Contralateral Breast Screening with Preoperative MRI: Long-Term Outcomes for Newly Diagnosed Breast Cancer

Preoperative breast MR imaging influences surgical management in patients with invasive lobular carcinoma

INTRODUCTION

The purpose of the study is to assess the role of preoperative magnetic resonance (MR) imaging on the surgical management of invasive lobular carcinoma (ILC) and to evaluate whether breast density and background parenchymal enhancement (BPE) influence surgical treatment.

METHODS

This retrospective study was conducted on 56 patients who were diagnosed with ILC between 2014 and 2020. All patients had mammogram and ultrasound. Preoperative MRI was available in 34 patients. Age, menopausal status, breast density, BPE, multifocality/multicentricity and surgical treatment were collected.

RESULTS

Mean pathological tumour size was 36.4 mm (range 5-140 mm). Dense breasts had larger tumours compared to non-dense breasts (P = 0.072). Of the 34 patients with MRI, 6 opted for mastectomy. Of the remaining 28 cases, MRI findings upgraded surgery to mastectomy in 54% (15/28) because mammogram/ultrasound underestimated tumour extent in 25% (7/28), or multifocal/multicentric disease was identified in 29% (8/28). Tumour size was underestimated by MRI in 7% (2/28). In the non-MRI subgroup, 64% (14/22) of patients underwent breast-conserving surgery, but 29% of them (4/14) required a second-stage mastectomy due to extensive margin involvement. There was no difference in mastectomy rate between patients with MRI (62%) and without MRI (55%) (P = 0.061). Tumour size correlation between MRI and histopathology demonstrated an excellent intraclass correlation coefficient (P < 0.001). Surgical treatment recommendation was not significantly impacted by breast density or BPE.

CONCLUSION

Breast MRI improves surgical management of patients with ILC in providing additional diagnostic information often missed with standard imaging modalities, and without increasing mastectomy rate. Surgical treatment is not impacted by breast density or BPE.

Detection of Contralateral Malignancies on Breast MRI

INTRODUCTION

Women with unilateral breast cancer are at increased risk for having simultaneous cancer of the contralateral breast. Overall, earlier detection of contralateral breast cancer prevents the burden of additional surgery or chemotherapy rounds and is associated with higher overall survival. However, MRI screening for the contralateral breast is seldom done following an initial unilateral breast cancer diagnosis. The purpose of this study is to retrospectively evaluate patients with known, biopsy-proven malignancy who went on to obtain a breast MRI and were later found to have cancer of the contralateral breast.  Methods: This was a retrospective study that reviewed the charts of women aged over 18 years who were determined to have synchronous bilateral breast cancer from January 2017 to January 2022 at the University of Florida, Gainesville, FL. The study extracted data from this institution's cancer registry database, which provided information on patients with breast cancer diagnoses. The study conducted a review of mammography (MAM) and MRI imaging reports to ascertain the presence or absence of contralateral breast cancer identified by each respective imaging modality. Surgical pathology reports from the biopsy of the contralateral breast were reviewed to obtain information on the histological type of cancer and TNM (tumor, node, metastasis) staging.

RESULTS

Of the 17 cases in which MAM missed contralateral cancer, follow-up MRI detected contralateral malignancy in 12 cases (70.59%) and subsequently changed management, resulting in additional imaging, biopsy, and eventual diagnosis and treatment of contralateral breast cancer. Examining the number of contralateral breast cancers detected by patients who had undergone MAM followed by MRI and those who had only undergone MAM, the study found that the detection rate of contralateral breast cancer from MAM was 45.45% (15/33). The tumor stages of the missed cancers were all T1 or Tis stage with one T1mi, and there was no nodal involvement.  Conclusion: In addition to its utility in staging breast cancers, MRI also has the superior ability to detect otherwise undetected contralateral breast malignancy. This retrospective study found that MRI imaging led to a considerable increase in the detection of contralateral cancer. The study found that these undetected contralateral breast cancers by MAM were often of lower staging with no nodal involvement, highlighting the opportunity for MRI to assist in early cancer detection while the patient's prognosis is still good. Its high cost should be balanced with staging and occult malignancy detection utility in future practice.

Could breast multiparametric MRI discriminate between pure ductal carcinoma in situ and microinvasive carcinoma?

BACKGROUND

Ductal carcinoma in situ (DCIS) is often reclassified as invasive cancer in the final pathology report of the surgical specimen. It is of significant clinical relevance to acknowledge the possibility of underestimating invasive disease when utilizing preoperative biopsies for a DCIS diagnosis. In cases where such histologic upgrades occur, it is imperative to consider them in the preoperative planning process, including the potential inclusion of sentinel lymph node biopsy due to the risk of axillary lymph node metastasis.

