Magnetic resonance imaging of ductal carcinoma in situ: what is its clinical application? A review

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.

Accuracy of Breast Magnetic Resonance Imaging Compared to Mammography in the Preoperative Detection and Measurement of Pure Ductal Carcinoma In Situ: A Retrospective Analysis

RATIONALE AND OBJECTIVES

Ductal carcinoma in situ (DCIS) hinders imaging detection due to multifocal appearance and discontinuous growth. Preoperative determination of its extent is therefore challenging. Aim of this study was to investigate the additional benefit of breast magnetic resonance imaging (MRI) to mammography (MG) in the diagnosis of DCIS according to size and grading.

MATERIALS AND METHODS

Retrospective analysis of 295 patients with biopsy-proven, pure DCIS. Mean patient age was 57.0 years (27-87 years). All patients obtained MG. Additional MRI was performed in 41.7% (123/295). Mammographic breast density, background parenchymal enhancement (BPE), tumor size and grading were analysed. Tumor size on MG and MRI were compared to histopathological size of the surgical specimen.

RESULTS

Mean tumor size was 39.6 mm. DCIS was occult on MG in 24.4% (30/123) and on MRI in 1.6% (2/123). Size was underestimated by 4.6 mm (mean) mammographically. DCIS was high grade in 54.5% (67/123), intermediate grade in 40.7% (50/123) and low grade in 4.9% (6/123). MG was exact regarding tumor size in low grade DCIS, underestimated intermediate grade DCIS by 1 mm (median) and high grade DCIS by 10.5 mm. MRI overestimated low grade DCIS by 1 mm (median), was exact regarding intermediate grade DCIS and underestimated high grade DCIS by 1 mm. BPE did not influence tumor detection and measurement.

CONCLUSION

MRI outperforms MG in the detection and size estimation of DCIS and can reduce positive margin rates.

Breast magnetic resonance elastography: a review of clinical work and future perspectives

This review on magnetic resonance elastography (MRE) of the breast provides an overview of available literature and describes current developments in the field of breast MRE, including new transducer technology for data acquisition and multi-frequency-derived power-law behaviour of tissue. Moreover, we discuss the future potential of breast MRE, which goes beyond its original application as an additional tool in differentiating benign from malignant breast lesions. These areas of ongoing and future research include MRE for pre-operative tumour delineation, staging, monitoring and predicting response to treatment, as well as prediction of the metastatic potential of primary tumours.

Feasibility of mapping breast cancer with supine breast MRI in patients scheduled for oncoplastic surgery

OBJECTIVES

To prospectively determine the feasibility of preoperative supine breast MRI in breast cancer patients scheduled for oncoplastic breast-conserving surgery.

METHODS

In addition to a diagnostic prone breast MRI, a supplementary supine MRI was performed with the patient in the surgical position including skin markers. Tumours' locations were ink-marked on the skin according to findings obtained from supine MRI. Changes in tumours' largest diameter and locations between prone and supine MRI were measured and compared to histology. Nipple-to-tumour and tumour-to-chest wall distances were also measured. Tumours and suspicious areas were surgically removed according to skin ink-markings. The differences between MRI measurements with reference to histopathology were evaluated with the paired-sample t test.

RESULTS

Fourteen consecutive patients, 15 breasts and 27 lesions were analysed. Compared to histology, prone MRI overestimated tumour size by 47.1% (p = 0.01) and supine MRI by 14.5% (p = 0.259). In supine MRI, lesions' mean diameters and areas were smaller compared to prone MRI (- 20.9%, p = 0.009 and - 38.3%, p = 0.016, respectively). This difference in diameter was more pronounced in non-mass lesions (- 31.2%, p = 0.031) compared to mass lesions (- 9.2%, p = 0.009). Tumours' mean distance from chest wall diminished by 69.4% (p < 0.001) and from nipple by 18.2% (p < 0.001). Free microscopic margins were achieved in first operation in all patients.

CONCLUSIONS

Supine MRI in the surgical position is feasible and useful in the precise localisation of prone MRI-detected lesions and provides a helpful tool to implement in surgery. Supine MRI more accurately determines tumours' size and location and might have an important role to diminish overestimations.

KEY POINTS

• Breath-hold supine breast MRI is feasible using commercially available coils and sequences. • Size and area of lesions on MRI were consistently smaller when measured from the supine position as compared to the prone position. • Supine breast MRI is useful in the precise preoperative localisation of prone MRI-detected lesions. •.

Preoperative prediction of the size of pure ductal carcinoma in situ using three imaging modalities as compared to histopathological size: does magnetic resonance imaging add value?

PURPOSE

The purpose of this study was to evaluate whether magnetic resonance imaging (MRI) and ultrasonography add value to traditional mammography in an Asian population with ductal carcinoma in situ (DCIS).

METHODS

Data of 244 patients with pure DCIS treated at Severance Hospital between 2013 and 2015 were analyzed retrospectively. Data extracted included age, preoperative diagnosis, tumor size on preoperative imaging studies, and final histopathological tumor type and size, including hormone receptor status. The extent of correlation between imaging and histopathological tumor sizes was evaluated using a variety of methods, including Bland-Altman analysis.

