Low rates of additional cancer detection by magnetic resonance imaging in newly diagnosed breast cancer patients who undergo preoperative mammography and ultrasonography

Third-look contrast-enhanced ultrasonography plus needle biopsy for differential diagnosis of magnetic resonance imaging-only detected breast lesions

Research has shown that in approximately 20-30% of cases, breast lesions that were not detected on mammography (MG) or ultrasonography (US) were incidentally found during preoperative magnetic resonance imaging (MRI) examination for breast cancer. MRI-guided needle biopsy is recommended or considered for such MRI-only detected breast lesions invisible on second-look US, but many facilities in Japan cannot perform this biopsy procedure because it is expensive and time consuming. Thus, a simpler and more accessible diagnostic method is needed. Two studies to date have shown that third-look contrast-enhanced US (CEUS) plus needle biopsy for MRI-only detected breast lesions (i.e., MRI + /MG-/US-) that were not detected on second-look US showed moderate/high sensitivity (57.1 and 90.9%) and high specificity (100.0% in both studies) with no severe complications. In addition, the identification rate was higher for MRI-only lesions with a higher MRI BI-RADS category (i.e., category 4/5) than for those with a lower category (i.e., category 3). Despite the fact that there are limitations in our literature review, CEUS plus needle biopsy is a feasible and convenient diagnostic tool for MRI-only lesions invisible on second-look US and is expected to reduce the frequency of MRI-guided needle biopsy. When third-look CEUS does not reveal MRI-only lesions, a further indication for MRI-guided needle biopsy should be considered according to the BI-RADS category.

Breast Imaging During Pregnancy and Lactation

Breast imaging during pregnancy and lactation is important in order to avoid delays in the diagnosis and treatment of pregnancy-associated breast cancers. Radiologists have an opportunity to improve breast cancer detection by becoming familiar with appropriate breast imaging and providing recommendations to women and their referring physicians. Importantly, during pregnancy and lactation, both screening and diagnostic breast imaging can be safely performed. Here we describe when and how to screen, how to work up palpable masses, and evaluate bloody nipple discharge. The imaging features of common findings in the breasts of pregnant and lactating women are also reviewed. Finally, we address breast cancer staging and provide a brief primer on treatment options for pregnancy-associated breast cancers.

Is contralateral breast ultrasound worthwhile in preoperative staging of breast cancer?

BACKGROUND

Women with invasive breast cancer are at higher risk of contralateral synchronous cancer. This study aimed at determining if contralateral breast ultrasound (CBUS) examination should be routinely performed in the preoperative evaluation of breast cancer patients.

METHODS

This is a retrospective study of preoperative CBUS examinations performed between January 2012 and April 2015. The charts of patients presenting for biopsy of a Breast Imaging Reporting and Data System (BIRADS) 5 lesion and who had undergone a concomitant contralateral breast US examination were reviewed. Index tumor, lymph node status, American College of Radiology (ACR) breast density on mammogram, total scanning time, and results of CBUS were recorded.

RESULTS

Of the 3007 patients who underwent breast biopsies during the study period, 360 patients met the inclusion criteria. Index mass size was 19 ± 10 mm. CBUS examination led to 76 biopsies, of which 12 were positive in 11 patients. Detection rate for mammographically occult contralateral invasive cancers was 3.1% (11/360). Contralateral lesion size was 13 ± 10 mm. Breast density was rated ACR C/D for nine women and ACR B for two. In the ACR C/D subgroup (82%), the contralateral cancer detection rate was 4.1%. Average additional scanning time spent required to perform CBUS examination was 3.1 ± 4.9 min. Patients diagnosed with contralateral invasive breast cancer underwent surgery and/or chemotherapy. The treatment strategy was changed in all 11 patients after the detection of a second primary cancer.

CONCLUSION

Preoperative CBUS is effective and most beneficial with women presenting ACR C/D breast density. Given its impact on decreasing future morbidity, its routine use should be considered to improve quality healthcare for women diagnosed with breast cancer.