PURPOSE

To assess the capability of breast multiparametric magnetic resonance imaging (MP-MRI) in differentiating between pure DCIS and microinvasive carcinoma (MIC).

MATERIAL AND METHODS

Between January 2018 and November 2022, this retrospective study enrolled patients with biopsy-proven DCIS who had undergone preoperative breast MP-MRI. We assessed various MP-MRI features, including size, morphology, margins, internal enhancement pattern, extent of disease, presence of peritumoral edema, time-intensity curve value, diffusion restriction, and ADC value. Subsequently, a logistic regression analysis was conducted to explore the association of these features with the pathological outcome.

RESULTS

Of 129 patients with biopsy-proven DCIS, 36 had foci of micro-infiltration on surgical specimens and eight were diagnosed with invasive ductal carcinoma (IDC). The presence of micro-infiltration foci was significantly associated with several MP-MRI features, including tumor size (P <0.001), clustered ring enhancement (P <0.001), segmental distribution (P <0.001), diffusion restriction (P = 0.005), and ADC values <1.3 × 10-3 mm2/s (P = 0.004).

CONCLUSION

Breast MP-MRI has the potential to predict the presence of micro-infiltration foci in biopsy-proven DCIS and may serve as a valuable tool for guiding therapeutic planning.

ACR Appropriateness Criteria® Imaging of Invasive Breast Cancer

As the proportion of women diagnosed with invasive breast cancer increases, the role of imaging for staging and surveillance purposes should be determined based on evidence-based guidelines. It is important to understand the indications for extent of disease evaluation and staging, as unnecessary imaging can delay care and even result in adverse outcomes. In asymptomatic patients that received treatment for curative intent, there is no role for imaging to screen for distant recurrence. Routine surveillance with an annual 2-D mammogram and/or tomosynthesis is recommended to detect an in-breast recurrence or a new primary breast cancer in women with a history of breast cancer, and MRI is increasingly used as an additional screening tool in this population, especially in women with dense breasts. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Decoding the Prevalent High-Risk Breast Cancers: Demographics, Pathological, Imaging Insights, and Long-Term Outcome

Objective: To investigate the features and outcomes of breast cancer in high-risk subgroups. Materials and Methods: REB approved an observational study of women diagnosed with breast cancer from 2010 to 2019. Three radiologists, using the BI-RADS lexicon, blindly reviewed mammogram and MRI screenings without a washout period. Consensus was reached with 2 additional reviewers. Inter-rater agreement was measured by Fleiss Kappa. Statistical analysis included Mann-Whitney U, Chi-square tests for cohort analysis, and Kaplan-Meier for survival rates, with a Cox model for comparative analysis using gene mutation as a reference. Results: The study included 140 high-risk women, finding 155 malignant lesions. Significant age differences noted: chest radiation therapy (median age 44, IQR: 37.0-46.2), gene mutation (median age 49, IQR: 39.8-58.0), and familial risk (median age 51, IQR: 44.5-56.0) (P = .007). Gene mutation carriers had smaller (P = .01), higher-grade tumours (P = .002), and more triple-negative ER- (P = .02), PR- (P = .002), and HER2- (P = .02) cases. MRI outperformed mammography in all subgroups. Substantial to near-perfect inter-rater agreement observed. Over 10 years, no deaths occurred in chest radiation group, with no significant survival difference between gene mutation and familial risk groups, HR = 0.93 (95% CI: 0.27, 3.26), P = .92. Conclusion: The study highlights the importance of age and specific tumour characteristics in identifying high-risk breast cancer subgroups. MRI is confirmed as an effective screening tool. Despite the aggressive nature of cancers in gene mutation carriers, early detection is crucial for survival outcomes. These insights, while necessitating further validation with larger studies, advocate for a move toward personalized medical care, strengthening the existing healthcare guidelines.

The features associated with mammography-occult MRI-detected newly diagnosed breast cancer analysed by comparing machine learning models with a logistic regression model

PURPOSE

To compare machine learning (ML) models with logistic regression model in order to identify the optimal factors associated with mammography-occult (i.e. false-negative mammographic findings) magnetic resonance imaging (MRI)-detected newly diagnosed breast cancer (BC).

