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

Does pre-operative breast MRI have an impact on surgical outcomes in high-grade DCIS?

OBJECTIVES

High-grade DCIS (HG DCIS) is associated with upgrade to invasive disease but few studies evaluate the role of MRI in this subset of DCIS. This study compared surgical outcomes of females with HG DCIS on biopsy who had pre-operative MRI with those that proceeded directly to surgery.

METHODS

This single-centre retrospective, observational study identified patients with pure HG DCIS on pre-operative biopsy from the pathology database. Surgical outcomes, clinicopathological and radiological features were obtained for all patients.

RESULTS

From August 2015 to February 2020, 217 patients had HG DCIS on biopsy. Pre-operative MRI was performed in 40 (MRI group) and not in 88 (No MRI group) patients. Initial mastectomy was performed in 25/40 (63%) women in the MRI group and 20/88 (23%) women in the no MRI group (p < 0.0001). No difference was observed in re-operation rate between the two groups, 15% in MRI group vs 22% in No MRI group (p = 0.4749). Mean tumour size on histology was larger in mastectomy cases in the MRI group (73.4 mm, range 6-140 mm), than the total MRI group, (58.3 mm, range 0-140 mm) or no MRI group (30.7 mm, range 0-130 mm) (p < 0.0001).

CONCLUSIONS

Pre-operative MRI in HG DCIS is associated with higher mastectomy rates, possibly due to patient selection for MRI, as tumours on final histology were significantly larger. Fewer re-operations were observed in the MRI group although this was not significant.

ADVANCES IN KNOWLEDGE

Breast MRI performed pre-operatively in HG DCIS is associated with higher mastectomy rates and fewer re-operation rates.

Diffusion-weighted Breast MRI in Prediction of Upstaging in Women with Biopsy-proven Ductal Carcinoma in Situ

Background Accurate preoperative prediction of upstaging in women with biopsy-proven ductal carcinoma in situ (DCIS) is important for surgical planning, but published models using predictive MRI features remain lacking. Purpose To develop and validate a predictive model based on preoperative breast MRI to predict upstaging in women with biopsy-proven DCIS and to select high-risk women who may benefit from sentinel lymph node biopsy at initial surgery. Materials and methods Consecutive women with biopsy-proven DCIS who underwent preoperative 3.0-T breast MRI including dynamic contrast-enhanced (DCE) MRI and diffusion-weighted imaging (DWI) and who underwent surgery between June 2019 and March 2020 were retrospectively identified (development set) from an academic medical center. The apparent diffusion coefficients of lesions from DWI, lesion size and morphologic features on DCE MRI scans, mammographic findings, age, symptoms, biopsy method, and DCIS grade at biopsy were collected. The presence of invasive cancer and axillary metastases was determined with surgical pathology. A predictive model for upstaging was developed by using multivariable logistic regression and validated in a subsequent prospective internal validation set recruited between July 2020 and April 2021. Results Fifty-seven (41%) of 140 women (mean age, 53 years ± 11 [SD]) in the development set and 43 (41%) of 105 women (mean age, 53 years ± 10) in the validation set were upstaged after surgery. The predictive model combining DWI and clinical-pathologic factors showed the areas under the receiver operating characteristic curve at 0.87 (95% CI: 0.80, 0.92) in the development set and 0.76 (95% CI: 0.67, 0.84) in the validation set. The predicted probability of invasive cancer showed good interobserver agreement (intraclass correlation coefficient, 0.79); the positive predictive value was 85% (28 of 33), and the negative predictive value was 92% (22 of 24). Conclusion A predictive model based on diffusion-weighted breast MRI identified women at high risk of upstaging. © RSNA, 2022 Online supplemental material is available for this article See also the editorial by Baltzer in this issue.

The characteristics associated with upgrade on surgical pathology of conventional imaging occult DCIS diagnosed by MRI

PURPOSE

To characterize the clinical, pathological, and imaging features of DCIS occult on conventional imaging diagnosed on MRI-guided biopsy associated with increased risk of invasive disease on surgical excision.