ACR Appropriateness Criteria® Breast Imaging of Pregnant and Lactating Women

Breast imaging during pregnancy and lactation is challenging due to unique physiologic and structural breast changes that increase the difficulty of clinical and radiological evaluation. Pregnancy-associated breast cancer (PABC) is increasing as more women delay child bearing into the fourth decade of life, and imaging of clinical symptoms should not be delayed. PABC may present as a palpable lump, nipple discharge, diffuse breast enlargement, focal pain, or milk rejection. Breast imaging during lactation is very similar to breast imaging in women who are not breast feeding. However, breast imaging during pregnancy is modified to balance both maternal and fetal well-being; and there is a limited role for advanced breast imaging techniques in pregnant women. Mammography is safe during pregnancy and breast cancer screening should be tailored to patient age and breast cancer risk. Diagnostic breast imaging during pregnancy should be obtained to evaluate clinical symptoms and for loco-regional staging of newly diagnosed PABC. 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 include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Predictive value of breast magnetic resonance imaging in detecting mammographically occult contralateral breast cancer: Can we target women more likely to have contralateral breast cancer?

BACKGROUND AND OBJECTIVES

Preoperative breast magnetic resonance imaging (B-MRI) staging in newly diagnosed breast cancer increases detection of synchronous contralateral findings, but may result in false-positive outcomes. This study objective was to identify women more likely of having mammographically occult, MRI detected contralateral breast cancer (CBC).

METHODS

We performed a retrospective review of patients who had preoperative B-MRI prior to surgery from 2010 to 2015 and collected patient imaging and clinicopathologic data. Multivariate logistic regression was used to identify predictors of CBC.

RESULTS

MRI resulted in contralateral findings in 201 of 1894 patients (10.6%). Overall 3.2% (60 of 1894) had synchronous CBC detected on B-MRI. The majority of CBCs (n = 60) were stage 0 or IA (85.0%), hormone receptor positive (94.9%), human epidermal growth factor receptor 2 (HER2/neu) negative (89.7%), and low/intermediate pathological grade (87.2%). Women more likely to have CBC were older (P < .001), had lobular index cancer (P = .03), and estrogen receptor (ER)+ (P = .027) or progesterone receptor (PR)+ (P = .002) tumors. On multivariate analysis (receiver operating characteristic curve area = 0.75), PR + status (P = .022), and older age (P = .004) were predictive of CBC.

CONCLUSIONS

Preoperative MRI is most effective in detecting early stage, hormone receptor-positive CBC in older women.

Preoperative Breast Magnetic Resonance Imaging Use by Breast Density and Family History of Breast Cancer

BACKGROUND

Use of preoperative breast magnetic resonance imaging (MRI) among women with a new breast cancer has increased over the past decade. MRI use is more frequent in younger women and those with lobular carcinoma, but associations with breast density and family history of breast cancer are unknown.

MATERIALS AND METHODS

Data for 3075 women ages >65 years with stage 0-III breast cancer who underwent breast conserving surgery or mastectomy from 2005 to 2010 in the Breast Cancer Surveillance Consortium were linked to administrative claims data to assess associations of preoperative MRI use with mammographic breast density and first-degree family history of breast cancer. Multivariable logistic regression estimated adjusted odds ratios (OR) and 95% confidence intervals (95% CI) for the association of MRI use with breast density and family history, adjusting for woman and tumor characteristics.

RESULTS

Overall, preoperative MRI use was 16.4%. The proportion of women receiving breast MRI was similar by breast density (17.6% dense, 16.9% nondense) and family history (17.1% with family history, 16.5% without family history). After adjusting for potential confounders, we found no difference in preoperative MRI use by breast density (OR = 0.95 for dense vs. nondense, 95% CI: 0.73-1.22) or family history (OR = 0.99 for family history vs. none, 95% CI: 0.73-1.32).

CONCLUSIONS

Among women aged >65 years with breast cancer, having dense breasts or a first-degree relative with breast cancer was not associated with greater preoperative MRI use. This utilization is in keeping with lack of evidence that MRI has higher yield of malignancy in these subgroups.

