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.

Preoperative breast cancer staging with multi-modality imaging and surgical outcomes.

PURPOSE: To compare the rates of mastectomy and re-operation after breast-conserving surgery (BCS) among patients who had different pre-operative multi-modality imaging, hence identifying significant predictors of mastectomy and re-operations within each group. METHOD: Retrospective study of consecutive patients with primary breast cancer treated January 2010 - December 2016, divided in 3 groups, undergoing pre-operative local staging respectively with conventional imaging modalities only (2D mammography, ultrasound (US)), conventional imaging and tomosynthesis (DBT) and/or MRI. The primary outcome was identification of significant predictors of surgical outcomes, within each group. Study variables examined in univariate analysis were age, lesion dimension, breast density, multifocality, tumor size, histology, and if associated with outcomes they were included in binary logistic regression analysis. RESULTS: Amongst 1547 patients, patient and tumor characteristics differed across the three groups, as did mastectomy rates which were 18 % (102/562) for 2D + US, 36 % (154/428) for 2D + DBT + US, 45 % (250/557) for 2D+/-DBT + US + MRI(p < 0.001). Variables strongly associated with mastectomy were larger lesions and multifocality (as was multi-modality group). Re-operation rate showed an opposite trend: 12.2 % (56/459) for 2D + US, 8 % (22/272) for 2D + DBT + US, 6.5 % (20/306) for 2D+/-DBT + US + MRI. Re-operation rate for 2D+/-DBT + US + MRI was lower than for 2D + US (p = 0.01) but similar to 2D + DBT + US (p = 0.58). Patients who had 2D + US and re-operations had significantly larger lesions, more underestimation, higher proportion of invasive carcinoma with in-situ component than those who did not require re-operation. CONCLUSIONS: Patients who had larger tumors and multifocal disease were more frequently staged by adding DBT and/or MRI to conventional imaging (mammography and US) which was associated with more extensive surgical treatment but lower reoperation rates.

Preoperative breast MRI and mortality in older women with breast cancer.

PURPOSE: The survival benefit from detecting additional breast cancers by preoperative magnetic resonance imaging (MRI) continues to be controversial. METHODS: We followed a cohort of 4454 women diagnosed with non-metastatic breast cancer (stage I-III) from 2/2005-6/2010 in five registries of the breast cancer surveillance consortium (BCSC). BCSC clinical and registry data were linked to Medicare claims and enrollment data. We estimated the cumulative probability of breast cancer-specific and all-cause mortality. We tested the association of preoperative MRI with all-cause mortality using a Cox proportional hazards model. RESULTS: 917 (20.6%) women underwent preoperative MRI. No significant difference in the cumulative probability of breast cancer-specific mortality was found. We observed no significant difference in the hazard of all-cause mortality during the follow-up period after adjusting for sociodemographic and clinical factors among women with MRI (HR 0.90; 95% CI 0.72-1.12) compared to those without MRI. CONCLUSION: Our findings of no breast cancer-specific or all-cause mortality benefit supplement prior results that indicate a lack of improvement in surgical outcomes associated with use of preoperative MRI. In combination with other reports, the results of this analysis highlight the importance of exploring the benefit of preoperative MRI in patient-reported outcomes such as women's decision quality and confidence levels with decisions involving treatment choices.

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.

Current Approaches to Diagnosis and Treatment of Ductal Carcinoma In Situ and Future Directions.

The presentation and treatment of ductal carcinoma in situ (DCIS) has changed substantially over the years. While previously an incidental pathologic finding in more advanced, palpable tumors, the institution of screening mammography has repositioned this disease entity as one largely diagnosed as a non-palpable lesion, often prior to any invasive disease. As DCIS is a precursor to invasive carcinoma, evolution in the approach to treatment has followed in the footsteps of that for invasive disease, including breast conservation therapy, adjuvant radiation, and use of antihormonal therapy. Survival outcomes for DCIS are very high and more recent literature has investigated tailoring therapeutic approaches to avoid overtreatment. Two important areas of ongoing clinical debate concerning overtreatment include use of preoperative MRI and the role of adjuvant radiation. The heterogeneity of the disease makes it difficult to differentiate lesions that would benefit from more aggressive treatment from those in which overtreatment could be avoided. Clinical characteristics, such as histologic appearance, age at diagnosis, and margin status at tumor excision have been established as moderate predictors of disease recurrence, but none has provided strong enough evidence as to guide consensus decisions on adjuvant therapy. Continuing research seeks to define the genetic and molecular characteristics that can predict disease course and serve as the potential targets for novel therapeutic agents. While several markers have shown promise in differentiating tumor aggressiveness, there is still much to be discovered about the precise mechanisms of disease progression and how this can be applied clinically to optimize treatment.

Relationship between preoperative breast MRI and surgical treatment of non-metastatic breast cancer.

