The Impact of Preoperative Breast MRI on Surgical Management of Women with Newly Diagnosed Ductal Carcinoma In Situ

Preoperative breast MRI positively impacts surgical outcomes of needle biopsy-diagnosed pure DCIS: a patient-matched analysis from the MIPA study

OBJECTIVES

To investigate the influence of preoperative breast MRI on mastectomy and reoperation rates in patients with pure ductal carcinoma in situ (DCIS).

METHODS

The MIPA observational study database (7245 patients) was searched for patients aged 18-80 years with pure unilateral DCIS diagnosed at core needle or vacuum-assisted biopsy (CNB/VAB) and planned for primary surgery. Patients who underwent preoperative MRI (MRI group) were matched (1:1) to those who did not receive MRI (noMRI group) according to 8 confounding covariates that drive referral to MRI (age; hormonal status; familial risk; posterior-to-nipple diameter; BI-RADS category; lesion diameter; lesion presentation; surgical planning at conventional imaging). Surgical outcomes were compared between the matched groups with nonparametric statistics after calculating odds ratios (ORs).

RESULTS

Of 1005 women with pure unilateral DCIS at CNB/VAB (507 MRI group, 498 noMRI group), 309 remained in each group after matching. First-line mastectomy rate in the MRI group was 20.1% (62/309 patients, OR 2.03) compared to 11.0% in the noMRI group (34/309 patients, p = 0.003). The reoperation rate was 10.0% in the MRI group (31/309, OR for reoperation 0.40) and 22.0% in the noMRI group (68/309, p < 0.001), with a 2.53 OR of avoiding reoperation in the MRI group. The overall mastectomy rate was 23.3% in the MRI group (72/309, OR 1.40) and 17.8% in the noMRI group (55/309, p = 0.111).

CONCLUSIONS

Compared to those going directly to surgery, patients with pure DCIS at CNB/VAB who underwent preoperative MRI had a higher OR for first-line mastectomy but a substantially lower OR for reoperation.

CLINICAL RELEVANCE STATEMENT

When confounding factors behind MRI referral are accounted for in the comparison of patients with CNB/VAB-diagnosed pure unilateral DCIS, preoperative MRI yields a reduction of reoperations that is more than twice as high as the increase in overall mastectomies.

KEY POINTS

• Confounding factors cause imbalance when investigating the influence of preoperative MRI on surgical outcomes of pure DCIS. • When patient matching is applied to women with pure unilateral DCIS, reoperation rates are significantly reduced in women who underwent preoperative MRI. • The reduction of reoperations brought about by preoperative MRI is more than double the increase in overall mastectomies.

A Comprehensive Review on Electrochemical Nano Biosensors for Precise Detection of Blood-Based Oncomarkers in Breast Cancer

Breast cancer (BC), one of the most common and life-threatening cancers, has the highest incidence rate among women. Early diagnosis of BC oncomarkers is considered the most effective strategy for detecting and treating BC. Finding the type and stage of BC in women as soon as possible is one of the greatest ways to stop its incidence and negative effects on medical treatment. The development of biosensors for early, sensitive, and selective detection of oncomarkers has recently attracted much attention. An electrochemical nano biosensor (EN) is a very suitable option for a powerful tool for cancer diagnosis. This comprehensive review provides information about the prevalence and pathobiology of BC, recent advances in clinically available BC oncomarkers, and the most common electrochemical nano biosensors for point-of-care (POC) detection of various BC oncomarkers using nanomaterial-based signal amplification techniques.

Preoperative Breast MRI: Current Evidence and Patient Selection

Breast MRI is the most sensitive imaging modality for the assessment of newly diagnosed breast cancer extent and can detect additional mammographically and clinically occult breast cancers in the ipsilateral and contralateral breasts. Nonetheless, appropriate use of breast MRI in the setting of newly diagnosed breast cancer remains debated. Though highly sensitive, MRI is less specific and may result in false positives and overestimation of disease when MRI findings are not biopsied prior to surgical excision. Furthermore, improved anatomic depiction of breast cancer on MRI has not consistently translated to improved clinical outcomes, such as lower rates of re-excision or breast cancer recurrence, though there is a paucity of well-designed studies examining these issues. In addition, current treatment paradigms have been developed in the absence of this more accurate depiction of disease span, which likely has limited the value of MRI. These issues have led to inconsistent and variable utilization of preoperative MRI across practice settings and providers. In this review, we discuss the history of breast MRI and its current use and recommendations with a focus on the preoperative setting. We review the evidence surrounding the use of preoperative MRI in the evaluation of breast malignancies and discuss the data on breast MRI in the setting of specific patient factors often used to determine breast MRI eligibility, such as age, index tumor phenotype, and breast density. Finally, we review the impact of breast MRI on surgical outcomes (re-excision and mastectomy rates) and long-term breast recurrence and survival outcomes.

