Magnetic resonance imaging in patients diagnosed with ductal carcinoma-in-situ: value in the diagnosis of residual disease, occult invasion, and multicentricity

Current Trends and Beyond Conventional Approaches: Advancements in Breast Cancer Surgery through Three-Dimensional Imaging, Virtual Reality, Augmented Reality, and the Emerging Metaverse

Breast cancer stands as the most prevalent cancer globally, necessitating comprehensive care. A multidisciplinary approach proves crucial for precise diagnosis and treatment, ultimately leading to effective disease management. While surgical interventions continue to evolve and remain integral for curative treatment, imaging assumes a fundamental role in breast cancer detection. Advanced imaging techniques not only facilitate improved diagnosis but also contribute significantly to the overall enhancement of breast cancer management. This review article aims to provide an overview of innovative technologies such as virtual reality, augmented reality, and three-dimensional imaging, utilized in the medical field to elevate the diagnosis and treatment of breast cancer. Additionally, the article delves into an emerging technology known as the metaverse, still under development. Through the analysis of impactful research and comparison of their findings, this study offers valuable insights into the advantages of each innovative technique. The goal is to provide physicians, surgeons, and radiologists with information on how to enhance breast cancer management.

Breast Cancer Disparities and Innovations: A Focus on Kosovo

Due to the current limited capacity to provide digital mammography-based screening to all women, and the lack of modern surgical oncology methods, mastectomy is still the predominant form of surgical treatment in many parts of the world. As such there is little incentive to detect breast cancer earlier and significant fear of treatment and outcomes continues to contribute to late presentations. Neoadjuvant chemotherapy, pre-operative breast MRI and surgical mapping techniques can combine forces to allow for more women to be treated with breast conservation, decrease fear of treatment and improve outcomes.

Magnetic resonance imaging system for intraoperative margin assessment for DCIS and invasive breast cancer using the ClearSight™ system in breast-conserving surgery-Results from a postmarketing study

BACKGROUND AND OBJECTIVES

Breast-conserving surgery (BCS) is followed by reoperations in approximately 25%. Reoperations lead to an increased risk of infection and wound healing problems as well as a worse cosmetic outcome. Several technical approaches for an intraoperative margin assessment to decrease the reoperation rate are under evaluation, some of them are still experimental.

METHODS

A prospective single-arm post-marketing study with 60 patients undergoing BCS for ductal carcinoma in situ (DCIS) and invasive breast cancer was conducted. The specimen was intraoperatively examined by the ClearSight™ system, a mobile magnetic resonance imaging system that is based on a diffusion-weighted imaging protocol. However, the results were blinded to the surgeon.

RESULTS

The ClearSight™ system was performed for both ductal and lobular breast cancer and DCIS, with a sensitivity of 0.80 (95% confidence interval [CI]: 0.44-0.96) and a specificity of 0.84 (95% CI 0.72-0.92), with an overall diagnostic accuracy of 80%.

CONCLUSION

Had the ClearSight™ been known to the surgeon intraoperatively, the reoperation rate would have been reduced by 83% for invasive carcinoma, from 10% to 2%, and 50% for DCIS, from 30% to 15% reoperations. A trial designed to examine the impact on reoperation rates is currently ongoing.

The additive role of dynamic contrast-enhanced and diffusion-weighted MR imaging in preoperative staging of breast cancer

Background

In women with diagnosed breast cancer, accurate loco-regional staging and preoperative examination are of utmost importance for optimal patient management decisions. MRI may be warranted for correct preoperative staging as recommended from international guidelines. DWI-MRI can be combined with CE-MRI to assess more functional data. So we aimed to evaluate the performance of CE-MRI and qualitative DWI-MRI in preoperative loco-regional staging of malignant breast lesions as regards the local extension of the disease and axillary lymph node status, beyond standard assessment with mammography and ultrasound. This prospective study included 50 female patients with pathologically proven malignant breast lesions (BIRADS VI) coming for preoperative staging. Full-field digital mammography (FFDM) and ultrasound, CE-MRI, and DWI-MRI findings were compared for all patients, and the findings were evaluated independently. Results were then correlated to postoperative histopathology.

Results

Fifty women with pathologically proven malignant breast lesions (BIRADS VI) were enrolled in this study; the mean age of this study population was 43.25 years. The 50 patients were divided into 2 groups: 37/50 (74%) underwent upfront surgery and 13/50 (26%) received neoadjuvant therapy before surgery. All patients performed DCE and DWI-MRI breast. Among patients who underwent upfront surgery, DCE-MRI showed the highest correlation with the postoperative pathology size and the overall sensitivity regarding multiplicity. Regarding patients who received neoadjuvant therapy, DCE-MRI was found to have the highest correlation with the postoperative pathology concerning lesion size and multiplicity after completion of the neoadjuvant chemotherapy cycles.