BACKGROUND AND OBJECTIVES: More extensive surgical treatments for early stage breast cancer are increasing. The patterns of preoperative MRI overall and by stage for this trend has not been well established. METHODS: Using Breast Cancer Surveillance Consortium registry data from 2010 through 2014, we identified women with an incident non-metastatic breast cancer and determined use of preoperative MRI and initial surgical treatment (mastectomy, with or without contralateral prophylactic mastectomy (CPM), reconstruction, and breast conserving surgery ± radiation). Clinical and sociodemographic covariates were included in multivariable logistic regression models to estimate adjusted odds ratios and 95% confidence intervals. RESULTS: Of the 13 097 women, 2217 (16.9%) had a preoperative MRI. Among the women with MRI, results indicated 32% higher odds of unilateral mastectomy compared to breast conserving surgery and of mastectomy with CPM compared to unilateral mastectomy. Women with preoperative MRI also had 56% higher odds of reconstruction. CONCLUSION: Preoperative MRI in women with DCIS and early stage invasive breast cancer is associated with more frequent mastectomy, CPM, and reconstruction surgical treatment. Use of more extensive surgical treatment and reconstruction among women with DCIS and early stage invasive cancer whom undergo MRI warrants further investigation.

Practical Considerations for the Use of Breast MRI for Breast Cancer Evaluation in the Preoperative Setting.

Preoperative contrast-enhanced (CE) breast magnetic resonance imaging (MRI) remains controversial in the newly diagnosed breast cancer patient. Additional lesions are frequently discovered in these patients with CE breast MRI. As staging and treatment planning evolve to include more information on tumor biology and aggression, so should our consideration of extent of disease. Directing CE breast MRI to those patients most likely to have additional disease may be beneficial. We sought to develop practical guidance for the use of preoperative CE breast MRI in the newly diagnosed breast cancer patient based on recent scientific data. Our review suggests several populations for whom preoperative breast MRI is most likely to find additional disease beyond that seen on conventional imaging. These can be viewed in three categories: (1) tumor biology-patients with invasive lobular carcinoma or aggressive tumors such as triple negative breast cancer (estrogen receptor negative, progesterone receptor negative, and human epidermal growth factor receptor 2 (HER2) negative) and HER2 positive tumors; (2) patient characteristics-dense breast tissue or younger age, especially those age <60; and (3) clinical scenarios-patients with more sonographic disease than expected or those who are node positive at initial diagnosis. Focusing breast MRI on patients with any of the aforementioned characteristics may help utilize preoperative breast MRI where it is likely to have the most impact.

Preoperative Breast MRI: Surgeons' Patient Selection Patterns and Potential Bias in Outcomes Analyses.

OBJECTIVE: The purpose of this study is to determine which patient- and tumor-related and clinical variables influence dedicated breast surgeons' and general surgeons' referrals for preoperative breast MRI for patients with newly diagnosed breast cancer. MATERIALS AND METHODS: Surgeons who perform breast surgery responded to a survey from June 16, 2014, through August 11, 2014. Participants self-identified as breast or general surgeons and provided professional practice details. They used Likert scores (range, 1-7 with increasing likelihood to order MRI) to weigh numerous patient- and tumor-related and clinical variables. Mean likelihood scores were calculated and compared using a linear mixed model. A p ≤ 0.05 was considered statistically significant. RESULTS: Two hundred eighty-nine surveys from 154 (53%) breast surgeons and 135 (47%) general surgeons showed an overall likelihood to refer for patients with a BRCA mutation (mean Likert score, 6.17), familial (mean Likert score, 5.33) or personal (mean Likert score, 5.10) breast cancer history, extremely dense breasts (mean Likert score, 5.30), age younger than 40 years (mean Likert score, 5.24), axillary nodal involvement (mean Likert score, 6.22), tumor that is mammographically occult (mean Likert score, 5.62) or fixed to the pectoralis (mean Likert score, 5.49), tumor that is a candidate for neoadjuvant treatment (mean Likert score, 5.38), multifocal or multicentric disease (mean Likert score, 5.22), invasive lobular carcinoma (mean Likert score, 5.20), T3 (mean Likert score, 4.48) or T2 (mean Likert score, 4.41) tumor, triple-negative breast cancer (mean Likert score, 4.66), a patient who is a candidate for mastectomy requesting breast conservation therapy (mean Likert score, 5.27), and radiologists' recommendations (mean Likert score, 5.19). Across all patient ages, breast surgeons referred more often than did general surgeons (mean Likert score, 4.32 vs 3.92; p = 0.03), especially for patients with BRCA mutation (mean Likert score, 6.39 vs 5.93; p = 0.01) and tumors smaller than 1 cm (mean Likert score, 3.84 vs 3.40; p = 0.002). Breast surgeons referred less often than did general surgeons for multifocal or multicentric disease (mean Likert score, 5.02 vs 5.44; p = 0.001). Breast surgeons and general surgeons similarly weighed other variables. CONCLUSION: Preoperative breast MRI referral trended with certain higher risk patient- and tumor-related and clinical variables and were nonuniform between the breast surgeons and general surgeon cohorts. Selection bias could affect outcomes analyses for preoperative breast MRI.