RESULTS

The mean patient age was 52.39 years (SD = 10.31). The mean measurements of the tumor on preoperative ultrasonography, mammography, MRI, and histopathology were 1.80 (SD = 1.23) cm, 2.97 (SD = 1.92) cm, 2.53(SD = 1.84) cm, and 1.88 (SD = 1.36) cm, respectively. The mean differences in tumor size between ultrasonography, mammography, and MRI compared with histopathology were -0.09 (SD = 1.39), 1.09 (SD = 1.89), and 0.65 (SD = 1.78), respectively. The correlation between the sizes was significant with r values for ultrasonography, mammography, and MRI of 0.447 (SE = 0.061), 0.375 (SE = 0.042), and 0.409 (SE = 0.043), respectively. Mammography and MRI estimated tumor size significantly better for patients older than 50 years (p = 0.045 and <0.001, respectively). Mammography also provided good estimation for patients with a body mass index under 25 (p = 0.041).

CONCLUSION

MRI is better at estimation of histopathological DCIS size compared with mammography. However, ultrasonography had better estimation compared with MRI and mammography, probably owing to the high breast density in this population.

Tumor characteristics of ductal carcinoma in situ of breast visualized on [F-18] fluorodeoxyglucose-positron emission tomography/computed tomography: Results from a retrospective study

AIM

To clarify clinicopathological features of ductal carcinoma in situ (DCIS) visualized on [F-18] fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT).

METHODS

This study retrospectively reviewed 52 consecutive tumors in 50 patients with pathologically proven pure DCIS who underwent [F-18] FDG-PET/CT before surgery. [F-18] FDG-PET/CT was performed after biopsy in all patients. The mean interval from biopsy to [F-18] FDG-PET/CT was 29.2 d. [F-18] FDG uptake by visual analysis and maximum standardized uptake value (SUVmax) was compared with clinicopathological characteristics.

RESULTS

[F-18] FDG uptake was visualized in 28 lesions (53.8%) and the mean and standard deviation of SUVmax was 1.63 and 0.90. On univariate analysis, visual analysis and the SUVmax were associated with symptomatic presentation (P = 0.012 and 0.002, respectively), palpability (P = 0.030 and 0.024, respectively), use of core-needle biopsy (CNB) (P = 0.023 and 0.012, respectively), ultrasound-guided biopsy (P = 0.040 and 0.006, respectively), enhancing lesion ≥ 20 mm on magnetic resonance imaging (MRI) (P = 0.001 and 0.010, respectively), tumor size ≥ 20 mm on histopathology (P = 0.002 and 0.008, respectively). However, [F-18] FDG uptake parameters were not significantly associated with age, presence of calcification on mammography, mass formation on MRI, presence of comedo necrosis, hormone status (estrogen receptor, progesterone receptor and human epidermal growth factor receptor-2), and nuclear grade. The factors significantly associated with visual analysis and SUVmax were symptomatic presentation (P = 0.019 and 0.001, respectively), use of CNB (P = 0.001 and 0.031, respectively), and enhancing lesion ≥ 20 mm on MRI (P = 0.001 and 0.049, respectively) on multivariate analysis.

CONCLUSION

Although DCIS of breast is generally non-avid tumor, symptomatic and large tumors (≥ 20 mm) tend to be visualized on [F-18] FDG-PET/CT.

[Ductal carcinoma in situ diagnosis: 3 French national guidelines]

OBJECTIVE

Since the last guidelines published by the French National Cancer Institute (INCa) and the learning society "Société française de sénologie et de pathologie mammaire (SFSPM)" in 2009 about diagnosis and management of ductal carcinoma in situ, new data raised issues about overdiagnosis and its consequences, overtreatment. Therefore, an update was necessary, to provide healthcare professionals up-to-date guidelines and study therapeutic desescalation in particular.

METHODS

The clinical practice guidelines development process is based on systematic literature review and critical appraisal by a multidisciplinary experts workgroup. The recommendations are thus based on the best available evidence and experts agreement. Prior to publication, the guidelines are also reviewed by more than 100 independent practitioners in cancer care delivery.

RESULTS

This article presents French guidelines about MRI and vacuum assisted breast biopsy indications for DCIS diagnosis and the management of low-grade DCIS.

Feasibility of a prospective, randomised, open-label, international multicentre, phase III, non-inferiority trial to assess the safety of active surveillance for low risk ductal carcinoma in situ - The LORD study

BACKGROUND

The current debate on overdiagnosis and overtreatment of screen-detected ductal carcinoma in situ (DCIS) urges the need for prospective studies to address this issue. A substantial number of DCIS lesions will never form a health hazard, particularly if it concerns non- to slow-growing low-grade DCIS. The LORD study aims to evaluate the safety of active surveillance in women with low-risk DCIS.