Conclusion

CE-MRI can accurately map lesion extension and detect multifocality/multicentricity, thus tailor surgical management options (either conservative surgery or mastectomy). Qualitative DWI can be combined with ultrasonography for better evaluation of the axillary nodal status.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Charged with Discharge: A Case-based Review of Nipple Discharge Using the American College of Radiology's Appropriateness Guidelines

Nipple discharge, a relatively common presenting symptom for women of all ages, may be due to both benign and malignant conditions. Men can also present with nipple discharge, and when they do, they have a higher likelihood of malignancy than women. Radiologists vary in their evaluation of patients with nipple discharge, although the American College of Radiology practice guidelines for nipple discharge provides data-driven appropriate algorithms. In patients with physiologic discharge, imaging is not typically indicated. For those with pathologic nipple discharge, imaging typically starts with diagnostic mammography and retroareolar ultrasound for women over 40 years of age, diagnostic mammogram or ultrasound for women aged 30-39 years, and ultrasound for women younger than 30 years. Finally, contrast-enhanced breast MRI or galactography are usually reserved for identifying the cause of discharge when initial imaging with mammography and ultrasound is unrevealing.

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

RATIONALE AND OBJECTIVES

Use of preoperative breast MRI (pMRI) to evaluate ductal carcinoma in situ (DCIS) extent is controversial due to limited data on its impact on surgical management. We sought to evaluate the effect of pMRI on surgical management of women with core needle biopsy (CNB)-diagnosed pure DCIS at a multidisciplinary academic institution.

MATERIALS AND METHODS

This retrospective study included all women with CNB-diagnosed DCIS (1/2004-12/2013) without prior ipsilateral breast cancer and who underwent surgery within 180 days of diagnosis. Patient features, number of CNBs and surgeries, and single successful breast conserving surgery (BCS) rate were compared between pMRI and no-pMRI cohorts. Number of surgeries and single BCS success rates were also compared to published US (SEER) and Danish National Registry data.

RESULTS

Among the 373 women included, no clinical differences were identified between the pMRI (n = 332) and no-pMRI (n = 41) cohorts (p > 0.05). The pMRI group experienced a higher additional CNB rate (30% vs. 7%, p = 0.002) but fewer total surgeries (mean = 1.2 vs. 1.5, p < 0.001) than the no-pMRI group. Among the 245 women for whom BCS was attempted, the pMRI cohort underwent fewer mean surgeries (1.3 vs. 1.7, p < 0.001) with a greater single successful BCS rate (77% vs. 43%, p < 0.001). Compared to published data, women with pMRI who underwent BCS experienced fewer surgeries (difference (Δ) = -0.22 vs. -0.17, p < 0.001) with a higher single successful BCS rate (Δ = +20% vs. +14%, p < 0.001).

CONCLUSION

pMRI may improve surgical management of DCIS at multidisciplinary centers with breast cancer specialists.

Population-based study of the effect of preoperative breast MRI on the surgical management of ductal carcinoma in situ

BACKGROUND

Determinants of the use of breast MRI in patients with ductal carcinoma in situ (DCIS) in the Netherlands were studied, and whether using MRI influenced the rates of positive resection margins and mastectomies.

METHODS

All women aged less than 75 years, and diagnosed with DCIS between 2011 and 2015, were identified from the Netherlands Cancer Registry. Multivariable logistic regression analyses were performed, adjusting for incidence year, age, hospital type, DCIS grade and multifocality.

RESULTS

Breast MRI was performed in 2382 of 10 415 DCIS cases (22·9 per cent). In multivariable analysis, patients aged less than 50 years, those with high- or intermediate-grade DCIS and patients with multifocal disease were significantly more likely to have preoperative MRI. Patients undergoing MRI were more likely to have a mastectomy, either as first surgical treatment or following breast-conserving surgery (BCS) in the event of positive margins (odds ratio (OR) 2·11, 95 per cent c.i. 1·91 to 2·33). The risk of positive surgical margins after BCS was similar for those with versus without MRI. The secondary mastectomy rate after BCS was higher in patients who had MRI, especially in women aged less than 50 years (OR 1·94, 1·31 to 2·89). All findings were similar for low- and intermediate/high-grade DCIS.

CONCLUSION

Adding MRI to conventional breast imaging did not improve surgical outcome in patients diagnosed with primary DCIS. The likelihood of undergoing a mastectomy was twice as high in the MRI group, and no reduction in the risk of margin involvement was observed after BCS.

A Randomized Prospective Trial of Supine MRI-Guided Versus Wire-Localized Lumpectomy for Breast Cancer

BACKGROUND

Wire-localized excision of non-palpable breast cancer is imprecise, resulting in positive margins 15-35% of the time.

METHODS

Women with a confirmed diagnosis of non-palpable invasive breast cancer (IBC) or ductal carcinoma in situ (DCIS) were randomized to a new technique using preoperative supine magnetic resonance imaging (MRI) with intraoperative optical scanning and tracking (MRI group) or wire-localized (WL group) partial mastectomy. The main outcome measure was the positive margin rate.

RESULTS

In this study, 138 patients were randomly assigned. Sixty-six percent had IBC and DCIS, 22% had IBC, and 12% had DCIS. There were no differences in patient or tumor characteristics between the groups. The proportion of patients with positive margins in the MRI-guided surgery group was half that observed in the WL group (12 vs. 23%; p = 0.08). The specimen volumes in the MRI and WL groups did not differ significantly (74 ± 33.9 mL vs. 69.8 ± 25.1 mL; p = 0.45). The pathologic tumor diameters were underestimated by 2 cm or more in 4% of the cases by MRI and in 9% of the cases by mammography. Positive margins were observed in 68% and 58% of the cases underestimated by 2 cm or more using MRI and mammography, respectively, and in 15% and 14% of the cases not underestimated using MRI and mammography, respectively.