Clinical accuracy of preoperative breast MRI for breast cancer

BACKGROUND

It is unclear if breast magnetic resonance imaging (MRI) is more accurate than mammography (MGM) and ultrasound (U/S) in aggregate for patients with invasive cancer.

METHODS

We compared concordance of combined tumor size and tumor foci between MRI and MGM and U/S combined to pathological tumor size and foci as the gold standard from 2009 to 2015. Tumor size was nonconcordant if it differed from the pathologic size by ≥33% and tumor foci was nonconcordant if >1 foci were seen. If one or both of the MGM or U/S was nonconcordant and the MRI was concordant, MRI provided greater accuracy.

RESULTS

Of 471 patients with MGM, US, and MRI, MRI was more accurate for 32.9% of patients for tumor size and for 21.9% for tumor foci. Patients for whom MRI had greater accuracy were compared to those who did not for clinical and tumor factors. The only significant factor was calcifications on mammography. Tumor size, stage, molecular subtype, histology, grade, patient BMI, age, mammographic density, and use of hormone replacement therapy were not significantly different.

CONCLUSIONS

Breast MRI provides greater accuracy for a third of patients undergoing preoperative MGM and U/S. Mammographic calcifications were associated with MRI clinical accuracy for patients with invasive cancer.

Incremental Cancer Detection of Locoregional Restaging with Diagnostic Mammography Combined with Whole-Breast and Regional Nodal Ultrasound in Women with Newly Diagnosed Breast Cancer

RATIONALE AND OBJECTIVES

This study aims to determine if locoregional restaging with diagnostic mammography and ultrasound (US) of the whole breast and regional nodes performed for quality assurance in women with newly diagnosed breast cancer who were referred to a tertiary care center yields incremental cancer detection.

MATERIALS AND METHODS

An institutional review board-approved retrospective, single-institution database review was performed on the first 1000 women referred to our center in 2010 with a provisional breast cancer diagnosis. Locoregional restaging consisted of diagnostic full-field digital mammography combined with US of the whole breast and regional nodal basins. Bilateral whole-breast US was performed in women with contralateral mammographic abnormality or had heterogeneously or extremely dense parenchyma. Demographic, clinical, and pathologic factors were analyzed.

RESULTS

Final analyses included 401 women. Of the 401 women, 138 (34%) did not have their outside images available for review upon referral. The median age was 54 years (range 21-92); the median tumor size was 2.9 cm (range 0.6-18.0) for women whose disease was upstaged and 2.2 cm (range 0.4-15.0) for women whose disease was not upstaged. Incremental cancer detection rates were 15.5% (62 of 401) in the ipsilateral breast and 3.9% (6 of 154) in the contralateral breast (P < 0.0001). The total upstage rate was 25% (100 of 401). Surgical management changed from segmentectomy to mastectomy in 12% (50 of 401). The re-excision rate after segmentectomy was 19% (35 of 189).

CONCLUSIONS

Locoregional restaging with diagnostic mammography combined with whole-breast and regional nodal US that is performed for standardization of the imaging workup for newly diagnosed breast cancer patients can reduce underestimation of disease burden and impact therapeutic planning.

Whole-breast US following mammography and breast MRI in newly diagnosed breast cancer patients: can it be more than just a guidance tool for biopsy?

AIM

To evaluate the role of ultrasound (US) following magnetic resonance imaging (MRI) and mammography in patients with newly diagnosed breast cancers by assessing the additional cancer detection rate of US.

MATERIAL AND METHODS

Two hundred and twenty-five women who had undergone 225 MRI examinations followed by US were included. An US-detected additional cancer was defined as a lesion detected using breast US that had not been detected by MRI, and which was shown to be malignant at histopathology. The rate of additional cancer detection, incidence of additional malignancies, positive predictive value (PPV), and false-positive (FP) rate were analysed. Factors associated with an increase in the additional cancer detection rate were analysed.

