Role of Preoperative MRI in the Management of Newly Diagnosed Breast Cancer Patients

A Systematic Review and Meta-analysis of the Role of Preoperative MRI in In-breast Tumor Recurrence After Breast-Conserving Surgery

BACKGROUND

It is unknown whether the identification of additional tumors in the breast using preoperative magnetic resonance imaging (pMRI) results in a lower risk of in-breast tumor recurrence (IBTR) after breast-conserving surgery (BCS).

METHODS

A systematic review and meta-analysis of relevant studies were performed. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

From 768 citations, 20 studies met the inclusion criteria for the systematic review. The 20 studies consisted of 14 retrospective reviews, 3 matched cohorts, and 3 randomized controlled trials. Whereas 2 studies reported a statistically significant lower rate of IBTR with pMRI, 18 studies showed no difference, and no studies reported a higher rate. Of the 18 studies showing no significant difference, 12 demonstrated a trend toward a lower IBTR rate in the pMRI group. The criteria for meta-analysis were met by 16 studies. A meta-analysis of 11 studies that reported hazard ratios (HR) for IBTR showed a trend toward a lower rate of IBTR for patients who received preoperative MRI (hazard ratio (HR), 0.89; 95% confidence interval (CI), 0.74-1.05). A meta-analysis of five studies that reported event rates and had similar follow-up duration for both groups demonstrated a lower relative risk (RR) of IBTR (RR, 0.45; 95% CI 0.25-0.81).

CONCLUSIONS

Although some evidence supports the hypothesis that identification of additional tumors in the breast using pMRI results in lower rates of IBTR after BCS, the main meta-analysis in this study did not confirm this hypothesis.

Diffusion tensor imaging: survival analysis prediction in breast cancer patients

PURPOSE

We aimed to explore the performance of diffusion-tensor imaging (DTI) and apparent diffusion coefficient (ADC) parameters in evaluating disease-free survival (DFS) and overall survival (OS) in patients with invasive breast cancer.

MATERIAL AND METHODS

A total of 49 women with invasive breast cancer who were diagnosed between 2017 and 2022 were included. All patients underwent breast magnetic resonance imaging (MRI) with DTI and diffusion-weighted imaging (DWI) features, with examiners blinded to the clinical data. Volume anisotropy (VA), fractional anisotropy (FA), and ADC values were measured to assess intratumoral measured heterogeneity. Correlations and differences in diffusion metrics according to OS and DFS status of the cases were analyzed. The discriminative ability of the quantitative findings was assessed by receiver operating characteristic (ROC) curve analyses and validated in the independent cohort.

RESULTS

We evaluated patients with metastases (n = 13, 36.5%) and those without metastases (n = 36, 73.5%). Differences in the ADC, FA, and VA values were observed. The results of Cox regression survival analysis for all the patients included in the survival analysis revealed that DTI metrics contributed to the prediction of overall survival (OS) in the emerging models (p < 0.05). Both FA and VA were associated with OS (p = 0.037 and p = 0.038, respectively). However, ADC was not associated with OS (p = 0.177) or DFS (p = 0.252).

CONCLUSION

To the best of our knowledge, this is the first study to assess the prognostic value of DTI-MRI in breast cancer with statistical survival analysis techniques. We believe that DTI measurements can be used as a biomarker for OS analysis in breast cancer given the available data.

Screening and diagnostic breast MRI: how do they impact surgical treatment? Insights from the MIPA study

OBJECTIVES

To report mastectomy and reoperation rates in women who had breast MRI for screening (S-MRI subgroup) or diagnostic (D-MRI subgroup) purposes, using multivariable analysis for investigating the role of MRI referral/nonreferral and other covariates in driving surgical outcomes.

METHODS

The MIPA observational study enrolled women aged 18-80 years with newly diagnosed breast cancer destined to have surgery as the primary treatment, in 27 centres worldwide. Mastectomy and reoperation rates were compared using non-parametric tests and multivariable analysis.