CONCLUSIONS

A novel system using supine MRI images co-registered with intraoperative optical scanning and tracking enabled tumors to be resected with a trend toward a lower positive margin rate compared with wire-localized partial mastectomy. Margin positivity was more likely when imaging underestimated pathologic tumor size.

Is there any relationship between adc values of diffusion-weighted imaging and the histopathological prognostic factors of invasive ductal carcinoma?

OBJECTIVE

MRI is being used increasingly as a modality that can provide important information about breast cancer. Diffusion-weighted imaging (DWI) is an imaging technique from which apparent diffusion coefficient (ADC) values can be calculated in addition to obtaining important structural information which cannot be obtained from other imaging studies. We did not find any significant relationships between ADC values and prognostic factors, but did provide some explanations for conflicting results in the literature.

METHODS

The ADC results of 61 females with invasive ductal carcinomas were evaluated. DWI was performed and ADC values were calculated from the area in which restriction of diffusion was the highest in ADC mapping. B value was 500 and region of interest (ROI) was designated between 49 and 100 mm². Calculations were performed automatically by the device. Tissue samples were obtained for prognostic factor evaluation. The relationships between ADC and prognostic factors were investigated. Comparisons between groups were made with one-way ANOVA and Kruskal Wallis test. Pairwise comparisons were made with Dunn's test. Analyses of categorical variables were made with Chi-square test.

RESULTS

We found a weak negative correlation between ADC and Ki-67 values (r = -0.279; p = 0.029). When we compared ADC values in regard to tumour type, we found no significant differences for tumour grade, Ki-67 positivity, estrogen receptor positivity, progesterone receptor positivity, C-erb B2, lymphovascular invasion and ductal carcinoma in situ or lobular carcinoma in situ component. On a side note, we found that mean ADC values decreased as tumour grade increased; however, this was not statistically significant.

CONCLUSION

The literature contains studies that report conflicting results which may be caused by differences in B values, ROI area and magnetic field strength. Multicentre studies and systematic reviews of these findings may produce crucial data for the use of DWI in breast cancer. Advances in knowledge: To determine if any significant relationship exists between DWI findings and prognostic factors of breast cancer.

The impact of preoperative magnetic resonance imaging and lumpectomy cavity shavings on re-excision rate in pure ductal carcinoma in situ-A single institution's experience

BACKGROUND AND OBJECTIVES

The impact of preoperative magnetic resonance imaging (pMRI) and cavity shave margins (CSM) on re-excision rate (RR) in DCIS is unclear. We investigated whether either modality was associated with RR in DCIS.

METHODS

This is a single-institution retrospective study of 295 women undergoing breast conservation surgery for pure DCIS (2010-2013). CSM were the systematic resection of 4-6 margins during lumpectomy whereas selective shave margins (SSM) were the selective resection of 1-3 margins. Patient demographics and clinical characteristics were abstracted. RR was analyzed according to the use of pMRI, SSM, or CSM with respect to three high-volume breast surgeons at our institution.

RESULTS

RR was not associated with the use of pMRI (P = 0.87). Any shave margins (P = 0.05), DCIS size (P < 0.001), and DCIS grade (P = 0.14) associated with a lower RR. Of our high-volume surgeons, RR was lower for Surgeon A (P = 0.02). Multivariate analyses showed larger DCIS (OR 1.35, P = 0.005) and practices specific to surgeons B (OR 3.23, P = 0.04) and C (OR 3.57, P = 0.04) increased re-excision odds.

CONCLUSIONS

SSM/CSM and pMRI use varied among surgeons. Our results suggested the routine use of CSM, not pMRI, could lower re-excision rate, which highlighted a quality improvement opportunity at our institution.

Can algorithmically assessed MRI features predict which patients with a preoperative diagnosis of ductal carcinoma in situ are upstaged to invasive breast cancer?

PURPOSE

To assess the ability of algorithmically assessed magnetic resonance imaging (MRI) features to predict the likelihood of upstaging to invasive cancer in newly diagnosed ductal carcinoma in situ (DCIS).

MATERIALS AND METHODS

We identified 131 patients at our institution from 2000-2014 with a core needle biopsy-confirmed diagnosis of pure DCIS, a 1.5 or 3T preoperative bilateral breast MRI with nonfat-saturated T1 -weighted MRI sequences, no preoperative therapy before breast MRI, and no prior history of breast cancer. A fellowship-trained radiologist identified the lesion on each breast MRI using a bounding box. Twenty-nine imaging features were then computed automatically using computer algorithms based on the radiologist's annotation.

RESULTS

The rate of upstaging of DCIS to invasive cancer in our study was 26.7% (35/131). Out of all imaging variables tested, the information measure of correlation 1, which quantifies spatial dependency in neighboring voxels of the tumor, showed the highest predictive value of upstaging with an area under the curve (AUC) = 0.719 (95% confidence interval [CI]: 0.609-0.829). This feature was statistically significant after adjusting for tumor size (P < 0.001).

CONCLUSION

Automatically assessed MRI features may have a role in triaging which patients with a preoperative diagnosis of DCIS are at highest risk for occult invasive disease.

LEVEL OF EVIDENCE

4 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2017;46:1332-1340.