MATERIALS AND METHODS

All consecutive patients with MRI-detected DCIS occult on conventional imaging between January 2009 and December 2018 were included. Women were divided into two groups based on final pathology: Pure DCIS or DCIS with invasive component. Clinical, imaging, and pathological risk factors for upgrade to invasion were evaluated.

RESULTS

Of 50 patients who met the inclusion criteria, 12 (24%) were upgraded to invasive malignancy in the final pathology. The only parameters that showed statistically significant association with upgrade were related to kinetic characteristics: 53% of patients with the combination of fast early upstroke and either plateau or washout curve were upgraded, compared to 12% of women without this combination (p = 0.006). The sensitivity of combined kinetic features for predicting upgrade was 67% (95% CI 35-90%), specificity was 84% (CI 95% 68-94%), positive predictive value was 57% (CI 95% 37-75%), negative predictive value was 89% (CI 95% 77-95%), and OR was 78% (64-88%).

CONCLUSION

Kinetic characteristics show the strongest association with upgrade to invasion in DCIS occult on mammogram and US. Larger studies should be encouraged to consolidate our findings, which may have implication for treatment planning.

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.

Predictive factors for the presence of invasive components in patients diagnosed with ductal carcinoma in situ based on preoperative biopsy

Background

In patients diagnosed with ductal carcinoma in situ (DCIS) with needle biopsy before surgery, invasive component (IC) is often found in the postoperative tissue, which results in altered post-surgical care. However, there are no clinically available factors to predict IC, and few MRI studies are available for the detection of IC in DCIS patients. The purpose of this study was to evaluate which risk factors can predict IC preoperatively.

Methods

Patients with a DCIS diagnosis based on preoperative biopsy, who underwent breast surgery Kangbuk Samsung Hospital between Jan 2005 and June 2018, were retrospectively evaluated. Clinico-pathological and breast MRI factors were compared between DCIS and DCIS with IC in postsurgical specimens.

Results

Of the 431 patients with a preoperative diagnosis of DCIS, 34 (7.9%) showed IC during the postoperative pathological investigations, and 217 (50.3%) underwent breast MRI. Among MRI-related factors, Mass-like enhancement on MRI was the sole but significant predictor of IC (HR = 0.26, C.I. = 0.07–0.93, p = 0.038), while nipple-areolar complex invasion, enhancement peak and pattern were not statistically significant. Nuclear grade was the only significant predictor of IC in the analysis of other clinico-pathological factors (HR = 2.39, C.I. = 1.05–5.42, p = 0.038 in univariate analysis, HR = 2.86, C.I. = 1.14–7.14, p = 0.025 in multivariate analysis).

Conclusions

Mass-like enhancement on MRI and high nuclear grade were associated with IC in patients with preoperative diagnosis of DCIS. Considering the high sensitivity of breast MRI for IC, further evaluation of the predictive value of MRI in preoperative DCIS patients is desirable.

[Ductal carcinoma in situ diagnosis: 3 French national guidelines]

OBJECTIVE

Since the last guidelines published by the French National Cancer Institute (INCa) and the learning society "Société française de sénologie et de pathologie mammaire (SFSPM)" in 2009 about diagnosis and management of ductal carcinoma in situ, new data raised issues about overdiagnosis and its consequences, overtreatment. Therefore, an update was necessary, to provide healthcare professionals up-to-date guidelines and study therapeutic desescalation in particular.

METHODS

The clinical practice guidelines development process is based on systematic literature review and critical appraisal by a multidisciplinary experts workgroup. The recommendations are thus based on the best available evidence and experts agreement. Prior to publication, the guidelines are also reviewed by more than 100 independent practitioners in cancer care delivery.