Does Preoperative MRI Workup Affect Mastectomy Rates and/or Re-excision Rates in Patients with Newly Diagnosed Breast Carcinoma? A Retrospective Review.

The purpose of this study is to determine whether including breast magnetic resonance imaging (MRI) in the preoperative workup of patients with known breast cancer has an impact on mastectomy and/or re-excision rates. This is an Institutional Review Board approved HIPAA compliant retrospective study reviewing the impact MRI has on mastectomy and re-excision rates in patients with newly diagnosed breast cancer. Our study compares two groups: (i) 154 patients who did not receive preoperative MRIs and served as a control group and (ii) 96 patients who received preoperative breast MRIs. Patient race and age between the two populations were not statistically different. The difference in mastectomy rates between the two populations was 10.7%; although not statistically different, the p value of 0.10 suggests a trend toward significance. The re-excision rates between the two populations, however, were significantly different (p < 0.001), with women in the control group having a higher re-excision rate than those in the study group. The difference between involved and clear margins was significant as well (p = 0.002), with patients undergoing preoperative MRI more likely to have negative margins. Preoperative breast MRI significantly decreases the likelihood of involved margins as well as the need for surgical re-excision. Preoperative breast MRI does not result in a statistically significant difference in mastectomy rates, although further investigation is required to determine whether there is a trend towards statistical significance.

Resonancia magnética mamaria preoperatoria: la gran polémica / Preoperative breast MRI: the great controversy

Preoperative examination intended to detect multifocality, multicentricity and bilaterality-once considered the strongest indication of breast magnetic resonance imaging (MRI)-is currently being strongly questioned in medical literature. This paper aims at evaluating, based on our experience at Clínica Alemana, Santiago, Chile, breast MRI ability to improve preoperative radiological tumour staging by conventional methods, as well as to determine the proportion of patients in which this diagnostic procedure generated changes in the surgical management. We retrospectively reviewed preoperative MRI studies carried out between January 2009 and June 2010. Classification: Group 1: MRI provided no new information. Group 2: by detecting additional lesions, MRI improved radiological staging without changing the type of surgery planned. Group 3: MRI showed new benign lesions and caused unnecessary surgery. Group 4: MRI successfully changed the type of surgery planned based on conventional studies. A total of 419 breast MRI scans were performed during a 18-month period; 39 percent of them were carried out preoperatively. For the analysis, 128 patients were enrolled and distributed in the following categories: Group 1 (66 percent), Group 2 (20 percent), Group 3 (2 percent) and Group 4 (12 percent). In 95.3 percent of the patients, a single surgery with clear margins was performed. This work demonstrated the usefulness of preoperative MRI in our practice, i.e., it allowed for a better radiological staging in one third of the patients and even successfully changed the surgical approach in 12 percent of cases.

El estudio preoperatorio en búsqueda de multifocalidad, multicentricidad y bilateralidad -antes considerada la indicación más sólida de la resonancia magnética (RM) mamaria- hoy se encuentra fuertemente cuestionada en la literatura. En este trabajo nos propusimos evaluar la capacidad de la RM mamaria en nuestro centro para mejorar la etapificación radiológica preoperatoria realizada por métodos convencionales y determinar la proporción de las pacientes en que genera cambio en el enfoque quirúrgico. Hemos revisado retrospectivamente las RM preoperatorias entre enero de 2009 y junio de 2010. Clasificación: Grupo1: la RM no aportó información nueva. Grupo 2: al detectar lesiones adicionales, mejoró la etapificación radiológica, sin cambiar el tipo de la cirugía planificada. Grupo3: demostró nuevas lesiones no malignas y causó cirugía inútil. Grupo 4: cambió correctamente el tipo de cirugía planeada en base a los estudios convencionales. En los 18 meses se realizaron 419 RM mamarias, el 39 por ciento de ellas en preoperatorio. Para el análisis se han reclutado 128 pacientes con la siguiente distribución en los grupos predeterminados: Grupo 1(66 por ciento), Grupo 2(20 por ciento), Grupo 3(2 por ciento) y Grupo 4(12 por ciento). En el 95,3 por ciento de las pacientes se logró realizar una sola cirugía con márgenes libres. Este trabajo demostró la utilidad de la RM preoperatoria en nuestra práctica: permite una mejor etapificación radiológica en el tercio de las pacientes e incluso cambia correctamente el enfoque quirúrgico en el 12 por ciento de los casos.