A Patient-Specific 3D-Printed Form Accurately Transfers Supine MRI-Derived Tumor Localization Information to Guide Breast-Conserving Surgery

BACKGROUND

Wire-localized excision of nonpalpable breast cancer is imprecise, resulting in positive margins 25-30% of the time.

METHODS

Patients underwent preoperative supine magnetic resonance imaging (MRI). A radiologist outlined the tumor edges on consecutive images, creating a three-dimensional (3D) view of its location. Using 3D printing, a bra-like plastic form (the Breast Cancer Locator [BCL]) was fabricated, with features that allowed a surgeon to (1) mark the edges of the tumor on the breast surface; (2) inject blue dye into the breast 1 cm from the tumor edges; and (3) place a wire in the tumor at the time of surgery.

RESULTS

Nineteen patients with palpable cancers underwent partial mastectomy after placement of surgical cues using patient-specific BCLs. The cues were in place in <5 min and no adverse events occurred. The BCL accurately localized 18/19 cancers. In the 18 accurately localized cases, all 68 blue-dye injections were outside of the tumor edges. Median distance from the blue-dye center to the pathologic tumor edge was 1.4 cm, while distance from the blue dye to the tumor edge was <5 mm in 4% of injections, 0.5-2.0 cm in 72% of injections, and >2 cm in 24% of injections. Median distance from the tumor center to the BCL-localized wire and to the clip placed at the time of diagnosis was similar (0.49 vs. 0.73 cm) on specimen mammograms.

CONCLUSIONS

Information on breast cancer location and shape derived from a supine MRI can be transferred safely and accurately to patients in the operating room using a 3D-printed form.

Breast-conserving surgery in patients with Paget's disease

Background

Paget's disease of the breast is a rare condition that is associated with underlying breast cancer in the majority of patients. The conventional treatment for Paget's disease has been mastectomy, but there is an increasing trend to consider breast-conserving surgery (BCS) in selected patients. Owing to the uncommon nature of the disease, research studies tend to be small and retrospective. This systematic review presents the published evidence regarding BCS for patients with Paget's disease with a focus on patient selection and oncological safety.

Methods

A search of Ovid and PubMed databases was conducted to identify all papers published regarding BCS for Paget's disease.

Results

The search identified 172 papers of which 43 were clinically relevant. BCS is a safe alternative to mastectomy, provided a clear surgical margin is achieved and adjuvant radiotherapy used. However, patients with Paget's disease should be assumed to have underlying breast cancer, and these cancers tend to have poor biological profiles. When BCS is considered, careful preoperative investigation should be undertaken to identify the presence and extent of an underlying cancer. These cancers can be mammographically occult, multifocal or multicentric. Although the evidence is limited, there may be a role for MRI in selecting patients with Paget's disease for BCS.

Conclusion

Patients with Paget's disease are candidates for breast conservation with appropriate preoperative investigations. Oncological outcomes are equivalent to those of mastectomy if surgical margins are achieved and adjuvant radiotherapy is given.

Diffusion-tensor imaging as an adjunct to dynamic contrast-enhanced MRI for improved accuracy of differential diagnosis between breast ductal carcinoma in situ and invasive breast carcinoma

OBJECTIVE

To determine the value of diffusion-tensor imaging (DTI) as an adjunct to dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) for improved accuracy of differential diagnosis between breast ductal carcinoma in situ (DCIS) and invasive breast carcinoma (IBC).

METHODS

The MRI data of 63 patients pathologically confirmed as breast cancer were analyzed. The conventional MRI analysis metrics included enhancement style, initial enhancement characteristic, maximum slope of increase, time to peak, time signal intensity curve (TIC) pattern, and signal intensity on FS-T2WI. The values of apparent diffusion coefficient (ADC), directionally-averaged mean diffusivity (Davg), exponential attenuation (EA), fractional anisotropy (FA), volume ratio (VR) and relative anisotropy (RA) were calculated and compared between DCIS and IBC. Multivariate logistic regression was used to identify independent factors for distinguishing IBC and DCIS. The diagnostic performance of the diagnosis equation was evaluated using the receiver operating characteristic (ROC) curve. The diagnostic efficacies of DCE-MRI, DWI and DTI were compared independently or combined.

RESULTS

EA value, lesion enhancement style and TIC pattern were identified as independent factor for differential diagnosis of IBC and DCIS. The combination diagnosis showed higher diagnostic efficacy than a single use of DCE-MRI (P=0.02), and the area of the curve was improved from 0.84 (95% CI, 0.67-0.99) to 0.94 (95% CI, 0.85-1.00).

CONCLUSIONS

Quantitative DTI measurement as an adjunct to DCE-MRI could improve the diagnostic performance of differential diagnosis between DCIS and IBC compared to a single use of DCE-MRI.

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.

Accuracy of 3 T versus 1.5 T breast MRI for pre-operative assessment of extent of disease in newly diagnosed DCIS

OBJECTIVES

While 3T breast magnetic resonance imaging has increased in use over the past decade, there is little data comparing its use for assessing ductal carcinoma in situ (DCIS) versus 1.5 T. We sought to compare the accuracies of DCIS extent of disease measures on pre-operative 3T versus 1.5 T MRI.