DESIGN

This is a randomised, international multicentre, open-label, phase III non-inferiority trial, led by the Dutch Breast Cancer Research Group (BOOG 2014-04) and the European Organization for Research and Treatment of Cancer (EORTC-BCG 1401). Standard treatment will be compared to active surveillance in 1240 women aged ⩾ 45 years with asymptomatic, screen-detected, pure low-grade DCIS based on vacuum-assisted biopsies of microcalcifications only. Both study arms will be monitored with annual digital mammography for a period of 10 years. The primary end-point is 10-year ipsilateral invasive breast cancer free percentage. Secondary end-points include patient reported outcomes, diagnostic biopsy rate during follow-up, ipsilateral mastectomy rate and translational research.

FEASIBILITY

To explore interest in and feasibility of the LORD study we conducted a survey among EORTC and BOOG centres. A vast majority of EORTC and BOOG responding centres expressed interest in participation in the LORD study. The proposed study design is endorsed by nearly all centres.

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.

3.0 Tesla breast magnetic resonance imaging in patients with nipple discharge when mammography and ultrasound fail

OBJECTIVES

To compare 3.0 Tesla breast magnetic resonance imaging (MRI) with galactography for detection of benign and malignant causes of nipple discharge in patients with negative mammography and ultrasound.

METHODS

We prospectively evaluated 56 breasts of 50 consecutive patients with nipple discharge who had inconspicuous mammography and ultrasound, using 3.0 Tesla breast MRI with a dedicated 16-channel breast coil, and then compared the results with galactography. Histopathological diagnoses and follow-ups were used as reference standard. Lesion size estimated on MRI was compared with the size at histopathology.

RESULTS

Sensitivity and specificity of MRI vs. galactography for detecting pathologic findings were 95.7 % vs. 85.7 % and 69.7 % vs. 33.3 %, respectively. For the supposed concrete pathology based on MRI findings, the specificity was 67.6 % and the sensitivity 77.3 % (PPV 60.7 %, NPV 82.1 %). Eight malignant lesions were detected (14.8 %). The estimated size at breast MRI showed excellent correlation with the size at histopathology (Pearson's correlation coefficient 0.95, p < 0.0001).

CONCLUSIONS

MRI of the breast at 3.0 Tesla is an accurate imaging test and can replace galactography in the workup of nipple discharge in patients with inconspicuous mammography and ultrasound.

KEY POINTS

• Breast MRI is an excellent diagnostic tool for patients with nipple discharge. • MRI of the breast reveals malignant lesions despite inconspicuous mammography and ultrasound. • MRI of the breast has greater sensitivity and specificity than galactography. • Excellent correlation of lesion size measured at MRI and histopathology was found.

Endoscopy-assisted breast-conserving surgery for breast cancer patients

Breast-conserving surgery (BCS) combined with postoperative radiotherapy is a standard therapy for early-stage breast cancer patients. In addition, recent developments in oncoplastic surgery have improved cosmetic outcomes and patient satisfaction. Therefore, a breast surgeon's current role in BCS is not only to perform a curative resection of cancerous lesions with adequate surgical margins, but also to preserve the shape and appearance of the treated breast. Endoscopy-assisted breast-conserving surgery (EBCS), which has the advantage of a less noticeable scar, was developed more than ten years ago. Recently, some clinical studies have reported the feasibility, oncological outcomes, aesthetic outcomes, and patient satisfaction of EBCS. Herein, we will review the EBCS clinical studies that have been conducted so far and discuss current issues regarding this operative method.

Impact of preoperative breast MRI on surgical decision making and clinical outcomes: a systematic review

BACKGROUND

Preoperative magnetic resonance imaging (MRI) is increasingly used in the workup of breast cancer patients and could lead to changes in surgical management. It is unclear how the information gained from MRI studies affects surgical decision making and influences clinical outcomes. These issues are addressed in this review.

METHODS

PubMed database searches were performed to retrieve and analyze respective original research and review articles on preoperative MRI in the evaluation of breast cancer patients.

RESULTS

Preoperative MRI is a highly sensitive but nonspecific method that leads to changes in surgical management with increased numbers of more extended surgical interventions. It appears that a relatively large proportion of MRI-driven changes in surgical management result in overtreatment without conclusively proven beneficial effects on such clinical outcomes as decrease in reoperation rates or improved patient survival.

CONCLUSIONS

Thus, routine use of supplementary preoperative breast MRI should be discouraged until compelling evidence of its effectiveness is available.

Detecting breast microcalcifications with high-field MRI

The aim of this study was to detect microcalcifications in human whole breast specimens using high-field MRI. Four mastectomy specimens, obtained with approval of the institutional review board, were subjected to gradient-echo MRI acquisitions on a high-field MR scanner. The phase derivative was used to detect microcalcifications. The echo time and imaging resolution were varied to study the sensitivity of the proposed method. Computed tomography images of the mastectomy specimens and prior acquired mammography images were used to validate the results. A template matching algorithm was designed to detect microcalcifications automatically. The three spatial derivatives of the signal phase surrounding a field-perturbing object allowed three-dimensional localization, as well as the discrimination of diamagnetic field-perturbing objects, such as calcifications, and paramagnetic field-perturbing structures, e.g. blood. A longer echo time enabled smaller disturbances to be detected, but also resulted in shading as a result of other field-disturbing materials. A higher imaging resolution increased the detection sensitivity. Microcalcifications in a linear branching configuration that spanned over 8 mm in length were detected. After manual correction, the automatic detection tool identified up to 18 microcalcifications within the samples, which was in close agreement with the number of microcalcifications found on previously acquired in vivo mammography images. Microcalcifications can be detected by MRI in human whole breast specimens by the application of phase derivative imaging.