RESULTS

A total of 5828 patients entered analysis, 2763 (47.4%) did not undergo MRI (noMRI subgroup) and 3065 underwent MRI (52.6%); of the latter, 2441/3065 (79.7%) underwent MRI with preoperative intent (P-MRI subgroup), 510/3065 (16.6%) D-MRI, and 114/3065 S-MRI (3.7%). The reoperation rate was 10.5% for S-MRI, 8.2% for D-MRI, and 8.5% for P-MRI, while it was 11.7% for noMRI (p ≤ 0.023 for comparisons with D-MRI and P-MRI). The overall mastectomy rate (first-line mastectomy plus conversions from conserving surgery to mastectomy) was 39.5% for S-MRI, 36.2% for P-MRI, 24.1% for D-MRI, and 18.0% for noMRI. At multivariable analysis, using noMRI as reference, the odds ratios for overall mastectomy were 2.4 (p < 0.001) for S-MRI, 1.0 (p = 0.957) for D-MRI, and 1.9 (p < 0.001) for P-MRI.

CONCLUSIONS

Patients from the D-MRI subgroup had the lowest overall mastectomy rate (24.1%) among MRI subgroups and the lowest reoperation rate (8.2%) together with P-MRI (8.5%). This analysis offers an insight into how the initial indication for MRI affects the subsequent surgical treatment of breast cancer.

KEY POINTS

• Of 3065 breast MRI examinations, 79.7% were performed with preoperative intent (P-MRI), 16.6% were diagnostic (D-MRI), and 3.7% were screening (S-MRI) examinations. • The D-MRI subgroup had the lowest mastectomy rate (24.1%) among MRI subgroups and the lowest reoperation rate (8.2%) together with P-MRI (8.5%). • The S-MRI subgroup had the highest mastectomy rate (39.5%) which aligns with higher-than-average risk in this subgroup, with a reoperation rate (10.5%) not significantly different to that of all other subgroups.

Current Trends in the Utilization of Preoperative Breast Magnetic Resonance Imaging Among Women With Newly Diagnosed Breast Cancer

PURPOSE

The clinical benefit of preoperative breast magnetic resonance imaging (MRI) for early-stage breast cancer (BC) remains controversial. We examined trends and the associated factors of preoperative breast MRI use.

METHODS

This study cohort, constructed from Optum Clinformatics database, included women with early-stage BC who had a cancer surgery between March 1, 2008, and December 31, 2020. Preoperative breast MRI was performed between the date of BC diagnosis and index surgery. Multivariable logistic regressions, one for elderly (65 years and older) and the other for non-elderly patients (younger than 65 years), were performed to examine factors associated with the use of preoperative MRI.

RESULTS

Among 92,077 women with early-stage BC, the crude rate of preoperative breast MRI increased from 48% in 2008 to 60% in 2020 for nonelderly and from 27% to 34% for elderly women. For both age groups, non-Hispanic Blacks were less likely (odds ratio [OR]; 95% CI, younger than 65 years: 0.75, 0.70 to 0.81; 65 years and older: 0.77, 0.72 to 0.83) to receive preoperative MRI than non-Hispanic White patients. Across Census divisions, the highest adjusted rate was observed in Mountain division (OR compared with New England; 95% CI, younger than 65 years: 1.45, 1.27 to 1.65; 65 years and older: 2.42, 2.16 to 2.72). Other factors included younger age, fewer comorbidities, family history of BC, axillary node involvement, and neoadjuvant chemotherapy for both age groups.

CONCLUSION

The use of preoperative breast MRI has steadily increased. Aside from clinical factors, age, race/ethnicity, and geographic location were associated with preoperative MRI use. This information is important for future implementation or deimplementation strategies of preoperative MRI.