RESULTS

The additional cancer detection rate was 0% (0/225) for the ipsilateral breast and 0.9% (2/225) for the contralateral breast, and the PPVs were 0% (0/5) and 100% (2/2), respectively. The overall TP:FP ratio was 0.4 (2:5). The additional cancer detection rate was higher for cases with moderate and severe background parenchymal enhancement than cases with minimal and mild background parenchymal enhancement (p=0.003). The additional cancer detection rate for cases with moderate and severe background parenchymal enhancement was 5.7% (2/35) for the contralateral breast (p=0.003).

CONCLUSION

Preoperative breast US following MRI and mammography can help clinicians screen for contralateral cancers with an additional detection rate of 0.9%. Moreover, whole-breast US might be a useful contralateral screening modality in cases with moderate or marked parenchymal enhancement on breast MRI.

Malignancy Rate, Number Needed to Treat, and Positive Predictive Value for Breast MRI

Breast MRI is being used more frequently for advanced screening for breast cancer. Patients may be at increased risk, or are symptomatic, with nonsuspicious mammograms. There is little data regarding the likelihood of a recommendation for biopsy, or for detecting a malignancy, in this population. We intended to determine the malignancy rate, number needed to treat, and positive predictive value for patients receiving adjunctive MRI at our institution. A retrospective review of all breast MRIs from 2008 to 2010 was done. Patients with any prior diagnosis of breast cancer, or BRCA+ were excluded. There were 324 patients. Most common reasons for ordering the breast MRI included: abnormal test result 130 (44%), palpable mass 74 (23%), family history 58 (18%), breast pain 47 (15%), and nipple discharge 45 (14%). Breast Imaging-Reporting and Data System score (BIRADS) was 1 or 2 in 36 per cent, 4 or 5 in 18 per cent, 3 in 26 per cent, 0 in 10 per cent, and not given in 9 per cent. Biopsy was recommended in 77 (24%), with biopsy actually performed in 57 (18%). Of the eight cancers identified, four (1.2%) were ductal carcinoma in situ (DCIS) and four (1.2%) were invasive cancer, yielding a true-positive rate of 2.5 per cent. Number needed to treat was 40. Positive predictive value was 14 per cent with a false-positive rate of 86 per cent. In this group of generally higher risk women, typically prescreened with mammography, 1.2 per cent had an invasive cancer, and another 1.2 per cent had DCIS. Those who undergo biopsy are 6.1 times more likely to have benign pathology. The efficacy of adjunctive breast MRI could be improved through refinements in indication, test interpretation, or alternative screening strategies.

Incremental cancer detection using breast ultrasonography versus breast magnetic resonance imaging in the evaluation of newly diagnosed breast cancer patients

OBJECTIVE

To compare the incremental cancer detection rate (ICDR) using bilateral whole-breast ultrasonography (BWBUS) vs dynamic contrast-enhanced MRI in patients with primary breast cancer.

METHODS

A retrospective database search in a single institution identified 259 patients with breast cancer diagnosed from January 2011 to August 2014 who underwent mammography, BWBUS and MRI before surgery. Patient characteristics, tumour characteristics and lesions seen on each imaging modality were recorded. The sensitivity, specificity and accuracy for each modality were calculated. ICDRs according to index tumour histology and receptor status were also evaluated. The effect of additional cancer detection on surgical planning was obtained from the medical records.

RESULTS

A total of 266 additional lesions beyond 273 index malignancies were seen on at least 1 modality, of which 121 (45%) lesions were malignant and 145 (55%) lesions were benign. MRI was significantly more sensitive than BWBUS (p = 0.01), while BWBUS was significantly more accurate and specific than MRI (p < 0.0001). Compared with mammography, the ICDRs using BWBUS and MRI were significantly higher for oestrogen receptor-positive and triple-negative cancers, but not for human epidermal growth factor receptor 2-positive cancers. 22 additional malignant lesions in 18 patients were seen on MRI only. Surgical planning remained unchanged in 8 (44%) of those 18 patients.

CONCLUSION

MRI was more sensitive than BWBUS, while BWBUS was more accurate and specific than MRI. MRI-detected additional malignant lesions did not change surgical planning in almost half of these patients.

ADVANCES IN KNOWLEDGE

BWBUS may be a cost-effective and practical tool in breast cancer staging.