RESULTS

This article presents French guidelines about MRI and vacuum assisted breast biopsy indications for DCIS diagnosis and the management of low-grade DCIS.

Ductal carcinoma in situ diagnosed by breast needle biopsy: Predictors of invasion in the excision specimen

BACKGROUND

A substantial proportion of women with a pre-operative diagnosis of pure ductal carcinoma in situ (DCIS) has a final diagnosis of invasive breast cancer (IBC) after surgical excision and, consequently, a potential indication for lymph node staging. The aim of our study was to identify novel predictors of invasion in patients with a needle-biopsy diagnosis of DCIS that would help us to select patients that may benefit from a sentinel node biopsy (SNB).

PATIENTS AND METHODS

We included 153 patients with a needle-biopsy diagnosis of DCIS between 2000 and 2014, which was followed by surgical excision. Several pre-operative clinical, radiological and pathological features were assessed and correlated with the presence of invasion in the excision specimen. Features that were significantly associated with upstaging in the univariable analysis were combined to calculate upstaging risks.

RESULTS

Overall, 22% (34/155) of the patients were upstaged to IBC. The following risk factors were significantly associated with upstaging: palpability, age ≤40 years, mammographic mass lesion, moderate to severe periductal inflammation and periductal loss of decorin expression. The upstaging-risk correlated with the number of risk factors present: e.g. 9% for patients without risk factors, 29% for patients with 1 risk factor, 37% for patients with 2 risk factors and 54% for patients with ≥3 risk factors.

CONCLUSION

The identified risk factors may be helpful to predict the upstaging-risk for patients with a needle-biopsy diagnosis of pure DCIS, which facilitates the performance of a selective SNB for high-risk patients and avoid this procedure in low-risk patients.

DCIS of the breast: The value of preoperative MRI

INTRODUCTION

Ductal carcinoma in situ (DCIS) of the breast is commonly treated surgically. The intent of this study was to evaluate whether preoperative MRI could add to mammography in predicting the extent of the disease.

METHODS

A series of patients with DCIS attending our surgical clinic for preoperative assessment were offered MRI as part of a prospective study. The extent of the disease indicated by mammography and MRI was compared with histopathology after definitive treatment. The null hypothesis was that MRI does not add to mammography in accurately predicting disease extent.

RESULTS

Fifty patients make up the basis of this report. Mammography was concordant with the pathology in 31/50. MRI and mammography combined were concordant in 43/50. This is a statistically significant difference (P = 0.01, Fisher's exact test). Upstaging to mastectomy by MRI was correct in 7/8 patients, but downstaging was correct in only 2/4.

CONCLUSIONS

The null hypothesis is rejected. MRI does add to mammography in accurately predicting the extent of DCIS. Upstaging by MRI is usually reliable.

Preoperative clinicopathologic factors and breast magnetic resonance imaging features can predict ductal carcinoma in situ with invasive components

PURPOSE

Ductal carcinoma in situ (DCIS) is a non-invasive cancerous breast lesion; however, from 10% to 50% of patients with DCIS diagnosed by core needle biopsy (CNB) or vacuum-assisted core biopsy (VACB) are shown to have invasive carcinoma after surgical excision. In this study, we evaluated whether preoperative clinicopathologic factors and breast magnetic resonance image (MRI) features are predictive of DCIS with invasive components before surgery.

MATERIALS AND METHODS

Patients comprised 128 adult women with a diagnosis of DCIS as determined by pathological analysis of CNB or VACB specimens and positive MRI findings who underwent breast surgery during the period January 2011 to December 2013 at the Changhua Christian Hospital. Clinicopathologic and breast MRI factors were compared between patients with postoperative pathology indicative of true DCIS and those with postoperative pathology showing DCIS with invasive components.