Breast Cancer Statistics, 2022

This article is the American Cancer Society's update on female breast cancer statistics in the United States, including population-based data on incidence, mortality, survival, and mammography screening. Breast cancer incidence rates have risen in most of the past four decades; during the most recent data years (2010-2019), the rate increased by 0.5% annually, largely driven by localized-stage and hormone receptor-positive disease. In contrast, breast cancer mortality rates have declined steadily since their peak in 1989, albeit at a slower pace in recent years (1.3% annually from 2011 to 2020) than in the previous decade (1.9% annually from 2002 to 2011). In total, the death rate dropped by 43% during 1989-2020, translating to 460,000 fewer breast cancer deaths during that time. The death rate declined similarly for women of all racial/ethnic groups except American Indians/Alaska Natives, among whom the rates were stable. However, despite a lower incidence rate in Black versus White women (127.8 vs. 133.7 per 100,000), the racial disparity in breast cancer mortality remained unwavering, with the death rate 40% higher in Black women overall (27.6 vs. 19.7 deaths per 100,000 in 2016-2020) and two-fold higher among adult women younger than 50 years (12.1 vs. 6.5 deaths per 100,000). Black women have the lowest 5-year relative survival of any racial/ethnic group for every molecular subtype and stage of disease (except stage I), with the largest Black-White gaps in absolute terms for hormone receptor-positive/human epidermal growth factor receptor 2-negative disease (88% vs. 96%), hormone receptor-negative/human epidermal growth factor receptor 2-positive disease (78% vs. 86%), and stage III disease (64% vs. 77%). Progress against breast cancer mortality could be accelerated by mitigating racial disparities through increased access to high-quality screening and treatment via nationwide Medicaid expansion and partnerships between community stakeholders, advocacy organizations, and health systems.

Breast Magnetic Resonance Imaging for Patients With Newly Diagnosed Breast Cancer: A Review

Despite the high sensitivity and widespread use of preoperative magnetic resonance imaging (MRI), the American Cancer Society and the National Comprehensive Cancer Network guidelines do not recommend the routine use of preoperative MRI owing to the conflicting results and lack of clear benefit to the surgical outcome (reoperation and mastectomy) and long-term clinical outcomes (local recurrence and metachronous contralateral breast cancer). Preoperative MRI detects additional cancers that are occult at mammography and ultrasound but increases the rate of mastectomy. Concerns about overdiagnosis and overtreatment of preoperative MRI might be mitigated by adjusting the confounding factors when conducting studies, using the state-of-the-art image-guided biopsy technique, applying the radiologists’ cumulative experiences in interpreting MRI findings, and performing multiple lumpectomies in patients with multicentric cancer. Among the various imaging methods, dynamic contrast-enhanced MRI has the highest accuracy in predicting pathologic complete response after neoadjuvant chemotherapy. Prospective trials aimed at applying the MRI information to the de-escalation of surgical or radiation treatments are underway. In this review, current studies on the clinical outcomes of preoperative breast MRI are updated, and circumstances in which MRI may be useful for surgical planning are discussed.

Breast Cancer Epidemiology and Contemporary Breast Cancer Care: A Review of the Literature and Clinical Applications

Substantial progress has been made in contemporary breast cancer care, resulting in a consistently declining breast cancer mortality rate and an improvement in quality of life. Advancements include deescalation of therapy in low-risk populations and refining systemic therapy options. Research into molecular biomarkers continues to evolve and holds the promise of achieving the goal of precision medicine, while guidelines for supportive care and survivorship have been created to address the needs of an ever-increasing number of breast cancer survivors. A collaborative, multidisciplinary team approach is essential for patients and survivors to achieve optimal outcomes and enjoy productive high-quality lives. Gynecologists, in particular, play a key role in screening and survivorship care.

Additional Workups Recommended During Preoperative Breast MRI: Methods to Gain Efficiency and Limit Confusion

BACKGROUND

Preoperative breast MRI is indicated for staging but can lead to complex imaging workups. This study reviewed imaging recommendations made on preoperative MRI exams, to simplify management approaches for patients with newly diagnosed breast cancer.