MATERIAL AND METHODS

The present single-centre retrospective study included consecutive women with BC who underwent mammography and MRI (no more than 45 days apart) for breast cancer between January 2018 and May 2023. Various ML algorithms and binary logistic regression analysis were utilized to extract features linked to mammography-occult BC. These features were subsequently employed to create different models. The predictive value of these models was assessed using receiver operating characteristic curve analysis.

RESULTS

This study included 1957 malignant lesions from 1914 patients, with an average age of 51.64 ± 9.92 years and a range of 20-86 years. Among these lesions, there were 485 mammography-occult BCs. The optimal features of mammography-occult BC included calcification status, tumour size, mammographic density, age, lesion enhancement type on MRI, and histological type. Among the different ML models (ANN, L1-LR, RF, and SVM) and the LR-based combined model, the ANN model with RF features was found to be the optimal model. It demonstrated the best discriminative performance in predicting mammography false- negative findings, with an AUC of 0.912, an accuracy of 86.90%, a sensitivity of 85.85%, and a specificity of 84.18%.

CONCLUSION

Mammography-occult MRI-detected breast cancers have features that should be considered when performing breast MRI to improve the detection rate for breast cancer and aid in clinician management.

The Canadian Breast Cancer Symposium 2023 Meeting Report

On 15-16 June 2023, healthcare professionals and breast cancer patients and advocates from across Canada met in Toronto, Ontario, for the 2023 Canadian Breast Cancer Symposium (CBSC.). The CBSC. is a national, multidisciplinary event that occurs every 2 years with the goal of developing a personalized approach to the management of breast cancer in Canada. Experts provided state-of-the-art information to help optimally manage breast cancer patients, including etiology, prevention, diagnosis, experimental biology, and therapy of breast cancer and premalignant breast disease. The symposium also had the objectives of increasing communication and collaboration among breast cancer healthcare providers nationwide and providing a comprehensive and real-life review of the many facets of breast cancer. The sessions covered the patient voice, the top breast cancer papers from different disciplines in 2022, artificial intelligence in breast cancer, systemic therapy updates, the management of central nervous system metastases, multidisciplinary management of ductal carcinoma in situ, special populations, optimization-based individual prognostic factors, toxicity management of novel therapeutics, survivorship, and updates in surgical oncology. The key takeaways of these sessions have been summarized in this conference report.

The Impact of Preoperative Breast MRI on Timing of Surgical Management in Newly Diagnosed Breast Cancer

Purpose: Preoperative breast MRI has been recommended at our center since 2016 for invasive lobular carcinoma and cancers in dense breasts. This study examined how preoperative breast MRI impacted surgical timing and outcomes for patients with newly diagnosed breast cancer. Methods: Retrospective single-center study of consecutive women diagnosed with new breast cancer between June 1, 2019, and March 1, 2021, in whom preoperative breast MRI was recommended. MRI, tumor histology, breast density, post-MRI biopsy, positive predictive value of biopsy (PPV3), surgery, and margin status were recorded. Time from diagnosis to surgery was compared using t-tests. Results: There were 1054 patients reviewed, and 356 were included (mean age 60.9). Of these, 44.4% (158/356) underwent preoperative breast MRI, and 55.6% (198/356) did not. MRI referral was more likely for invasive lobular carcinoma, multifocal disease, and younger patients. Following preoperative MRI, 29.1% (46/158) patients required additional breast biopsies before surgery, for a PPV3 of 37% (17/46). The time between biopsy and surgery was 55.8 ± 21.4 days for patients with the MRI, compared to 42.8 ± 20.3 days for those without (P < .00001). MRI was not associated with the type of surgery (mastectomy vs breastconserving surgery) (P = .44) or rate of positive surgical margins (P = .52). Conclusion: Among patients who underwent preoperative breast MRI, we observed significant delays to surgery by almost 2 weeks. When preoperative MRI is requested, efforts should be made to mitigate associated delays.

The performance of contrast-enhanced mammography and breast MRI in local preoperative staging of invasive lobular breast cancer

PURPOSE

Breast MRI is considered the best modality for preoperative staging of invasive lobular carcinoma (ILC). However, contrast-enhanced mammography (CEM) shows comparable diagnostic performance to MRI, but evidence of CEM's accuracy in women diagnosed with ILC is scant. We aimed to retrospectively evaluate CEM and MRI accuracy in preoperative staging of ILC.

METHODS

ILC cases diagnosed between 2013 and 2021 were collected. For both modalities, tumour diameter was extracted from the reports. Bland-Altman plots were used to assess discrepancies between size measurements according to imaging and histopathological findings. CEM and MRI's ability to detect multifocal/contralateral cancer was expressed as sensitivity, specificity, and diagnostic odds ratios (DORs). Pairwise comparison of women undergoing both CEM and MRI was not performed.