Ductal carcinoma in situ: an overview

Advances in methods used to diagnose breast cancer have resulted in the increased detection of ductal carcinoma in situ; most of these are detected by screening mammograms and are confirmed by core needle biopsy. Currently, classification schemas are moving toward a molecular approach. Treatment options for patients with ductal carcinoma in situ are multiple and take into consideration end points such as local, regional or distant recurrence, overall survival and quality of life. Treatment methods continue to be controversial and debated in the oncology community. The quality of local control is multifactorial and depends on adequate surgical clearance, biological characteristics of the tumor, clinical presentation and the possibility of radiation therapies.

Ductal Carcinoma In Situ of the Breast

Ductal carcinoma in situ (DCIS) of the breast is a potentially invasive neoplasm. Risk factors include high estrogen states such as use of oral contraceptive (OC) pills, nulliparity, advanced age at first birth, and also family history and genetic mutations. The incidence of this usually clinically silent condition has risen in the past few decades due to widespread screening and diagnostic mammography, with final diagnosis confirmed by biopsy. At present, treatment options include total or simple mastectomy or lumpectomy with radiation. Adjuvant therapy includes antiestrogens like tamoxifen and human epidermal growth factor receptor 2 (HER2) suppression therapy. With the latest advances in chemotherapy and better understanding on the pathogenesis of the lesion, it is anticipated that more effective modalities of treatment may soon be available.

Variability of preoperative breast MRI utilization among older women with newly diagnosed early-stage breast cancer

While magnetic resonance imaging (MRI) is frequently used following breast cancer diagnosis, routine use of breast MRI for preoperative evaluation remains contentious. We identified factors associated with preoperative breast MRI utilization and investigated the variation among physicians. We used the surveillance, epidemiology, and end Results (SEER)-Medicare linked database to analyze the preoperative breast MRI utilization among patients with stage 0, I, or II breast cancer diagnosed between 2002 and 2007. Multilevel logistic regression models were used to identify patient- and physician-level predictors of preoperative MRI utilization. Of 56,743 women with early-stage breast cancer who were treated with surgery and evaluated by a preoperative mammogram and/or ultrasound during the study period, 8.7% (n = 4,913) received preoperative breast MRI. While patient and tumor characteristics did predict preoperative breast MRI utilization, they explained only 15.4% of the variation in utilization rates. Differences in preoperative breast MRI utilization across physicians were large, after controlling patient-level factors and physicians' volumes. Accounting for clustering of patients within individual physicians (n = 3,144), the multilevel logistic regression models explained 36.4% of variation. The median odds ratio of 3.2, corresponding with the median value of the relative odds of receiving preoperative breast MRI between two randomly chosen physicians, indicated a large individual physician effect. Our study found that preoperative breast MRI has been adopted rapidly and variably. Although patient characteristics were associated with preoperative breast MRI utilization, physician practice was a major determinant of whether women received preoperative breast MRI. Future studies should evaluate whether routine use of preoperative breast MRI in newly diagnosed early-stage breast cancer improves clinical outcomes.

Is DCIS breast cancer, and how do I treat it?

Ductal carcinoma in situ (DCIS) is a pre-invasive stage of breast cancer with a heterogeneous clinical behaviour. Since the introduction of mammographic screening programmes, the incidence of DCIS has shown a dramatic increase. Treatment should focus on the prevention of progression to invasive disease. If progression occurs, poorly differentiated DCIS frequently gives rise to grade III invasive breast cancer, whereas well differentiated DCIS more often recurs as grade I invasive disease. However, at present, validated diagnostic test are lacking to predict progression accurately. The majority of women with DCIS are suitable for breast conserving therapy. Obtaining clear surgical margins is the most important goal of a local excision. Radiotherapy is effective in reducing the risk of local recurrence with about 50 % in all subgroups of patients with DCIS. (Breast cancer specific) survival of women with DCIS is excellent, and radiotherapy does not further improve this. Future research should be directed in enabling to select women who have a high risk of--invasive--recurrence, so in which radiotherapy should be standard part of the breast conserving approach, and those women with a more indolent lesion, in which after surgery a watchful waiting approach can be followed.

Accuracy of tumour size assessment in the preoperative staging of breast cancer: comparison of digital mammography, tomosynthesis, ultrasound and MRI

PURPOSE

Accurate measurement of breast tumour size is fundamental for treatment planning. We compared the accuracy of digital mammography (DM), digital breast tomosynthesis (DBT), ultrasound (US) and magnetic resonance imaging (MRI) for the preoperative evaluation of breast cancer size.