Retrospective Cohort Study of Practical Applications of Paramagnetic Seed Localisation in Breast Carcinoma and Other Malignancies

(1) Background: Paramagnetic seeds are a safe alternative for the wire-guided localisation of non-palpable breast lesions, but can also be applied for non-breast lesions. This study presents the experience with a paramagnetic seed, MagSeed® (Endomagnetics Ltd., Cambridge, UK, CE-registered and FDA-cleared), in an academic and non-academic breast centre. (2) Methods: Multicentre, retrospective analysis of 374 consecutive patients who underwent surgery after paramagnetic seed localisation (MSL) between 2018 and 2020. Indications for localisation included non-palpable breast lesions (n = 356), lymph nodes (n = 15) or soft tissue lesions (n = 3). The primary outcome was feasibility and the rate of positive section margins. The secondary outcome was predictive factors for positive section margins. (3) Results: The accurate excision of high-risk breast lesions, lymph nodes and soft tissue lesions was seen in 91.07% (n = 56). Positive section margins were observed in 7.86% (n = 25) after breast conserving surgery for invasive or ductal carcinoma in situ (DCIS) (n = 318). Invasive breast cancer associated with DCIS (p = 0.043) and the size of DCIS (p < 0.001) were significantly correlated with the positive section margins. (4) Conclusion: This study confirms the feasibility of MSL, as well as the higher risk for positive margins in cases of breast carcinoma with associated DCIS. Soft tissue lesions and lymph nodes associated with other malignancies, e.g., melanoma, can also be localised with paramagnetic seeds. This offers perspectives for future applications, such as the de-escalation of axillary treatment in breast cancer.

Breast Cancer, Version 3.2022, NCCN Clinical Practice Guidelines in Oncology

The therapeutic options for patients with noninvasive or invasive breast cancer are complex and varied. These NCCN Clinical Practice Guidelines for Breast Cancer include recommendations for clinical management of patients with carcinoma in situ, invasive breast cancer, Paget disease, phyllodes tumor, inflammatory breast cancer, and management of breast cancer during pregnancy. The content featured in this issue focuses on the recommendations for overall management of ductal carcinoma in situ and the workup and locoregional management of early stage invasive breast cancer. For the full version of the NCCN Guidelines for Breast Cancer, visit NCCN.org.

Radiological Underestimation of Tumor Size as a Relevant Risk Factor for Positive Margin Rate in Breast-Conserving Therapy of Pure Ductal Carcinoma In Situ (DCIS)

Background: Radiological underestimation of the actual tumor size is a relevant problem in reaching negative margins in ductal carcinoma in situ (DCIS) associated with microcalcifications in breast-conserving therapy (BCT). The aim of this study is to evaluate whether the radiological underestimation of tumor size has an influence on the histopathological margin status. Methods: Patients who underwent BCT with preoperatively diagnosed pure DCIS were included (pooled analysis of two trials). Multiple factors were analysed regarding radiological underestimation ≥10 mm. Radiological underestimation was defined as mammographic minus histological tumor size in mm. Results: Positive margins occurred in 75 of 189 patients. Radiological underestimation ≥10 mm was an independent influencing factor (OR 5.80; 95%CI 2.55−13.17; p < 0.001). A radiological underestimation was seen in 70 patients. The following parameters were statistically significant associated with underestimation: pleomorphic microcalcifications (OR 3.77; 95%CI 1.27−11.18), clustered distribution patterns (OR 4.26; 95%CI 2.25−8.07), and mammographic tumor sizes ≤20 mm (OR 7.47; 95%CI 3.49−15.99). Only a mammographic tumor size ≤20 mm was an independent risk factor (OR 6.49; 95%CI 2.30−18.26; p < 0.001). Grading, estrogen receptor status, and comedo necrosis did not influence the size estimation. Conclusion: Radiological underestimation is an independent risk factor for positive margins in BCT of DCIS associated with microcalcifications predominantly occurring in mammographic small tumors.