RESULTS

Of the 128 patients with a preoperative diagnosis of DCIS, 73 (57.0%) had postoperative histopathologic evidence of true DCIS and 55 (43.0%) showed evidence of DCIS with invasive components. Results of statistical analyses revealed that MRI evidence of a mass-like lesion (P=0.025), nipple-areolar complex (NAC) invasion (P=0.029), larger tumor volume (P=0.010), larger maximum measurable apparent diffusion coefficient (ADC) area (P=0.039), heterogenous or rim enhancement pattern (P=0.010), as well as immunohistochemical evidence of human epidermal growth factor receptor 2 (HER-2) overexpression (P=0.010) were predictive of DCIS with an invasive component in postoperative surgical specimens.

CONCLUSION

Invasive component should be considered in biopsy proven DCIS patients with preoperative MRI evidence of a mass-like lesion, nipple-areolar complex invasion, large tumor volume, a larger maximum measurable ADC area, or a rim or heterogenous enhancement pattern, as well as in patients with immunohistochemical evidence of HER-2 overexpression.

MRI accurately identifies early murine mammary cancers and reliably differentiates between in situ and invasive cancer: correlation of MRI with histology

MRI methods that accurately identify various stages of mouse mammary cancer could provide new knowledge that may have a direct impact on the management of breast cancer in patients. This research investigates whether we can accurately follow the progression from in situ to invasive cancer by the evaluation of in vivo and ex vivo MRI, and in comparison with histology as the gold standard for the diagnosis and staging of cancer. Six C3(1)SV40Tag virgin female mice, aged 12-16 weeks, were studied. At this age, these mice develop in situ cancer that resembles human ductal carcinoma in situ (DCIS). Fast spin-echo images of inguinal mammary glands were acquired at 9.4 T. After in vivo MRI, mice were sacrificed; inguinal mammary glands were excised and fixed in formalin for ex vivo MRI. Three-dimensional, volume-rendered, in vivo and ex vivo MR images were then correlated with histology. High-resolution ex vivo scans facilitated the comparison of in vivo scans with histology. The sizes of mammary cancers classified as in situ on the basis of histology ranged from 150 to 400 µm in largest diameter, and the average signal intensity relative to muscle was 1.40 ± 0.18 on T2 -weighted images. Cancers classified as invasive on the basis of histology were >400 µm in largest diameter, and the average intensity relative to muscle on T2 -weighted images was 2.34 ± 0.26. Using a cut-off of 400 µm in largest diameter to distinguish between in situ and invasive cancers, a T2 -weighted signal intensity of at least 1.4 times that of muscle for in situ cancer, and at least 2.3 times that of muscle for invasive cancer, 96% of in situ and 100% of invasive cancers were correctly identified on in vivo MRI, using histology as the gold standard. Precise MRI-histology correlation demonstrates that MRI reliably detects early in situ cancer and differentiates in situ from invasive cancers in the SV40Tag mouse model of human breast cancer.

Intratumoral metabolic heterogeneity predicts invasive components in breast ductal carcinoma in situ

OBJECTIVES

This study investigated whether texture-based imaging parameters could identify invasive components of ductal carcinoma in situ (DCIS).

METHODS

We enrolled 65 biopsy-confirmed DCIS patients (62 unilateral, 3 bilateral) who underwent (18) F-FDG PET, diffusion-weighted imaging (DWI), or breast-specific gamma imaging (BSGI). We measured SUV max and intratumoral metabolic heterogeneity by the area under the curve (AUC) of cumulative SUV histograms (CSH) on PET, tumour-to-normal ratio (TNR) and coefficient of variation (COV) as an index of heterogeneity on BSGI, minimum ADC (ADC min ) and ADC difference (ADC diff ) as an index of heterogeneity on DWI. After surgery, final pathology was categorized as pure-DCIS (DCIS-P), DCIS with microinvasion (DCIS-MI), or invasive ductal carcinoma (IDC). Clinicopathologic features of DCIS were correlated with final classification.