METHODS

This institutional review board-approved prospective study included 20 patients with ductal carcinoma in situ diagnosed by core needle biopsy (CNB) who underwent pre-operative breast MRI at both 3T (resolution=0.5 mm×0.5 mm×1.3 mm) and 1.5 T (0.85 mm×0.85 mm×1.6 mm). All patients provided informed consent, and the study was HIPPA compliant. Lesion sizes and imaging characteristics (morphologic and kinetic enhancement) were recorded for the 3 T and 1.5 T examinations. Lesion size measures at both field strengths were correlated to final pathology, and imaging characteristics also were compared.

RESULTS

Of the initial cohort of 20 patients with CNB-diagnosed DCIS, 19 underwent definitive surgery. Median DCIS sizes of these 19 patients were 6mm (range: 0-67 mm) on 3T, 13 mm (0-60 mm) on 1.5 T, and 6mm (0-55 mm) on surgical pathology. Size correlation between MRI and pathology was higher for 3T (Spearman's ρ=0.66, p=0.002) than 1.5 T (ρ=0.36, p=0.13). In 10 women in which a residual area of suspicious enhancement was identified on both field strengths, there was agreement of morphologic description (NME vs. mass) in nine, and no significant difference in dynamic contrast enhanced kinetics at 3T compared to 1.5 T.

CONCLUSIONS

Pre-operative breast MRI at 3T provided higher correlation with final pathology size of DCIS lesions compared to 1.5 T, and may be more accurate for assessment of disease extent prior to definitive surgery.

Breast magnetic resonance imaging indications in current practice

Although mammography is the primary imaging modality for the breast, it has its limitations especially with dense breast parenchyma. Breast magnetic resonance imaging (MRI) has evolved into an important adjunctive tool as it is currently the most sensitive technique for breast cancer detection. Despite this high sensitivity, overlap in the appearances of some benign and malignant breast lesions results in additional unnecessary intervention with negative results. These false positives, in addition to high cost and limited availability, necessitate establishing proper indications for breast MRI. The literature was here reviewed for recent clinical trials, meta-analyses and review papers which have studied this important subject. PubMed; the US national library of medicine, was utilized to review the literature in the last twenty years. Using the obtained information, current uses of breast MRI are discussed in this paper to determine the indications which are relevant to clinical practice.

Features of occult invasion in biopsy-proven DCIS at breast MRI

The purpose of this study is to determine if MRI BI-RADS criteria or radiologist perception correlate with presence of invasive cancer after initial core biopsy of ductal carcinoma in situ (DCIS). Retrospective search spanning 2000-2007 identified all core-biopsy diagnoses of pure DCIS that coincided with preoperative MRI. Two radiologists fellowship-trained in breast imaging categorized lesions according to ACR MRI BI-RADS lexicon and estimated likelihood of occult invasion. Semiquantitative signal enhancement ratio (SER) kinetic analysis was also performed. Results were compared with histopathology. 51 consecutive patients with primary core biopsy-proven DCIS and concurrent MRI were identified. Of these, 13 patients (25%) had invasion at excision. Invasion correlated significantly with presence of a mass for both readers (p = 0.012 and 0.001), rapid initial enhancement for Reader 1 (p = 0.001), and washout kinetics for Reader 2 (p = 0.012). Significant correlation between washout and invasion was confirmed by SER (p = 0.006) when threshold percent enhancement was sufficiently high (130%), corresponding to rapidly enhancing portions of the lesion. Radiologist perception of occult invasion was strongly correlated with true presence of invasion. These results provide evidence that certain BI-RADS MRI criteria, as well as radiologist perception, correlate with occult invasion after an initial core biopsy of DCIS.

Evaluation of residual disease using breast MRI after excisional biopsy for breast cancer

OBJECTIVE

The purpose of our study was to assess the diagnostic performance of breast MRI in evaluating residual disease in patients after excisional biopsy for breast cancer on the basis of both morphologic and kinetic features.

MATERIALS AND METHODS

Of 5304 breast MRI examinations performed between January 2007 and December 2011, 308 evaluated postoperative sites after excisional biopsy of breast cancer. Among these, 203 patients who were not treated with chemotherapy or radiotherapy before MRI and underwent definitive surgery within 30 days after MRI were enrolled. MRI findings were analyzed on the basis of contrast-enhanced subtraction images. The enhancement patterns were classified into four categories: no enhancement (P1), thin regular rim enhancement (P2), thick or irregular rim enhancement (P3), and nodular or nonmasslike enhancement (P4) around the postoperative sites. The enhancement kinetics were assessed as follows: persistent, plateau, and washout pattern.

RESULTS

From 207 breast MRI examinations in 203 patients, 144 breasts had residual breast cancer at histopathologic examination after definitive surgery. When P1 and P2 were considered negative for residual cancer and P3 and P4 were considered positive, the sensitivity, specificity, positive and negative predictive values, and accuracy were 79.9%, 73.0%, 87.1%, 61.3%, and 77.8%, respectively. The specificity and positive predictive value improved to 90.5% and 91.7%, when analyzed with washout enhancement kinetics as another positive finding for residual cancer. A statistically significant trend of decreasing specificity and positive predictive value (p < 0.05) was found with the passage of a time interval between excision and breast MRI.

CONCLUSION

Although the overlapping features of the postsurgical changes and malignant lesions remain as the limitations, dynamic contrast-enhanced breast MRI is a useful tool for residual disease prediction after excisional biopsy for breast cancer. Combined use of morphologic and kinetic evaluation parameters improved the diagnostic performance. We do not recommend that MRI be unreasonably delayed after excisional biopsy considering the risk of prolonging definitive surgery.