Preoperative Breast MRI for Newly Diagnosed Ductal Carcinoma in Situ: Imaging Features and Performance in a Multicenter Setting (ECOG-ACRIN E4112 Trial)

Background There are limited data from clinical trials describing preoperative MRI features and performance in the evaluation of mammographically detected ductal carcinoma in situ (DCIS). Purpose To report qualitative MRI features of DCIS, MRI performance in the identification of additional disease, and associations of imaging features with pathologic, genomic, and surgical outcomes from the Eastern Cooperative Oncology Group-American College of Radiology Imaging Network (ECOG-ACRIN) E4112 trial. Materials and Methods Secondary analyses of a multicenter prospective clinical trial from the ECOG-ACRIN Cancer Research Group included women with DCIS diagnosed with conventional imaging techniques (mammography and US), confirmed via core-needle biopsy (CNB), and enrolled between March 2015 and April 2016 who were candidates for wide local excision (WLE) based on conventional imaging and clinical examination results. DCIS MRI features and pathologic features from CNB and excision were recorded. Each woman without invasive upgrade of the index DCIS at WLE received a 12-gene DCIS score. MRI performance metrics were calculated. Associations of imaging features with invasive upgrade, dichotomized DCIS score (<39 vs ≥39), and single WLE success were estimated in uni- and multivariable analyses. Results Among 339 women (median age, 60 years; interquartile range, 51-66 years), most DCIS cases showed nonmass enhancement (NME) (195 of 339 [58%]) on MRI scans with larger median size than on mammograms (19 mm vs 12 mm; P < .001). Positive predictive value of MRI-prompted CNBs was 32% (21 of 66) (95% CI: 22, 44), yielding an additional cancer detection rate of 6.2% (21 of 339) (95% CI: 4.1, 9.3). MRI false-positive rate was 14.2% (45 of 318) (95% CI: 10.7, 18.4). No imaging features were associated with invasive upgrade or DCIS score (P = .05 to P = .95). Smaller size and focal NME distribution at MRI were linked to single WLE success (P < .001). Conclusion Preoperative MRI depicted ductal carcinoma in situ (DCIS) diagnosed with conventional imaging most commonly as nonmass enhancement, with larger median span than mammography, and additional cancer detection rate of 6.2%. MRI features of this subset of DCIS did not enable prediction of pathologic or genomic outcomes. Clinical trial registration no. NCT02352883 © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Kuhl in this issue.

Preoperative breast magnetic resonance imaging in patients with ductal carcinoma in situ: a systematic review for the European Commission Initiative on Breast Cancer (ECIBC)

Objective

To evaluate the impact of preoperative MRI in the management of Ductal carcinoma in situ (DCIS).

Methods

We searched the PubMed, EMBASE and Cochrane Library databases to identify randomised clinical trials (RCTs) or cohort studies assessing the impact of preoperative breast MRI in surgical outcomes, treatment change or loco-regional recurrence. We provided pooled estimates for odds ratios (OR), relative risks (RR) and proportions and assessed the certainty of the evidence using the GRADE approach.

Results

We included 3 RCTs and 23 observational cohorts, corresponding to 20,415 patients. For initial breast-conserving surgery (BCS), the RCTs showed that MRI may result in little to no difference (RR 0.95, 95% CI 0.90 to 1.00) (low certainty); observational studies showed that MRI may have no difference in the odds of re-operation after BCS (OR 0.96; 95% CI 0.36 to 2.61) (low certainty); and uncertain evidence from RCTs suggests little to no difference with respect to total mastectomy rate (RR 0.91; 95% CI 0.65 to 1.27) (very low certainty). We also found that MRI may change the initial treatment plans in 17% (95% CI 12 to 24%) of cases, but with little to no effect on locoregional recurrence (aHR = 1.18; 95% CI 0.79 to 1.76) (very low certainty).