MATERIALS AND METHODS

We retrospectively reviewed 149 breast cancers in 110 patients who underwent DM, DBT, US and MRI between January 2010 and December 2011, before definitive surgery. The lesions were measured by two radiologists, without knowledge of the final histological examination, considered the gold standard. For each imaging modality, the maximum tumour size was measured to the nearest millimetre; the measurements were considered concordant if they were within ± 5 mm. Pearson's correlation coefficient was calculated for each imaging modality.

RESULTS

The median pathological tumour size was 22.3 mm. MRI and DBT had a level of concordance with pathology of 70% and 66%, respectively, which was higher than that of DM (54%). DBT and MRI measurements had a better correlation with pathological tumour size (R:0.89 and R:0.92, respectively) compared to DM (R:0.83) and US (R:0.77).

CONCLUSIONS

DBT and MRI are superior to DM and US in the preoperative assessment of breast tumour size. DBT seems to improve the accuracy of DM, although MRI remains the most accurate imaging modality for breast cancer extension.

Breast MRI of pure ductal carcinoma in situ: sensitivity of diagnosis and influence of lesion characteristics

OBJECTIVES

The purpose of the study was to evaluate the sensitivity of breast MRI in the detection of pure DCIS and to analyze the influence of lesion type and nuclear grade.

METHODS

58 consecutive patients with pathologically proven pure DCIS and preoperatively performed breast MRI were retrospectively reviewed and analyzed. Sensitivities in the detection of DCIS were calculated for MRI and mammography (Mx). Influence of MRI lesion type and nuclear grading on DCIS diagnosis was evaluated.

RESULTS

MRI detected pure DCIS with a sensitivity of 79.3%. The sensitivity of Mx was lower (69%), but the difference was not statistically significant (p=0.345). 46.2% of the DCIS presented as enhancing mass and 53.8% as non-mass-like enhancement (NMLE). None of the masses but 21.4% (n=6) of the NMLE were underestimated as probably benign (BI-RADS 3). MRI measured lesion sizes showed a moderate correlation (r=0.74) with histopathologically measured lesion sizes. MRI detection rate of DCIS decreased significantly (p=0.0458) with increasing nuclear grade. Calculated sensitivities were 100% for low-grade DCIS, 84.6% for intermediate-grade DCIS, and 66.7% for high-grade DCIS.

CONCLUSIONS

In this study MRI could detect pure DCIS more sensitively than Mx. Despite of missing statistically significance preoperative MRI seems to be helpful in patients with DCIS who are eligible for breast conservation. This applies in particular to patients with non-high-grade DCIS because those were significantly more often positive on MRI and significantly more often negative on Mx. Misinterpretation occurs especially in cases of NMLE and high-grade DCIS and therefore a correlation with Mx is also recommended.

Preoperative breast MRI can reduce the rate of tumor-positive resection margins and reoperations in patients undergoing breast-conserving surgery

OBJECTIVE

In breast cancer patients eligible for breast-conserving surgery, we evaluated whether the information provided by preoperative MRI of the breast would result in fewer tumor-positive resection margins and fewer reoperations.

SUBJECTS AND METHODS

The study group consisted of 123 consecutive patients diagnosed with either breast cancer or ductal carcinoma in situ eligible for breast-conserving surgery between April 2007 and July 2010. For these patients, a first plan for breast-conserving surgery was made on the basis of clinical examination and conventional imaging. The final surgical plan was made with knowledge of the preoperative breast MRI. The rates of tumor-positive resection margins and reoperations were compared with those of a historical control group consisting of 119 patients who underwent 123 breast-conserving procedures between January 2005 and December 2006. The percentage of change in the surgical plan was recorded.

RESULTS

Preoperative breast MRI changed the surgical plan to more extensive surgery in 42 patients (34.1%), mainly to mastectomy (29 patients, 23.6%). Ninety-four patients underwent 95 breast-conserving procedures. Significantly fewer patients had tumor-positive resection margins than in the control group (15.8%, 15/95 versus 29.3%, 36/123; p < 0.01). Patients in the study group underwent significantly fewer reoperations compared with the historical control group (18.9%, 18/95 vs 37.4%, 46/123; p < 0.01).

CONCLUSION

Preoperative breast MRI can substantially decrease the rate of tumor-positive resection margins and reoperations in breast cancer patients eligible for breast-conserving surgery.

[Does molecular biology play any role in ductal carcinoma in situ?]

The natural history of ductal carcinoma in situ (DCIS) is not fully elucidated, but it is recognized that DCIS is the true precursor of invasive carcinoma. Studies could show that DCIS is as heterogeneous as invasive ductal carcinoma, yet, they were unable to predict which DCIS will progress to invasion. Several biomarkers were also demonstrated to have a certain prognostic value. However, except for estrogen receptors and HER2, biomarkers are not yet widely used in clinical practice since their predictive value has not proven to be better than the grade and the classical classifying systems of DCIS. Identifying biomarkers for risk of invasiveness in DCIS could be of great value to help high risk patients through the management of their disease and to avoid overtreatment in low risk patients.