RESULTS

Final pathology confirmed 44 DCIS-P, 14 DCIS-MI, and 10 IDC. The invasive component of DCIS was significantly correlated with higher SUV max (p = 0.017) and lower AUC-CSH (p < 0.001) on PET, higher TNR (p = 0.008) and COV (p = 0.035) on BSGI, lower ADC min (p = 0.016) and higher ADC diff (p = 0.009) on DWI, and larger pathologic size (p = 0.018). On multiple regression analysis, AUC-CSH was the only significant predictor of invasive components (p = 0.044).

CONCLUSIONS

The intratumoral metabolic heterogeneity of (18) F-FDG PET was the most important predictor of invasive components of DCIS.

KEY POINTS

• Preoperative identification of invasion in DCIS is important for axillary nodal management • Higher SUV max and lower AUC-CSH from FDG PET may indicate invasive components of DCIS • Higher TNR and COV from BSGI may indicate invasive components of DCIS • Lower ADC min and higher ADC diff from DWI may indicate invasive components of DCIS • AUC-CSH, an index of metabolic heterogeneity, is an independent predictor for invasive components.

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.

Positive enhancement integral values in dynamic contrast enhanced magnetic resonance imaging of breast carcinoma: ductal carcinoma in situ vs. invasive ductal carcinoma

OBJECTIVES

The aim of this study was to contribute to the standardization of the numeric positive enhancement integral (PEI) values in breast parenchyma, ductal carcinoma in situ (DCIS) and invasive ductal carcinoma (IDC) and to evaluate the significance of the difference in PEI values between IDC and parenchyma, DCIS and parenchyma and IDC and DCIS.

MATERIALS AND METHODS

In the prospective trial, we analyzed the dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) of 60 consecutive patients with histologically confirmed unilateral DCIS (n=30) and IDC (n=30) and defined the PEI values (range; mean ± SD) for the lesions and the breast parenchyma. Tumor-to-non-tumor (T/NT) ratios were calculated for DCIS and IDC and compared. PEI color maps (PEICM) were created. The differences in PEI values between IDC and parenchyma and between DCIS and parenchyma were tested according to t-test. Analysis of variance (ANOVA) was used to test the differences between the mean PEI values of parenchyma, DCIS and IDC.

RESULTS

IDC showed highly statistically different PEI numeric values compared to breast parenchyma (748.7 ± 32.2 vs. 74.6 ± 17.0; p<0.0001). The same applied to the differences in the group of patients with DCIS (428.0 ± 25.0 vs. 66.0 ± 10.6; p<0.0001). The difference between IDC, DCIS and parenchyma were also considered highly statistically significant (p<0.0001) and so were the T/NT ratios for IDC and DCIS (10.1 ± 2.4 vs. 6.6 ± 1.4; p<0.0001).

CONCLUSIONS

PEI numeric values may contribute to differentiation between invasive and in situ breast carcinoma.

Is DCIS breast cancer, and how do I treat it?

Ductal carcinoma in situ (DCIS) is a pre-invasive stage of breast cancer with a heterogeneous clinical behaviour. Since the introduction of mammographic screening programmes, the incidence of DCIS has shown a dramatic increase. Treatment should focus on the prevention of progression to invasive disease. If progression occurs, poorly differentiated DCIS frequently gives rise to grade III invasive breast cancer, whereas well differentiated DCIS more often recurs as grade I invasive disease. However, at present, validated diagnostic test are lacking to predict progression accurately. The majority of women with DCIS are suitable for breast conserving therapy. Obtaining clear surgical margins is the most important goal of a local excision. Radiotherapy is effective in reducing the risk of local recurrence with about 50 % in all subgroups of patients with DCIS. (Breast cancer specific) survival of women with DCIS is excellent, and radiotherapy does not further improve this. Future research should be directed in enabling to select women who have a high risk of--invasive--recurrence, so in which radiotherapy should be standard part of the breast conserving approach, and those women with a more indolent lesion, in which after surgery a watchful waiting approach can be followed.