RESULTS

305 ILC-cases fulfilled preset inclusion criteria. Mean age was 63.7 years. Preoperative staging was performed using MRI or CEM in 266 (87.2%) and 77 (25.2%) cases, respectively. MRI and CEM overestimated tumour size by 1.5 and 2.1 mm, respectively. Sensitivity to detect multifocal disease was higher for MRI than for CEM (86% versus 78%), but specificity was lower for MRI (79% versus 92%). For detection of contralateral breast cancer, sensitivity for MRI was 96% versus 88% for CEM, and specificity was 92% and 99%, respectively. For both indications, DOR was higher for CEM, but differences were non-significant (p = 0.56 and p = 0.78).

CONCLUSION

CEM and MRI overestimate ILC size with comparable systematic and random errors. MRI's higher sensitivity for detection of multifocal/contralateral cancers is accompanied by lower specificity, but discriminative ability for both modalities was non-significant.

Low-Risk Women with Suspicious Microcalcifications in Mammography-Can an Additional Breast MRI Reduce the Biopsy Rate?

BACKGROUND

In the German Mammography Screening Program, 62% of ductal carcinoma in situ (DCIS) and 38% of invasive breast cancers are associated with microcalcifications (MCs). Vacuum-assisted stereotactic breast biopsies are necessary to distinguish precancerous lesions from benign calcifications because mammographic discrimination is not possible. The aim of this study was to investigate if breast magnetic resonance imaging (MRM) could assist the evaluation of MCs and thus help reduce biopsy rates.

METHODS

In this IRB-approved study, 58 women (mean age 58 +/- 24 years) with 59 suspicious MC clusters in the MG were eligible for this prospective single-center trial. Additional breast magnetic resonance imaging (MRI) was conducted before biopsy.

RESULTS

The breast MRI showed a sensitivity of 86%, a specificity of 84%, a positive predictive value (PPV) of 75% and a negative predictive value (NPV) of 91% for the differentiation between benign and malignant in these 59 MCs found with MG. Breast MRI in addition to MG could increase the PPV from 36% to 75% compared to MG alone. The MRI examination led to nine additional suspicious classified lesions in the study cohort. A total of 55% (5/9) of them turned out to be malignant. A total of 32 of 59 (54 %) women with suspicious MCs and benign histology were classified as non-suspicious by MRI.

CONCLUSION

An additionally performed breast MRI could have increased the diagnostic reliability in the assessment of MCs. Further, in our small cohort, a considerable number of malignant lesions without mammographically visible MCs were revealed.

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.

Clinical impact of MRI-detected additional lesions in breast cancer patients with neoadjuvant systemic therapy at the Netherlands cancer institute

BACKGROUND

In breast cancer patients treated with neoadjuvant systemic therapy (NST), MRI is used pre- and post-NST for response monitoring. The relevance of additional MRI-detected lesions in these patients is unclear. Therefore, we aimed to assess the impact of pre-NST MRI-detected additional lesions on surgical treatment and outcome.

METHODS

We retrospectively selected all early-stage breast cancer patients with MRI pre-NST at our institute from January 2010-2015. MRI-detected lesions were defined as separated from the index tumor and occult at conventional mammography and ultrasound. Outcomes were change in surgical treatment and five-year recurrence-free and overall survival.

RESULTS

Overall, MRI detected additional lesions in 206 (31%) of 656 patients: in 160 patients in the ipsilateral breast and in 78 contralateral breasts, including 32 bilateral cases. Ipsilateral lesions were mostly categorized BI-RADS 5 (54 %) and contralateral lesions BI-RADS 3 (64%). Targeted ultrasound was performed in 115 (56%) patients: in 70 ipsilateral and in 64 contralateral cases. Biopsy was obtained in 44 (28% of 160) ipsilateral and 50 (64% of 78) contralateral breasts, containing tumor foci in 20 (13% of 160) and 11 (14% of 78) cases, respectively. Surgical treatment changed in 54 (26% of 206) patients: 19 (9%) had mastectomy, 24 (12%) had wider local excision and 11 (5%) underwent contralateral surgery. Five-year recurrence-free and overall survival did not differ for patients with local excision or mastectomy.

CONCLUSION

Pre-NST MRI-detected additional lesions in 31% of patients, resulting in more extensive surgery in 26% of these patients, including 5% contralateral surgeries.

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.

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.