Pre-operative breast MRI in women with recently diagnosed breast cancer – Where to next?

Preoperative magnetic resonance imaging use and oncologic outcomes in premenopausal breast cancer patients

Breast magnetic resonance imaging (MRI) delineates disease extent sensitively in newly diagnosed breast cancer patients, but improved cancer outcomes are uncertain. Young women, for whom mammography is less sensitive, are expected to benefit from MRI-based resection. We identified 512 women aged ≤50 years, undergoing breast-conserving treatment (BCT: tumor-free resection margins and radiotherapy) during 2006–2013 through Northwestern Medicine database queries; 64.5% received preoperative MRI and 35.5% did not. Tumor and treatment parameters were similar between groups. We estimated the adjusted hazard ratios (aHR) for local and distant recurrences (LR and DR), using multivariable regression models, accounting for important therapeutic and prognostic parameters. LR rate with MRI use was 7.9 vs. 8.2% without MRI, aHR = 1.03 (95% CI 0.53–1.99). DR rate was 6.4 vs. 6.6%, aHR = 0.89 (95% CI 0.43–1.84). In 119 women aged ≤40, results were similar to LR aHR = 1.82 (95% CI 0.43–7.76) and DR aHR = 0.93 (95% CI 0.26–3.34). Sensitivity analyses showed similar results. The use of preoperative MRI in women aged ≤50 years should be reconsidered until there is proof of benefit.

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 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.

Controversies in breast MRI

When used for appropriate indications, breast magnetic resonance imaging (MRI) is a powerful diagnostic tool. However, breast MRI has its share of controversies. These controversies can be a source of confusion for the radiologist or referring physician. This paper addresses 4 breast MRI controversies that we frequently encounter at our university hospital practice: (1) what are the appropriate indications for screening breast MRI? (2) what are the appropriate indications for the use of breast MRI as a problems-solving modality? (3) how does one interpret MRI imaging features that have substantial overlap between benign and malignant conditions? and (4) what are the appropriate indications for preoperative breast MRI? Illustrative case examples are provided.

EUSOMA criteria for performing pre-operative MRI staging in candidates for breast conserving surgery: hype or helpful?

Ongoing debate regarding the value of pre-operative MRI in staging patients with newly diagnosed breast cancer has resulted from the lack of evidence on its clinical efficacy, which contrasts MRIs capability for detecting additional disease (occult on conventional imaging) in the cancerous breast. We undertook a validation study of EUSOMA criteria that recommend selection of breast conserving surgery (BCS) candidates to pre-operative MRI. We examined whether these criteria were associated with a differential likelihood of a recommendation for mastectomy. In a cohort of 200 subjects, recommended for BCS following mammography (M) and ultrasound (US), and who also subsequently had pre-operative MRI, the proportions recommended for mastectomy based on MRI, where the criterion was present versus absent were: invasive lobular cancer (17.9% versus 17.4%; p=0.87); high familial risk (14.7% versus 18.1%; p=0.82); M/US tumour size discrepancy >1cm (32.1% versus 15.1%; p=0.05); and for any of these criteria versus none (21.6% versus 14.3%; p=0.24). These findings suggest that EUSOMA criteria for selection to pre-operative MRI may be inefficient as they do not appear to differentiate those at risk of having more extensive disease and likely to receive a mastectomy recommendation, with the exception of M/US tumour size discrepancy.

The role of magnetic resonance imaging in early breast cancer

Despite recent evidence that fails to detect a benefit in surgical and local recurrence outcomes in those who receive optimal surgery and adjuvant systemic and radiotherapy, magnetic resonance imaging (MRI) is still being employed. We review the recent literature to clarify the role in the use of MRI in early breast cancer. A literature search using the Medline and Ovid databases was conducted between 2004 and 2011 using the terms "magnetic resonance imaging' and 'early breast cancer'. Only articles with clinical trials published in English in adult humans with available abstracts were included. Articles on high-risk women, response to neoadjuvant therapy, advanced breast cancer, the occult primary, the contralateral breast and technical articles were excluded. Articles examining the role of MRI in the staging of early breast cancer were retained. Over 260 articles regarding breast MRI have been published in the last 5 years. Additional foci may be found in 16% of patients but the impact on the extent of surgery and local recurrence rate is yet to be defined. Certain sub-groups who may benefit include those with invasive lobular carcinoma and mammographically dense breasts and those for consideration of partial breast irradiation. With standard adjuvant radiotherapy, there is no benefit in routine MRI with respect surgical extent and local recurrence. Should MRI be used, pre-operative biopsy to confirm additional disease must be undertaken prior to a change in surgical extent of resection. However, MRI may be useful in the evaluation of those who can be considered for partial breast irradiation. Centres undertaking breast MRI must have MRI-biopsy capabilities and constantly audit the reporting of MRI with correlation to the final pathology.

Contemporary breast imaging and concordance assessment: a surgical perspective

Disease conditions of the breast are very common. Patients with such conditions often present to surgeons for both diagnostic evaluation and treatment. Nearly all of them will require breast imaging. This article summarizes the use, applicability, and concordance assessment of mammography, ultrasonography, and magnetic resonance imaging in patients who have breast complaints or abnormalities on clinical examination or imaging.