High-risk breast lesions at imaging-guided needle biopsy: usefulness of MRI for treatment decision

OBJECTIVE

The purpose of this study is to evaluate the role of MRI for characterization of high-risk breast lesions diagnosed at imaging-guided needle biopsy.

MATERIALS AND METHODS

In this retrospective analysis of 220 patients, 227 high-risk lesions (94 papillomas, 64 radial sclerosing lesions, 46 lobular neoplasias, and 23 atypical ductal hyperplasias) found at 11-gauge vacuum-assisted or 14-gauge needle biopsy were studied with dynamic MRI (time resolution, 84 or 88 seconds; gadopentetate dimeglumine or gadobenate dimeglumine, 0.1 mmol/kg). When lesions showed contrast enhancement on subtracted images, they were considered suspicious for malignancy. The reference standard was histopathologic examination after surgical excision in 190 of 227 (84%) lesions and negative follow-up (≥ 24 months) in 37 of 227 (16%) lesions. Predictive values and likelihood ratios were calculated.

RESULTS

Of 227 lesions, 155 (68%) were contrast enhancing and 72 (32%) were not. Of 155 contrast-enhancing lesions, 28 (18%) were upgraded to malignancy after surgical excision (nine papillomas, one radial sclerosing lesion, 11 lobular neoplasias, and seven atypical ductal hyperplasias); there were 11 invasive carcinomas and 17 ductal carcinomas in situ, four of the latter being G3. Of 72 non-contrast-enhancing lesions, two (3%) were upgraded to malignancy after surgical excision (one radial sclerosing lesion and one lobular neoplasia), both of which were G1 ductal carcinoma in situ. Cancer probability was significantly higher for contrast-enhancing (18%) than for non-contrast-enhancing (3%) lesions (p = 0.001) and for nonmasslike (43%) than for masslike (14%) lesions (p = 0.005). The positive predictive value was 18% (28/155; 95% CI, 13-24%), the negative predictive value was 97% (70/72; 95% CI, 94-99%), the positive likelihood ratio was 1.448 (95% CI, 1.172-1.788), and the negative likelihood ratio was 0.188 (95% CI, 0.152-0.232).

CONCLUSION

The absence of enhancement at dynamic MRI allowed reliable exclusion of invasive cancers among high-risk lesions diagnosed at needle biopsy.

Breast density as indicator for the use of mammography or MRI to screen women with familial risk for breast cancer (FaMRIsc): a multicentre randomized controlled trial

BACKGROUND

To reduce mortality, women with a family history of breast cancer often start mammography screening at a younger age than the general population. Breast density is high in over 50% of women younger than 50 years. With high breast density, breast cancer incidence increases, but sensitivity of mammography decreases. Therefore, mammography might not be the optimal method for breast cancer screening in young women. Adding MRI increases sensitivity, but also the risk of false-positive results. The limitation of all previous MRI screening studies is that they do not contain a comparison group; all participants received both MRI and mammography. Therefore, we cannot empirically assess in which stage tumours would have been detected by either test.The aim of the Familial MRI Screening Study (FaMRIsc) is to compare the efficacy of MRI screening to mammography for women with a familial risk. Furthermore, we will assess the influence of breast density.

METHODS/DESIGN

This Dutch multicentre, randomized controlled trial, with balanced randomisation (1:1) has a parallel grouped design. Women with a cumulative lifetime risk for breast cancer due to their family history of ≥20%, aged 30-55 years are eligible. Identified BRCA1/2 mutation carriers or women with 50% risk of carrying a mutation are excluded. Group 1 receives yearly mammography and clinical breast examination (n = 1000), and group 2 yearly MRI and clinical breast examination, and mammography biennially (n = 1000).Primary endpoints are the number and stage of the detected breast cancers in each arm. Secondary endpoints are the number of false-positive results in both screening arms. Furthermore, sensitivity and positive predictive value of both screening strategies will be assessed. Cost-effectiveness of both strategies will be assessed. Analyses will also be performed with mammographic density as stratification factor.

DISCUSSION

Personalized breast cancer screening might optimize mortality reduction with less over diagnosis. Breast density may be a key discriminator for selecting the optimal screening strategy for women < 55 years with familial breast cancer risk; mammography or MRI. These issues are addressed in the FaMRIsc study including high risk women due to a familial predisposition.

TRIAL REGISTRATION

Netherland Trial Register NTR2789.

Multicentric and contralateral invasive tumors identified with pre-op MRI in patients newly diagnosed with ductal carcinoma in situ of the breast

Preoperative breast MRI in newly diagnosed cancer patients has several potential benefits. Improved survival for patients with invasive disease as the index lesion is unlikely to be one of these benefits, given what is known from variations in locoregional management in the historic conservation trials. However, this may not be the case for patients with ductal carcinoma in situ (DCIS), as the discovery of unsuspected invasive cancer located elsewhere from the biopsy-proven DCIS could result in decreased survival if left undetected and untreated. In support of this hypothesis, a previous observational study of a large cohort of DCIS patients revealed the development of invasive cancer to be the most common event after unilateral DCIS treatment, occurring in 3.9%, mostly in the opposite breast. These cancers appeared on mammography or clinical exam within a short time frame (median 2.9 years) and were associated with a diminution in survival. Given these second events occurring so soon after DCIS treatment, it must be considered that invasive cancers were present elsewhere, but mammographically occult, at the time of DCIS diagnosis. To examine this possibility, 288 consecutive patients with newly diagnosed DCIS underwent preoperative MRI, with the discovery of separate foci of invasive cancer, either multicentric or contralateral, occurring in 3.5% of patients, a similar incidence to the short-term observational study. These "elsewhere" invasive cancers are presented here with details of pathology such that both Stage I and Stage II disease can be seen as clinically significant, with the usual stage-based survival implications.