Ductal carcinoma in situ of the breast: a surgical perspective

Ductal carcinoma in situ (DCIS) of the breast is a heterogeneous neoplasm with invasive potential. Risk factors include age, family history, hormone replacement therapy, genetic mutation, and patient lifestyle. The incidence of DCIS has increased due to more widespread use of screening and diagnostic mammography; almost 80% of cases are diagnosed with imaging with final diagnosis established by biopsy and histological examination. There are various classification systems used for DCIS, the most recent of which is based on the presence of intraepithelial neoplasia of the ductal epithelium (DIN). A number of molecular assays are now available that can identify high-risk patients as well as help establish the prognosis of patients with diagnosed DCIS. Current surgical treatment options include total mastectomy, simple lumpectomy in very low-risk patients, and lumpectomy with radiation. Adjuvant therapy is tailored based on the molecular profile of the neoplasm and can include aromatase inhibitors, anti-estrogen, anti-progesterone (or a combination of antiestrogen and antiprogesterone), and HER2 neu suppression therapy. Chemopreventive therapies are under investigation for DCIS, as are various molecular-targeted drugs. It is anticipated that new biologic agents, when combined with hormonal agents such as SERMs and aromatase inhibitors, may one day prevent all forms of breast cancer.

Ductal carcinoma in situ of the breast

Ductal carcinoma in situ (DCIS) of the breast represents a complex, heterogeneous pathologic condition in which malignant epithelial cells are confined within the ducts of the breast without evidence of invasion. The increased use of screening mammography has led to a significant shift in the diagnosis of DCIS, accounting for approximately 27% of all newly diagnosed cases of breast cancer in 2011, with an overall increase in incidence. As the incidence of DCIS increases, the treatment options continue to evolve. Consistent pathologic evaluation is crucial in optimizing treatment recommendations. Surgical treatment options include breast-conserving surgery (BCS) and mastectomy. Postoperative radiation therapy in combination with breast-conserving surgery is considered the standard of care with demonstrated decrease in local recurrence with the addition of radiation therapy. The role of endocrine therapy is currently being evaluated. The optimization of diagnostic imaging, treatment with regard to pathological risk assessment, and the role of partial breast irradiation continue to evolve.

MRI of the breast in patients with DCIS to exclude the presence of invasive disease

OBJECTIVES

Core biopsy underestimates invasion in more than 20% of patients with preoperatively diagnosed ductal carcinoma in situ (DCIS) without evidence of invasion (pure DCIS). The aim of the current study was to evaluate the efficacy of preoperative magnetic resonance imaging (MRI) to discriminate between patients with DCIS who are at high risk of invasive breast cancer and patients at low risk.

METHODS

One hundred and twenty-five patients, preoperatively diagnosed with pure DCIS (128 lesions; 3 bilateral) by core-needle biopsy, were prospectively included. Clinical, mammographic, histological (core biopsy) and MRI features were assessed. All patients underwent breast surgery. Analyses were performed to identify features associated with presence of invasion.

RESULTS

Eighteen lesions (14.1%) showed invasion on final histology. Seventy-three lesions (57%) showed suspicious enhancement on MRI with a type 1 (n = 12, 16.4%), type 2 (n = 19, 26.0%) or type 3 curve, respectively (n = 42, 57.5%). At multivariate analysis, the most predictive features for excluding presence of invasive disease were absence of enhancement or a type 1 curve on MRI (negative predictive value 98.5%; A(Z) 0.80, P = 0.00006).

CONCLUSION

Contrast medium uptake kinetics at MRI provide high negative predictive value to exclude presence of invasion and may be useful in primary surgical planning in patients with a preoperative diagnosis of pure DCIS.

KEY POINTS

It is important to determine invasion in breast DCIS. • MRI contrast medium uptake kinetics can help exclude the presence of invasion. • However, the positive predictive value for the presence of invasion is limited. • MRI features were more accurate at predicting invasion than mammographic features alone.

Ductal carcinoma in situ, and the influence of the mode of detection, population characteristics, and other risk factors

Approximately 25% of breast cancers in the United States are diagnosed as ductal carcinoma in situ (DCIS). Rates of DCIS have risen from 5.8 per 100,000 women in the 1970s to 32.5 per 100,000 in 2004. This pattern is generally attributed to increased use of screening mammography. DCIS is a major risk factor for invasive breast cancer, and considerable controversy remains about whether DCIS should be considered a direct precursor of invasive breast cancer. There is, however, a general consensus that DCIS represents an intermediate step between normal breast tissue and invasive breast cancer. Although the majority of major risk factors are similar for DCIS and invasive breast cancer, prognostic factors including estrogen and progesterone receptor status and HER2 positivity are less well studied but look to have similar value in both cases. The use of postdiagnostic MRI, sentinel lymph node biopsy, surgery, radiation, and endocrine therapy are all evolving as evidence from randomized and observational studies continues to accumulate. Treatment of DCIS requires a balance between risk of overtreatment and undertreatment. Ongoing studies are focusing on whether partial-breast irradiation is as effective as whole-breast irradiation and whether treatment with endocrine therapies can reduce the likelihood of either invasive breast cancer or DCIS recurrence. In general, treatment decisions should take into account the likelihood that an apparent case of DCIS could harbor foci of invasive disease.

