imaging findings and for hormone receptors (estrogen and progesterone subtypes), human epidermal growth factor receptor type 2 (HER2 subtype), tumor size, and tumor grade. Surrogates were used to categorize tumors by molecular subtype: hormone receptor positive and HER2 negative (luminal A subtype); hormone receptor positive and HER2 positive (luminal B subtype); hormone receptor negative and HER2 positive (HER2 subtype); hormone receptor negative and HER2 negative (basal subtype). All patients included in the study had a histologic correlation with MR imaging findings or they were excluded. χ(2) analysis was used to compare differences between subtypes, with multivariate logistic regression analysis used to assess for variable independence.

RESULTS

Identified were 289 (65.5%) luminal A, 45 (10.2%) luminal B, 26 (5.9%) HER2, and 81 (18.4%) basal subtypes. Among subtypes, significant differences were found in the frequency of multicentric and/or multifocal disease (luminal A, 27.3% [79 of 289]; luminal B, 53.3% [24 of 45]; HER2, 65.4% [17 of 26]; basal, 27.2% [22 of 81]; P < .001) and lymph node involvement (luminal A, 17.3% [50 of 289]; luminal B, 35.6% [26 of 45]; HER2, 34.6% [nine of 26]; basal 24.7% [20 of 81]; P = .014). Multivariate analysis showed that molecular subtype was independently predictive of multifocal and/or multicentric disease.

CONCLUSION

Preoperative breast MR imaging is significantly more likely to help detect multifocal and/or multicentric disease and lymph node involvement in luminal B and HER2 molecular subtype breast cancers. Molecular subtype may help to select patients for preoperative breast MR imaging.

Importance of presurgical breast MRI in patients 60 years of age and older

Objective:

To demonstrate the importance of presurgical bilateral breast Magnetic Resonance Imaging (MRI) in women 60 years of age and older.

Materials and Methods:

Institutional review board approval was obtained with waiver of informed consent for this retrospective review. From December 2003 to December 2011, all patients 60 years and older who had presurgical bilateral breast MRI were reviewed, revealing 1268 presurgical MRI examinations; 310 had a new lesion identified by MRI. Cases were excluded due to incomplete or missing data, resulting in 243 patients with 272 findings eligible for analysis. Data recorded included patient demographics, core biopsy method and pathology, type of surgery, and surgical pathology results.

Results:

Of 1268 exams performed in this population, 272 (21.5%) patients with suspicious MRI findings underwent needle biopsy. Malignancy was found in 114 (42%), benign findings in 127 (47%), and atypia in 31 (11%). Of the malignancies, 83 were in the ipsilateral breast and 31 in the contralateral breast to the original diagnosis. Of the ipsilateral findings, 47 were in the same quadrant as the primary diagnosis, 28 in a different quadrant, and 8 were metastatic lymph nodes. Of the 31 atypical findings, 14 were contralateral to the primary diagnosis and 17 were ipsilateral. Two hundred and thirty-three patients underwent surgical excision; 111 changed their surgical management as a lesion was seen on MRI and was diagnosed as cancer on needle biopsy.

Conclusions:

Among the patients aged 60 years and above who had presurgical bilateral breast MRI, we found additional cancers in 9.0% (n = 114/1268) and atypia in 2.4% (n = 31/1268). A change in management as a result of the MRI-detected lesion occurred in 8.8% (n = 111/1268). These results demonstrate that performing presurgical bilateral breast MRI is of value in women 60 years of age and above.

Current clinical indications for magnetic resonance imaging of the breast

MRI is increasingly used in breast cancer patients. MRI has a high sensitivity compared to mammography and ultrasound. The specificity is moderate leading to an increased risk of false positive findings. Currently, a beneficial effect of breast MRI has been established in some patient groups and is debated in the general breast cancer population. The diagnostic ability of MRI and its role in various groups of breast cancer patients are discussed in this review.

First international consensus guidelines for breast cancer in young women (BCY1)

The 1st International Consensus Conference for Breast Cancer in Young Women (BCY1) took place in November 2012, in Dublin, Ireland organized by the European School of Oncology (ESO). Consensus recommendations for management of breast cancer in young women were developed and areas of research priorities were identified. This manuscript summarizes these international consensus recommendations, which are also endorsed by the European Society of Breast Specialists (EUSOMA).

Magnetic resonance imaging in patients with newly diagnosed breast cancer: a review of the literature

The use of magnetic resonance imaging (MRI) in patients with newly diagnosed breast cancer remains controversial. Here we review the current use of breast MRI and the impact of MRI on short-term surgical outcomes and rates of local recurrence. In addition, we address the use of MRI in specific patient populations, such as those with ductal carcinoma in situ, invasive lobular carcinoma, and occult primary breast cancer, and discuss the potential role of MRI for assessing response to neoadjuvant chemotherapy. Although MRI has improved sensitivity compared with conventional imaging, this has not translated into improved short-term surgical outcomes or long-term patient benefit, such as improved local control or survival, in any patient population. MRI is an important diagnostic test in the evaluation of patients presenting with occult primary breast cancer and has shown promise in monitoring response to neoadjuvant chemotherapy; however, the data do not support the routine use of perioperative MRI in patients with newly diagnosed breast cancer. Cancer 2014;120:120:2080-2089. © 2014 American Cancer Society.