Ductal carcinoma in situ: recent advances and future prospects

Introduction. This article reviews current management strategies for DCIS in the context of recent randomised trials, including the role of sentinel lymph node biopsy (SLNB), adjuvant radiotherapy (RT) and endocrine treatment. Methods. Literature review facilitated by Medline, PubMed, Embase and Cochrane databases. Results. DCIS should be managed in the context of a multidisciplinary team. Local control depends upon clear surgical margins (at least 2 mm is generally acceptable). SLNB is not routine, but can be considered in patients undergoing mastectomy (Mx) with risk factors for occult invasion. RT following BCS significantly reduces local recurrence (LR), particularly in those at high-risk. There remains a lack of level-1 evidence supporting omission of adjuvant RT in selected low-risk cases. Large, multi-centric or recurrent lesions should be treated by Mx and immediate reconstruction should be discussed. Adjuvant hormonal treatment may reduce the risk of LR in selected cases with hormone sensitive disease. Conclusion. Further research is required to determine the role of new RT regimes and endocrine therapies. Biological profiling and molecular analysis represent an opportunity to improve our understanding of tumour biology in DCIS to rationalise treatment. Reliable identification of low-risk lesions could allow treatment to be less radical.

The role of breast MR imaging in pre-operative determination of invasive disease for ductal carcinoma in situ diagnosed by needle biopsy

OBJECTIVES

To evaluate whether magnetic resonance (MR) imaging features can predict the presence of occult invasion in cases of biopsy-proven pure ductal carcinoma in situ (DCIS).

METHODS

We retrospectively reviewed 92 biopsy-proven pure DCIS in 92 women who underwent MR imaging. The following MR imaging findings were compared between confirmed DCIS and invasive breast cancer (IBC): lesion size, type, morphological and kinetic assessments by ACR BI-RADS MRI, and findings of fat-suppressed T2-weighted (FS-T2W) imaging.

RESULTS

Sixty-eight of 92 (74%) were non-mass-like enhancements (NMLE) and 24 were mass lesions on MR imaging. Twenty-one of 68 (31%) NMLE and 13 of 24 (54%) mass lesions were confirmed as IBC. In NMLE lesions, large lesions (P = 0.007) and higher signal intensities (SI) on FS-T2W images (P = 0.032) were significantly associated with IBC. Lesion size remained a significant independent predictor of invasion in multivariate analysis (P = 0.032), and combined with FS-T2W SIs showed slightly higher observer performances (area under the curve, AUC, 0.71) than lesion size alone (AUC 0.68). There were no useful findings that enabled the differentiation of mass-type lesions.

CONCLUSIONS

Breast MR imaging is potentially useful to predict the presence of occult invasion in biopsy-proven DCIS with NMLE.

KEY POINTS

MR mammography permits more precise lesion assessment including ductal carcinoma in situ A correct diagnosis of occult invasion before treatment is important for clinicians This study showed the potential of MR mammography to diagnose occult invasion Treatment and/or aggressive biopsy can be given with greater confidence MR mammography can lead to more appropriate management of patients.

Preoperative breast MRI in the surgical treatment of ductal carcinoma in situ

Accurate determination of the size or extent of ductal carcinoma in situ (DCIS) by imaging is uncertain, and incomplete resection of tumor results in involved margins in up to 81% of cases. This study examined the accuracy of magnetic resonance imaging (MRI) for assessment of DCIS size, and evaluated the effect of preoperative breast MRI on achievement of tumor-free surgical margins after breast-conserving surgery (BCS). One-hundred and fifty-eight female patients with DCIS were identified from a prospective database: 60 patients (62 cases) had preoperative breast MRI, and 98 patients did not have MRI. The accuracy of tumor size assessed by MRI was determined by comparison with histopathologic size. All patients underwent BCS initially. The rate of involved margins after resection was compared in MRI and no-MRI groups. The overall correlation between MRI size and histopathologic size was high (p < 0.0001). MRI assessment of size was significantly more accurate when DCIS was high grade (p < 0.0001) or intermediate grade (p = 0.005) versus low grade (p = 0.187). The rate of tumor-involved margins was not significantly different in MRI and no-MRI groups (30.7% and 24.7%, respectively; p = 0.414). The rate of mastectomy was significantly higher in the MRI group than the no-MRI group (17.7% versus 4.1%; p = 0.004). These findings indicate that MRI can detect DCIS, especially when lesions are high or intermediate grade, but that MRI does not accurately predict the size of DCIS. In this study, MRI did not improve the surgeon's ability to achieve clear margins following BCS.