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.

Outcome of long term active surveillance for estrogen receptor-positive ductal carcinoma in situ

INTRODUCTION

An option for active surveillance is not currently offered to patients with ductal carcinoma in situ (DCIS); however a small number of women decline standard surgical treatment for noninvasive cancer. The purpose of this study was to assess outcomes in a cohort of 14 well-informed women who elected non-surgical active surveillance with endocrine treatment alone for estrogen receptor-positive DCIS.

METHODS

Retrospective review of 14 women, 12 of whom were enrolled in an IRB-approved single-arm study of 3 months of neoadjuvant endocrine therapy prior to definitive surgical management. The patients in this report withdrew from the parent study opting instead for active surveillance with endocrine treatment and imaging.

RESULTS

8 women had surgery at a median follow up of 28.3 months (range 10.1-70 months), 5 had stage I IDC at surgical excision, and 3 had DCIS alone. 6 women remain on surveillance without evidence of invasive disease for a median of 31.8 months (range 11.8-80.8 months).

CONCLUSION

Long-term active surveillance for DCIS is feasible in a well-informed patient population, but is associated with risk of invasive cancer at surgical excision.

Management of breast magnetic resonance imaging-detected lesions

Breast magnetic resonance imaging (MRI) has become an essential component of breast imaging. Whether it is used as a problem-solving tool or a screening test or for staging patients with breast cancer, it detects many lesions in the breast. The challenge for the radiologist is to distinguish significant from insignificant lesions and to direct their management. A brief summary of the terminology according to the American College of Radiologists lexicon will be provided. This review article will cover the differential diagnosis of enhancing lesions, including masses and nonmass enhancement, from benign and malignant causes. Some of the specific morphologic and kinetic features that help to differentiate benign from malignant lesions will be illustrated, and positive predictive values of these features will be reviewed. The various methods of investigating enhancing lesions of the breast will be discussed, including second-look ultrasound, ultrasound-guided biopsy, stereotactic biopsy, and MRI-guided biopsy. A practical approach to the management of MRI-detected lesions will include timing of follow-up, when to biopsy and when to ignore enhancing lesions in the breast.

The impact of preoperative magnetic resonance imaging on surgical treatment and outcomes for ductal carcinoma in situ

BACKGROUND

Although magnetic resonance imaging (MRI) is a useful imaging modality for invasive cancer, its role in preoperative surgical planning for ductal carcinoma in situ (DCIS) has not been established. We sought to determine whether preoperative MRI affects surgical treatment and outcomes in women with pure DCIS.

PATIENTS AND METHODS

We reviewed consecutive records of women diagnosed with pure DCIS on core biopsy between 2000 and 2007. Patient characteristics, surgical planning, and outcomes were compared between patients with and without preoperative MRI. Multivariable regression was performed to determine which covariates were independently associated with mastectomy or sentinel lymph node biopsy (SLNB).

RESULTS

Of 149 women diagnosed with DCIS, 38 underwent preoperative MRI. On univariate analysis, patients undergoing MRI were younger (50 years vs. 59 years; P < .001) and had larger DCIS size on final pathology (1.6 cm vs. 1.0 cm; P = .007) than those without MRI. Mastectomy and SLNB rates were significantly higher in the preoperative MRI group (45% vs. 14%, P < .001; and 47% vs. 23%, P = .004, respectively). However, there were no differences in number of re-excisions, margin status, and margin size between the two groups. On multivariate analysis, preoperative MRI and age were independently associated with mastectomy (OR, 3.16, P = .018; OR, 0.95, P = .031, respectively), while multifocality, size, and family history were not significant predictors.

CONCLUSION

We found a strong association between preoperative MRI and mastectomy in women undergoing treatment for DCIS. Additional studies are needed to examine the increased rates of mastectomy as a possible consequence of preoperative MRI for DCIS.

Ductal carcinoma in situ (DCIS) of the breast: perspectives on biology and controversies in current management

The incidence of ductal carcinoma in situ (DCIS) has increased because of increasing use of sensitive imaging modalities. MRI is commonly used for the detection of breast cancer but has not yet been validated in randomized trials. There have not been randomized trials addressing optimal margins of excision or axillary sampling. Whole breast radiation after lumpectomy decreases the risk of recurrence but may be omitted in selected patients. Adjuvant Tamoxifen reduces the risk of recurrence but has no impact on overall survival rates.

Characterization of ductal carcinoma in situ on diffusion weighted breast MRI

OBJECTIVES

To characterize ductal carcinoma in situ (DCIS) and its subtypes on diffusion-weighted imaging (DWI).

METHODS

We retrospectively reviewed 74 pure DCIS lesions in 69 women who underwent DWI at 1.5 T (b = 0 and 600 s/mm(2)). Each lesion was characterized by qualitative DWI intensity, quantitative DWI lesion-to-normal contrast-to-noise ratio (CNR), and quantitative apparent diffusion coefficient (ADC). The detection rate was calculated with predetermined thresholds for each parameter. The effects of lesion size, grade, morphology, and necrosis were assessed.