METHODS

This retrospective single-institution review was restricted to women with breast cancer who underwent staging MRI. Additional breast lesions, separate from index tumors, recommended for additional workup or surveillance were assessed to see which were detected and which characteristics predicted success in detection. Univariate mixed-effects logistic modeling predicted the likelihood of finding lesions using MRI-directed ultrasound (US), with odds ratios reported. Tests were two-sided, with a p value lower than 0.05 considered significant.

RESULTS

In this study, 534 (39.6%) patients had recommendations for additional workup after preoperative MRI. MRI detected additional malignancy in 178 patients (33.3%). Half of the 66 patients who refused an additional workup and opted for mastectomy had additional malignancies at mastectomy. MRI-directed US was 14 times more likely to detect masses than nonmass enhancement (NME) (p < 0.001). NME was detected on US in only 16% of cases, with one third of subsequent biopsy results considered discordant. Probably benign assessments were given to 35 patients, with 23% not returning for follow-up evaluation and 7% returning at least 6 months later than recommended.

CONCLUSION

Use of preoperative breast MRI has increased. Although it can add value, institutions should establish indications and expectations to prevent unnecessary workups. Limiting MRI-directed US to masses, avoiding probably benign assessments, and consulting with patients after MRI but prior to workups can prevent unnecessary exams and confusion.

Impact of Preoperative Magnetic Resonance Imaging on Surgical Outcomes in Women with Invasive Breast Cancer: A Systematic Review and Meta-Analysis

BACKGROUND

Currently, whether magnetic resonance imaging (MRI) should be routinely applied to patients with breast cancer before surgery remains controversial. A pooled analysis of the association between preoperative MRI and surgical outcomes in female patients with newly diagnosed invasive breast cancer was conducted to provide evidence-based medicine for clinical practice.

METHODS

Three independent researchers searched the following databases: PubMed, Medline, Embase, Ovid, Cochrane Library, and Web of Science from inception to April 2022. Literature was included and excluded according to Cochrane's principles. The basic information from eligible documents was extracted. Systematic evaluation and meta-analysis were performed, and the odds ratio (OR) was analyzed by the random-effect model. The quality of the literature was assessed using the modified Jadad scale and the Newcastle-Ottawa (NOS) mean scale.

RESULTS

A total of 19 studies were included, including 4 randomized controlled trials and 15 observational comparative studies. Among them, most studies were not limited to a specific pathological type, with the exception of 3 that were limited to invasive lobular carcinoma. The results showed that preoperative MRI examination would significantly reduce the reoperation rate (OR = 0.77, P=0.02) and increase the mastectomy rate (OR = 1.36, P=0.001). In comparison, preoperative MRI did not significantly affect the rate of secondary mastectomy (OR = 0.77, P=0.02), the rate of positive margin (OR = 1.08, P=0.66), the rate of mastectomy (OR = 1.00, P < 0.05), and reoperations (OR = 0.65, P=0.19) in the subgroup analysis of patients with invasive lobular carcinoma.

CONCLUSION

Available evidence suggests that preoperative MRI examination increases the rate of mastectomy and reduces the rate of reoperations. The results indicate that preoperative MRI examination has the potential to benefit patients with breast cancer, but more high-quality studies are needed for confirmation.

Development of intraoperative assessment of margins in breast conserving surgery: a narrative review

OBJECTIVE

We intend to provide an informative and up-to-date summary on the topic of intraoperative assessment of margins in breast conserving surgery (BCS). Conventional methods as well as cutting-edge technologies are analyzed for their advantages and limitations in the hope that clinicians can turn to this for reference. This review can also offer guidance for technicians in the future design of intraoperative margin assessment tools.

BACKGROUND

Achieving negative margins during BCS is one of the vital factors for preventing local recurrence. Conducting intraoperative margin assessment can ensure negative margins to a large extent and possibly relieve patients of the anguish of re-interventions. In recent years, innovative methods for margin assessment during BCS are advancing rapidly. And there is a lack of summary regarding the development of intraoperative margin assessment in BCS.