Preoperative breast magnetic resonance imaging: applications in clinical practice

Results of large randomized trials have shown that survival rates after breast conserving surgery are equivalent to those obtained by radical mastectomy. Breast conserving surgery with wide local excision in women with early stage breast cancer who are thought to have a single and resectable tumour as determined by clinical examination and conventional imaging followed by postoperative irradiation is the standard of care in early breast cancer. Mapping of local disease is the key element to guide optimal surgery to obtain tumour-free margins, thereby decreasing risk of local recurrence. The usual preoperative workup of breast malignancy consists of clinical breast examination and mammography with or without ultrasound. However, mammography and ultrasound fail to accurately assess tumour extent in as many as a third of patients eligible for breast conserving therapy. It is well established that magnetic resonance imaging is far superior to mammography (with and without ultrasound) for mapping the local extent of breast cancer. Experts advocate its use despite its high costs, high number of false positive findings, and lack of evidence from randomized prospective trials and, notably, fear of "overtreatment." This article discusses the current role of breast magnetic resonance imaging with its clinical advantages and applications.

MRI findings of cancers preoperatively diagnosed as pure DCIS at core needle biopsy

BACKGROUND

Under-estimation of invasion components occur occasionally at core needle diagnosed ductal carcinoma in situ (DCIS) that may change the prognosis or treatment planning.

PURPOSE

To determine whether enhanced magnetic resonance imaging (MRI) features of biopsy-proven ductal cancers in situ help predict the under-estimation of invasive breast cancers.

MATERIAL AND METHODS

After a retrospective review of the enhanced MRI features on preoperative proven breast ductal cancers in situ by biopsy, tumor morphology (mass and non-mass), enhancing curve patterns, and non-mass enhanced appearances were compared between pure ductal cancers in situ and invasive ductal cancers (IDCs) after surgery. A statistical analysis was performed, and P values <0.05 were deemed significant.

RESULTS

Twenty-five breast cancers from 24 women were analyzed. Eleven DCIS remained as DCISs, and 14 were upgraded to IDC after surgery. Eight of 14 IDCs (57%) and one of 11 DCISs (9%) presented as mass lesions; otherwise six (43%) IDCs and 10 (91%) DCISs were non-mass lesions (P = 0.013). Among the non-mass cancers, six of 10 DCISs (60%) were focally enhanced and six of 6 IDCs (100%) were segmentally enhanced. The overall cancer sizes measured on enhanced MRI were moderately correlated with histopathology, with a Spearman's rank correlation coefficient of 0.656 (P = 0.001). The mean diameter of the IDCs was larger than that of the pure DCISs on enhanced MRI (2.69 ± 1.42 cm for IDC and 1.62 ± 1.03 cm for DCIS; P = 0.048). The cut-off size was optimally selected at 1.95 cm with a 64% sensitivity and a 77% specificity, using a receiver-operating characteristic curve. The enhancement curves, with washout or persistent rising, were statistically insignificant (P = 0.085 and 0.93, respectively).

CONCLUSION

Enhanced MRI provided informative morphology and size features that might help to predict the underestimation of invasiveness in preoperative biopsy-proven DCIS.

Ductal carcinoma in-situ: an update for clinical practice

INTRODUCTION

Ductal carcinoma in-situ (DCIS) is a heterogeneous entity with an elusive natural history. The objective of radiological, histological and molecular characterisation remains to reliably predict the biological behaviour and optimise clinical management strategies. Increases in diagnostic frequency have followed the introduction of mammographic screening and increased utility of magnetic resonance imaging. However, progress remains limited in distinguishing non-progressive incidental lesions from their progressive and clinically relevant counterparts. This article reviews current management strategies for DCIS in the context of recent randomized trials, including the role of sentinel lymph node biopsy (SLNB), adjuvant radiotherapy (RT) and endocrine treatment.

METHODS

Literature review facilitated by Medline, PubMed, Embase and Cochrane databases.

RESULTS

DCIS should be managed in the context of a multidisciplinary team. Local control depends upon adequate surgical clearance with margins of at least 2 mm. SLNB is not routinely indicated and should be reserved for those with concurrent or recurrent invasive disease. SLNB can be considered in patients undergoing mastectomy (MX) and those with risk factors for invasion such as palpability, comedo morphology, necrosis or recurrent disease. RT following BCS significantly reduces local recurrence (LR), particularly in those at high-risk. There remains a lack of level-1 evidence supporting the omission of adjuvant RT in selected low-risk cases. Large, multi-centric or recurrent lesions (particularly in cases of prior RT) should be treated by MX with the opportunity for immediate reconstruction. Adjuvant Tamoxifen may reduce the risk of LR in selected cases with hormone sensitive disease.

CONCLUSION

Further research is required to determine the role of contemporary RT regimes and endocrine therapies. Biological profiling and molecular analysis represent an opportunity to improve our understanding of the tumour biology of this condition and rationalise its treatment. Reliable identification of low-risk lesions could allow treatment to be less radical or safely omitted.