RESULTS

Ninety-six percent (71/74) of DCIS lesions demonstrated greater qualitative DWI intensity than normal breast tissue. Quantitatively, DCIS lesions demonstrated on average 56% greater signal than normal tissue (mean CNR = 1.83  ±  2.7) and lower ADC values (1.50 ± 0.28 × 10(-3) mm(2)/s) than normal tissue (2.01 ± 0.37 × 10(-3) mm(2)/s, p < 0.0001). A 91% detection rate was achieved utilizing an ADC threshold (<1.81 × 10(-3) mm(2)/s ). Non-high-grade DCIS exhibited greater qualitative DWI intensity (p = 0.02) and quantitative CNR (p = 0.01) than high-grade DCIS but no difference in ADC (p = 0.40). Lesion size, morphology, and necrosis did not affect qualitative or quantitative DWI parameters of DCIS lesions (p > 0.05).

CONCLUSIONS

DCIS lesions have higher DWI signal intensity and lower ADC values than normal breast tissue. DWI warrants further investigation as a potential non-contrast MRI tool for early breast cancer detection.

The impact of sentinel lymph node biopsy and magnetic resonance imaging on important outcomes among patients with ductal carcinoma in situ

The objective of this systematic review was to determine the impact of sentinel lymph node (SLN) biopsy and breast magnetic resonance imaging (MRI) on important outcomes for patients with ductal carcinoma in situ. We identified no study that directly evaluated important outcomes for SLN biopsy. So, we determined the incidence of SLN metastases among patients with ductal carcinoma in situ. Using American Joint Committee on Cancer criteria, the incidence of pN1 and pN1(mic) SLN metastases were 0.9% and 1.5%, respectively. Because the incidence of SLN metastasis is very low, SLN biopsy is not likely to affect important outcomes. We identified one study that directly evaluated important outcomes after breast MRI. In this study, the use of MRI did not affect local recurrence rates after breast-conserving surgery and radiation. Although MRI may identify occult multicentric or contralateral breast cancer in some patients, it may also lead to unnecessary biopsies and overtreatment.

Magnetic resonance imaging of the breast: recommendations from the EUSOMA working group

The use of breast magnetic resonance imaging (MRI) is rapidly increasing. EUSOMA organised a workshop in Milan on 20-21st October 2008 to evaluate the evidence currently available on clinical value and indications for breast MRI. Twenty-three experts from the disciplines involved in breast disease management - including epidemiologists, geneticists, oncologists, radiologists, radiation oncologists, and surgeons - discussed the evidence for the use of this technology in plenary and focused sessions. This paper presents the consensus reached by this working group. General recommendations, technical requirements, methodology, and interpretation were firstly considered. For the following ten indications, an overview of the evidence, a list of recommendations, and a number of research issues were defined: staging before treatment planning; screening of high-risk women; evaluation of response to neoadjuvant chemotherapy; patients with breast augmentation or reconstruction; occult primary breast cancer; breast cancer recurrence; nipple discharge; characterisation of equivocal findings at conventional imaging; inflammatory breast cancer; and male breast. The working group strongly suggests that all breast cancer specialists cooperate for an optimal clinical use of this emerging technology and for future research, focusing on patient outcome as primary end-point.

Diagnostic breast MR imaging: current status and future directions

Breast MRI has become an integral component in breast imaging. Indications have become clearer and better defined. Guidelines and recommendations are evolving and many are recognized and published. Future applications are exciting and may possibly improve our ability to diagnose breast cancer, improving the patient's treatment options and ultimately patient outcome.

Ductal carcinoma in situ of the breast: a systematic review of incidence, treatment, and outcomes

BACKGROUND

The National Institutes of Health Office of Medical Applications of Research commissioned a structured literature review on the incidence, treatment, and outcomes of ductal carcinoma in situ (DCIS) as a background article for the State of the Science Conference on Diagnosis and Management of DCIS.

METHODS

Published studies were identified and abstracted from MEDLINE and other sources. We include articles published between 1965 and January 31, 2009; 374 publications were identified that addressed DCIS incidence, staging, treatment, and outcomes in adult women.

RESULTS

In the United States, DCIS incidence rose from 1.87 per 100 000 in 1973-1975 to 32.5 in 2004. Incidence increased in all ages but more so in women older than 50 years. Increased use of mammography explains some but not all of the increased incidence. Risk factors for incident DCIS include older age and family history. Although tamoxifen treatment prevented both invasive breast cancer and DCIS, raloxifene treatment decreased incidence of invasive breast cancer but not DCIS. Among patients with DCIS, magnetic resonance imaging was more sensitive than mammography for detecting multicentric disease and estimating tumor size. Because about 15% of patients with DCIS identified on core needle biopsy are diagnosed with invasive breast cancer after excision or mastectomy, the accuracy of sentinel lymph node biopsy after excision is relevant to surgical management of DCIS. Most studies demonstrated that sentinel lymph node biopsy is feasible after breast-conserving surgery (BCS). Younger age, positive surgical margins, tumor size and grade, and comedo necrosis were consistently related to DCIS recurrence. DCIS outcomes after either mastectomy or BCS plus radiation therapy were superior to BCS alone. Tamoxifen treatment after DCIS diagnosis reduced risk of recurrent disease.

CONCLUSIONS

Scientific questions deserving further investigation include the relationship between mammography use and DCIS incidence and whether imaging technologies and treatment guidelines can be modified to focus on lesions that are most likely to become clinically problematic.