METHODS

A PubMed search with keywords "intraoperative margin assessment" and "breast conserving surgery" was conducted. Relevant publications were screened manually for its title, abstract and even full text to determine its true relevance. Publications on neo-adjuvant therapy and intraoperative radiotherapy were excluded. References from the searched articles and other supplementary articles were also looked into.

CONCLUSIONS

Conventional methods for margin assessment yields stable outcome but its use is limited because of the demand on pathology staff and the trade-off between time and precision. Conventional imaging techniques pass the workload to radiologists at the cost of a significantly low duration of time. Involving artificial intelligence for image-based assessment is a further improvement. However, conventional imaging is inherently flawed in that occult lesions can't show on the image and the showing ones are ambiguous and open to interpretation. Unconventional techniques which base their judgment on cellular composition are more reassuring. Nonetheless, unconventional techniques should be subjected to clinical trials before putting into practice. And studies regarding comparison between conventional methods and unconventional methods are also needed to evaluate their relative efficacy.

Diagnostic performance of dynamic contrast-enhanced magnetic resonance imaging for breast cancer detection: An update meta-analysis

Objective

To evaluate the diagnostic performance of dynamic contrast‐enhanced magnetic resonance imaging (DCE‐MRI) for breast cancer identification.

Methods

A comprehensive electronic systematic searching of Medline, Ovid, EMBASE, Web of Science, CNK, and Cochrane Library databases was performed up to 2 August 2021. Clinical studies associated with DCE‐MRI for breast cancer detection were screened and inlcuded in the meta‐analysis. The data of true positive(tp), false positive(fp), false negative(fn) and true negative(tn) was extracted from includded studies. The sensitivity, specificity, diagnostic odds ratio (DOR), and area under the summary receiver operating characteristic (SROC) were pooled under fixed or random effect models. Publication bias was evaluated by Deek's funnel plot.

Results

A final set of 15 studies with 1321 breast lesions were included in the present work. The pooled diagnostic sensitivity, specificity, and DOR were 0.87 (95% confidence interval [CI] 0.81–0.92), 0.74 (95% CI 0.68–0.80), and 18.83 (95% CI 9.07–36.54), respectively, and the area under the SROC was 0.86 (95% CI 0.82–0.88). Given a pretest probability of 50%, the positive post‐test probability was 77%, and the negative post‐test probability was 14%. Deek's funnel plot indicated low publication bias (p = 0.61).

Conclusion

DCE‐MRI is a noninvasive method of breast cancer diagnosis for suspected malignant breast lesions with relative high diagnostic sensitivity and specificity.

Which Patients With Newly Diagnosed Breast Cancer Benefit From Preoperative Magnetic Resonance Imaging?

Objective

The aim of this study was to identify the effectiveness and selective applications of preoperative magnetic resonance imaging (MRI) by investigating clinicopathologic factors of the index tumor with or without false lesions on MRI.

Summary of background data

Preoperative MRI is commonly performed in patients with newly diagnosed breast cancer, but its clinical significance is unclear.

Methods

A total of 103 breast cancer patients who had undergone MRI or ultrasound followed by mastectomy were included in this retrospective investigation of pathologic, clinical, and imaging findings.

Results

MRI showed 29 false-positive lesions in 57 patients, 5 false-negative lesions in 5 patients, and 69 true-positive lesions in 103 patients. More false lesions on MRI were found in patients with more lesions on ultrasound, small-sized index tumors on ultrasound, or early-stage cancer. The sensitivity of MRI and ultrasound were 96.5% and 92.3% (P = 0.119), respectively, and the positive predictive value of them were 71.5% and 72.5% (P = 0.828), respectively.

Conclusions

Preoperative MRI is more useful in patients with newly diagnosed breast cancer who have large-sized or more advanced cancers or fewer lesions on ultrasound.

Is radiomic MRI a feasible alternative to OncotypeDX® recurrence score testing? A systematic review and meta-analysis

BACKGROUND

OncotypeDX® recurrence score (RS) aids therapeutic decision-making in oestrogen-receptor-positive (ER+) breast cancer. Radiomics is an evolving field that aims to examine the relationship between radiological features and the underlying genomic landscape of disease processes. The aim of this study was to perform a systematic review of current evidence evaluating the comparability of radiomics and RS.