Conclusion

We found evidence of low to very low certainty which may suggest there is no improvement of surgical outcomes with pre-operative MRI assessment of women with DCIS lesions. There is a need for large rigorously conducted RCTs to evaluate the role of preoperative MRI in this population.

Key Points

• Evidence of low to very low certainty may suggest there is no improvement in surgical outcomes with pre-operative MRI.

• There is a need for large rigorously conducted RCTs evaluating the role of preoperative MRI to improve treatment planning for DCIS.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-021-07873-2.

Breast MRI in DCIS size estimation, breast-conserving surgery and oncoplastic breast surgery

The impact of MRI on improving surgical outcomes in DCIS is debated. Here, we explore the utility of MRI in the investigation and management of DCIS in three key areas. Firstly, we highlight that MRI is likely to be a more accurate predictor of actual tumour size than conventional imaging. Secondly, we examine mastectomy rates and reoperation rates across the literature and suggest that surgical outcomes do not differ between pre-operative MRI and conventional imaging groups, despite improved size estimation on MRI. Finally, we examine the rapidly developing field of oncoplastic breast surgery and highlight a paucity of data in determining the usefulness of pre-operative MRI in this field, despite this being an oncologically safe alternative with improved patient outcomes and satisfaction.

The Value of Patient and Tumor Factors in Predicting Preoperative Breast MRI Outcomes

Purpose

To identify patient and tumor features that predict true-positive, false-positive, and negative breast preoperative MRI outcomes.

Materials and Methods

Using a breast MRI database from a large regional cancer center, the authors retrospectively identified all women with unilateral breast cancer who underwent preoperative MRI from January 2005 to February 2015. A total of 1396 women with complete data were included. Patient features (ie, age, breast density) and index tumor features (ie, type, grade, hormone receptor, human epidermal growth factor receptor type 2/neu, Ki-67) were extracted and compared with preoperative MRI outcomes (ie, true positive, false positive, negative) using univariate (ie, Fisher exact) and multivariate machine learning approaches (ie, least absolute shrinkage and selection operator, AutoPrognosis). Overall prediction performance was summarized using the area under the receiver operating characteristic curve (AUC), calculated using internal validation techniques (bootstrap and cross-validation) to account for model training.

Results

At the examination level, 181 additional cancers were identified among 1396 total preoperative MRI examinations (median patient age, 56 years; range, 25-94 years), resulting in a positive predictive value for biopsy of 43% (181 true-positive findings of 419 core-needle biopsies). In univariate analysis, no patient or tumor feature was associated with a true-positive outcome (P > .05), although greater mammographic density (P = .022) and younger age (< 50 years, P = .025) were associated with false-positive examinations. Machine learning approaches provided weak performance for predicting true-positive, false-positive, and negative examinations (AUC range, 0.50-0.57).

Conclusion

Commonly used patient and tumor factors driving expert opinion for the use of preoperative MRI provide limited predictive value for determining preoperative MRI outcomes in women. Supplemental material is available for this article. © RSNA, 2020See also the commentary by Grimm in this issue.

Preoperative breast MRI in management of patients with needle biopsy-proven ductal carcinoma in situ (DCIS)

BACKGROUND

In 20-25% of patients with biopsy-proven DCIS underestimation occurs. Sentinel lymph node biopsy (SLNB) is offered to patients with biopsy-proven ductal carcinoma in situ (DCIS) and a high risk of occult invasive cancer. However, assessment of high risk is controversial. We aimed to improve selection of patients for SLNB with preoperative breast magnetic resonance imaging (MRI).

METHODS

In this prospective observational study, MRI was offered to all subsequent patients with a biopsy-proven DCIS admitted to a large Dutch teaching hospital between April 2012 and March 2017. MRI images were analysed for signs of invasive cancer and the results were compared with the pathologic results after surgical treatment. The diagnostic accuracy of additional MRI in detecting occult invasive cancer was determined.

RESULTS

Of 211 patients eligible for additional MRI analysis, 149 underwent breast MRI. The majority (67%) received breast-conserving therapy, and the underestimation rate was 20%. Subsequent to MRI analysis, 20 additional invasive diagnostic procedures were performed. Occult invasive cancer was suspected on MRI in 46 patients (31%) and was confirmed in 18 (12%). In this study, breast MRI had a sensitivity of 67%, a specificity of 77%, and a true negative rate of 91%.

