Avoiding preoperative breast MRI when conventional imaging is sufficient to stage patients eligible for breast conserving therapy
Introduction
There is a persisting controversy about the role of contrast-enhanced magnetic resonance imaging (MRI) of the breast in patients with known breast cancer and eligible for breast conserving therapy (BCT). BCT includes limited surgery to excise the tumor and postoperative radiotherapy. Several studies demonstrated that MRI has superior sensitivity to detect invasive breast cancer compared to conventional imaging (mammography and ultrasound) and clinical breast examination (CBE) [1], [2], [3], [4]. This sensitivity leads to improved definition of tumor extent [4], [5]. As a result, MRI has been expected to increase complete resection rates, breast cancer control and cosmetic outcome, but these effects have not been demonstrated consistently.
Opponents of the routine use of preoperative breast MRI point at the risk of overdiagnosis and overtreatment, increase in cost, delay in surgery, increased patient anxiety, and the ability of adjuvant therapy to eradicate possible additional disease foci [2], [6]. Conversely, it has been postulated that if lumpectomy margins need to be clear from microscopic disease in order to reduce the risk of local recurrence, small foci detected on MRI also need identification and excision [7].
The use of MRI in the preoperative staging of BCT is recommended by a number of studies [8], [9], but remains controversial in others [2], [6]. Meanwhile, preoperative breast MRI is increasingly used, and the need for clinical guidelines rises.
Parallel to the efforts to define the role of preoperative MRI in the ipsilateral breast, both the European Society of Breast Imaging, and the American College of Radiology (ACR) have recommended the use of MRI to screen the contralateral breast in patients with proven cancer [9], [10]. More recently the European Society of Breast Cancer Specialists (EUSOMA) has published general recommendations for the application of breast MRI [11]. The authors acknowledged that preoperative MRI may have potential advantages for particular subgroups (e.g., patients with invasive lobular cancer and women at high risk for breast cancer), but recommended further research.
There is similarity between conventional imaging and MRI in approximately 85% of BCT patients [12], [13], [14]. So regardless which guidelines are used for preoperative breast MRI, the value of this technique can be disputed in this group of patients. If this group could be identified prior to the decision to perform the MRI, studies on MRI-detected additional disease could be powered more efficiently while reducing the number of clinical procedures and cost.
Our aim was to investigate clinical, pathological and imaging characteristics available prior to MRI to identify patients who are expected to have MRI findings similar to conventional imaging findings. Combined with existing knowledge on preoperative breast MRI we formulated practical guidelines to determine in which patients a preoperative breast MRI can be omitted.
Section snippets
Patients
The cohort consisted of women with invasive breast cancer who participated in the MARGINS (Multi-modality Analysis and Radiogical Guidance IN breast conServing therapy) study conducted at the Netherlands Cancer Institute, between 2000 and 2008. The aim of this single-institution study was to investigate the use of conventional imaging in combination with MRI to improve the assessment of extent and localization of the disease. In the MARGINS study, women with pathology-proven invasive breast
Results
The study group consisted of 685 women with 692 breasts cancers (7 initially bilateral). The mean age was 56.6 years, standard deviation 10.4 years. The majority, 76.5%, had invasive ductal cancer (IDC) and 20% had invasive lobular cancer (ILC). Additional malignant disease on MRI (i.e., discordant findings with conventional imaging) was detected in 107 of the 692 breasts (15.5%) (Table 1).
Of the 237 tumors with postoperative positive lymph nodes, 54 (22.8%) were detected preoperatively by
Discussion
Since the introduction of BCT it is known and accepted that not all disease is visualized on imaging. It was and still is assumed that undetected disease foci will be controlled by adjuvant treatments [19], [20]. Progression in the field of preoperative imaging, in particular MRI, enabled detection and addressing of these foci more extensively, but it is currently unclear if patients benefit from this development in terms of a better surgical outcome and prognosis. These aspects of breast MRI,
Conclusion
Prior to preoperative breast MRI, it is feasible to identify a subgroup of patients who will most likely show similar results on conventional imaging as on the MRI. These findings enabled us to establish a practical consensus when to avoid preoperative breast MRI in our clinical practice.
Conflict of interest statement
The authors declare that they have no conflict of interest.
Acknowledgments
This work was financially supported by The Dutch Cancer Foundation; grant number NKB 2004-3082.
The authors thank Angelique Schlief, Anita Paape, Eline Deurloo, and Wilma Heemsbergen for their contribution.
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