METHODS

A systematic review was performed as per PRISMA guidelines. Studies comparing radiomic MRI tumour analyses and RS were identified. Sensitivity, specificity and area under curve (AUC) delineating low risk (RS less than 18) versus intermediate-high risk (equal to or greater than 18) and low-intermediate risk (RS less than 30) and high risk (RS greater than 30) were recorded. Log rate ratios (lnRR) and standard error were determined from AUC and 95 per cent confidence intervals.

RESULTS

Nine studies including 1216 patients met inclusion criteria; the mean age at diagnosis was 52.9 years. Mean RS was 16 (range 0-75); 401 patients with RS less than 18, 287 patients with RS 18-30 and 100 patients with RS greater than 30. Radiomic analysis and RS were comparable for differentiating RS less than 18 versus RS 18 or greater (RR 0.93 (95 per cent c.i. 0.85 to 1.01); P = 0.010, heterogeneity (I2)=0%) as well as RS less than 30 versus RS 30 or greater (RR 0.76 (95 per cent c.i. 0.70 to 0.83); P < 0.001, I2=0%). MRI sensitivity and specificity for RS less than 18 versus 18 or greater was 0.89 (95 per cent c.i. 0.85 to 0.93) and 0.72 (95 per cent c.i. 0.66 to 0.78) respectively, and 0.79 (95 per cent c.i. 0.72 to 0.86) and 0.74 (95 per cent c.i. 0.68 to 0.80) for RS less than 30 versus 30 or greater.

CONCLUSION

Radiomic tumour analysis is comparable to RS in differentiating patients into clinically relevant subgroups. For patients requiring MRI, radiomics may complement and enhance RS for prognostication and therapeutic decision making in ER+ breast cancer.

Preoperative Breast MRI in Women 35 Years of Age and Younger with Breast Cancer: Benefits in Surgical Outcomes by Using Propensity Score Analysis

Background The role of preoperative MRI in women 35 years of age or younger with breast cancer remains controversial. Purpose To determine the association between preoperative MRI and surgical outcomes in women aged 35 years or younger with breast cancer by using propensity score (PS) analysis to investigate the impact of preoperative MRI. Materials and Methods Women 35 years of age or younger diagnosed with breast cancer between 2007 and 2017 who had or had not undergone preoperative breast MRI were retrospectively identified. The MRI detection rate of additional suspicious lesions was analyzed, and changes in surgical management were recorded. Inverse probability weighting (IPW) and PS matching were used to adjust 19 variables and to create a balance between the two groups. Surgical outcomes were compared by using univariable logistic regression. Results Among 964 women (mean age ± standard deviation, 32 years ± 3), 665 (69%) had undergone preoperative MRI (MRI group; mean age, 32 years ± 3) and 299 (31%) had not (no-MRI group; mean age, 32 years ± 3). In the MRI group, additional suspicious lesions were found in 178 of the 665 women (27%), with 88 of those 178 women (49%) having malignant lesions. The surgical management was changed in 99 of the 665 women (15%) due to MRI findings, which was appropriate for 62 of those 99 women (63%). In the IPW analysis, the MRI group showed lower odds of repeat surgery (odds ratio [OR], 0.13; 95% CI: 0.07, 0.21; P < .001) and higher odds of initial mastectomy (OR, 1.62; 95% CI: 1.17, 2.25; P = .004). However, there was no difference in the overall mastectomy rate (OR, 1.24; 95% CI: 0.91, 1.68; P = .17) compared with the no-MRI group. These results were consistent when using the PS matching method. Conclusion Preoperative MRI in young women with breast cancer is useful for detecting additional malignancy and improving surgical outcomes by reducing the repeat surgery rate, with a similar likelihood of overall mastectomy. © RSNA, 2021 Online supplemental material is available for this article.