CONCLUSION

Preoperative breast MRI cannot reliably predict the presence of invasive cancer in patients with biopsy proven DCIS. Therefore, it cannot be used to in the selection of patients for a SLNB.

Pre-operative MRI in patients with ductal carcinoma in situ: Is MRI useful for identifying additional disease?

PURPOSE

To determine if pre-operative MRI is useful for identifying additional disease that would impact surgical management in women with ductal carcinoma in situ (DCIS).

METHODS

We conducted a retrospective review of consecutive women with calcifications at mammography yielding DCIS at core biopsy from 2007 to 2016 who subsequently underwent MRI examinations. Patient characteristics, imaging findings, and pathology outcomes were collected from the medical records. Standard statistical tests were used to compare the patients who underwent MRI examinations (MRI group) and those who did not (no MRI group).

RESULTS

963 women (age 58 years, range 28-89 years) presented with calcifications that yielded DCIS at biopsy, of whom 236 (24.5 %) underwent MRI examinations. The MRI group was younger, less likely to have a prior breast cancer, and more likely to have dense breasts than the no MRI group (all p < 0.001). 66 women (28.0 %) had 80 MRI findings that were recommended for work-up and/or biopsy. 21 patients had 23 MRI findings that were not pursued pre-operatively, and 45 patients with 57 MRI findings underwent biopsy. The positive predictive value of biopsies performed (PPV3) was 45.6 % (26/57). 26 cancers were detected in 24 women; thus, MRI detected additional sites of cancer in 11.2 % (24/215) of patients. Of the 26 cancers, 13 (50.0 %) were DCIS and 13 (50.0 %) were invasive.

CONCLUSIONS

MRI in selected women with DCIS identified additional sites of disease in 11.2 % and thus could be considered in the pre-operative evaluation of this specific patient cohort.

Performance of preoperative breast MRI based on breast cancer molecular subtype

PURPOSE

To assess the performance of preoperative breast MRI biopsy recommendations based on breast cancer molecular subtype.

METHODS

All preoperative breast MRIs at a single academic medical center from May 2010 to March 2014 were identified. Reports were reviewed for biopsy recommendations. All pathology reports were reviewed to determine biopsy recommendation outcomes. Molecular subtypes were defined as Luminal A (ER/PR+ and HER2-), Luminal B (ER/PR+ and HER2+), HER2 (ER-, PR- and HER2+), and Basal (ER-, PR-, and HER2-). Logistic regression assessed the probability of true positive versus false positive biopsy and mastectomy versus lumpectomy.

RESULTS

There were 383 patients included with a molecular subtype distribution of 253 Luminal A, 44 Luminal B, 20 HER2, and 66 Basal. Two hundred and thirteen (56%) patients and 319 sites were recommended for biopsy. Molecular subtype did not influence the recommendation for biopsy (p = 0.69) or the number of biopsy site recommendations (p = 0.30). The positive predictive value for a biopsy recommendation was 42% overall and 46% for Luminal A, 43% for Luminal B, 36% for HER2, and 29% for Basal subtype cancers. The multivariate logistic regression model showed no difference in true positive biopsy rate based on molecular subtype (p = 0.78). Fifty-one percent of patients underwent mastectomy and the multivariate model demonstrated that only a true positive biopsy (odds ratio: 5.3) was associated with higher mastectomy rates.

CONCLUSION

Breast cancer molecular subtype did not influence biopsy recommendations, positive predictive values, or surgical approaches. Only true positive biopsies increased the mastectomy rate.

Surgical Outcomes for Ductal Carcinoma in Situ: Impact of Preoperative MRI

Background The role of preoperative MRI for predicting surgical outcomes in patients diagnosed with ductal carcinoma in situ (DCIS) remains uncertain. Purpose To investigate the associations between preoperative MRI and surgical outcomes in DCIS confirmed by using US-guided core-needle biopsy (CNB) and to evaluate clinical-pathologic variables associated with a benefit from MRI. Materials and Methods Women with DCIS confirmed by using US-guided CNB between January 2012 and December 2016 were included in this retrospective study. Propensity score matching using 18 confounding covariates was used to create matched groups with MRI and without MRI, and surgical outcomes were compared. Clinical-pathologic variables were evaluated to determine women who benefited from MRI. Results A total of 541 women (mean age ± standard deviation, 50 years ± 10) were evaluated. Among 430 women who underwent MRI, 67 additional lesions (16%) were depicted, with 25 (37%) of the 67 additional lesions being malignant. Fifty-seven (13%) of the 430 women had a change in surgical plan because of their MRI findings; the change was appropriate for 31 (54%) women. In matched groups, the MRI group was associated with lower odds of positive resection margin (odds ratio [OR], 0.39; 95% confidence interval [CI]: 0.16, 0.93; P = .03) and repeat surgery (OR, 0.33; 95% CI: 0.12, 0.92; P = .03) compared with the non-MRI group. There was no difference in likelihood of initial mastectomy (OR, 1.2; 95% CI: 0.7, 2.0; P = .59) and overall mastectomy (OR, 0.93; 95% CI: 0.5, 1.6; P = .79). In the MRI group, low nuclear grade (90% [28 of 31] vs 69% [275 of 399]; P = .01), progesterone receptor positivity (81% [25 of 31] vs 61% [244 of 399]; P = .03), and human epidermal growth factor receptor 2 negativity (90% [28 of 31] vs 68% [270 of 399]; P = .01) were associated with a benefit from MRI versus no MRI. Conclusion Preoperative MRI depicted additional malignancy and reduced positive surgical margins and repeat surgery for ductal carcinoma in situ confirmed at US-guided biopsy without a higher mastectomy rate. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Pinker in this issue.

Diagnostic Performance of MRI, Molecular Breast Imaging, and Contrast-enhanced Mammography in Women with Newly Diagnosed Breast Cancer

Background Staging newly diagnosed breast cancer by using dynamic contrast material-enhanced MRI is limited by access, high cost, and false-positive findings. The utility of contrast-enhanced mammography (CEM) and ^99mTc sestamibi-based molecular breast imaging (MBI) in this setting is largely unknown. Purpose To compare extent-of-disease assessments by using MRI, CEM, and MBI versus pathology in women with breast cancer. Materials and Methods In this HIPAA-compliant prospective study, women with biopsy-proven breast cancer underwent MRI, CEM, and MBI between October 2014 and April 2018. Eight radiologists independently interpreted each examination result prospectively and were blinded to interpretations of findings with the other modalities. Visibility of index malignancies, lesion size, and additional suspicious lesions (malignant or benign) were compared during pathology review. Accuracy of index lesion sizing and detection of additional lesions in women without neoadjuvant chemotherapy were compared. Results A total of 102 women were enrolled and 99 completed the study protocol (mean age, 51 years ± 11 [standard deviation]; range, 32-77 years). Lumpectomy or mastectomy was performed in 71 women (79 index malignancies) without neoadjuvant chemotherapy and in 28 women (31 index malignancies) with neoadjuvant chemotherapy. Of the 110 index malignancies, MRI, CEM, and MBI depicted 102 (93%; 95% confidence interval [CI]: 86%, 97%), 100 (91%; 95% CI: 84%, 96%), and 101 (92%; 95% CI: 85%, 96%) malignancies, respectively. In patients without neoadjuvant chemotherapy, pathologic size of index malignancies was overestimated with all modalities (P = .02). MRI led to overestimation of 24% (17 of 72) of malignancies by more than 1.5 cm compared with 11% (eight of 70) with CEM and 15% (11 of 72) with MBI. MRI depicted more (P = .007) nonindex lesions, with sensitivity similar to that of CEM or MBI, resulting in lower positive predictive value of additional biopsies (13 of 46 [28%; 95% CI: 17%, 44%] for MRI; 14 of 27 [52%; 95% CI: 32%, 71%] for CEM; and 11 of 25 [44%; 95% CI: 24%, 65%] for MBI (overall P = .01). Conclusion Contrast-enhanced mammography, molecular breast imaging, and MRI showed similar detection of all malignancies. MRI depicted more nonindex suspicious benign lesions than did contrast-enhanced mammography or molecular breast imaging, leading to lower positive predictive value of additional biopsies. All three modalities led to overestimation of index tumor size, particularly MRI. © RSNA, 2019 Online supplemental material is available for this article.