Breast MRI increases the number of mastectomies for ductal cancers, but decreases them for lobular cancers

Preoperative breast MRI for invasive ductal carcinoma with or without a DCIS component at needle biopsy: influence on surgical outcomes in the MIPA study

OBJECTIVES

To analyse the impact of preoperative breast MRI on surgical outcomes of patients diagnosed with pure invasive ductal carcinoma (IDC) or IDC with an associated in situ component (IDC + ductal carcinoma in situ [DCIS]) at needle biopsy.

METHODS

Patients aged 18-80 years referred for upfront surgery after a diagnosis of pure IDC or IDC + DCIS at needle biopsy were retrieved from the Multicenter International Prospective Analysis (MIPA) database. In each subgroup, patients who underwent preoperative MRI (MRI groups) were matched 1:1 to those who did not (noMRI groups) according to eight confounding covariates. Surgical outcomes were compared with non-parametric statistics after calculating odds ratios (ORs).

RESULTS

Among 1051 patients with IDC + DCIS, 510 were retained after matching (255 in each group): in comparison to the noMRI group, the MRI group had significantly higher rates of first-line mastectomy (13.3% vs 6.3%; OR 2.30, p = 0.011) and of overall mastectomy (14.5% vs 7.5%; OR 2.11, p = 0.016), without significantly lowering the reoperation rate (9.4% vs 10.6%, OR 0.88, p = 0.768). Among 2459 patients with pure IDC, 1638 were retained after matching (819 in each group): the first-line mastectomy rate was not significantly higher in the MRI group (12.9% vs 12.1% in the noMRI group; OR 1.08, p = 0.654). Instead, the reoperation rate was significantly lower (2.6% vs 7.9%; OR 3.28 for avoiding reoperation, p < 0.001) with no increase in overall mastectomies (13.6% vs 13.7%: OR 0.99, p = 1.000).

CONCLUSIONS

In patients with IDC + DCIS, preoperative MRI did not reduce reoperations and increased mastectomies. Conversely, in patients with pure IDC, preoperative MRI reduced reoperations without increasing mastectomies.

KEY POINTS

Question The impact of preoperative breast MRI on surgical outcomes of patients with IDC at needle biopsy is controversial and lacks large-scale investigations. Findings For pure IDC at needle biopsy, MRI reduced reoperations without increasing mastectomies; for IDC + DCIS, MRI did not reduce reoperations and increased mastectomies. Clinical relevance In patients with IDC at needle biopsy, the decision to perform preoperative breast MRI should take into account the presence of associated DCIS, as the benefits of MRI on surgical outcomes were observed only in patients with pure IDC.

Breast cancer staging with contrast-enhanced imaging. The benefits and drawbacks of MRI, CEM, and dedicated breast CT

Pretherapeutic breast cancer staging is pivotal for patient-centered disease management, guiding treatment stratification and assessing prognostic outcomes. Breast imaging plays a key role in both anatomic and prognostic staging by providing comprehensive insights into disease extent, localization, and tumor aggressiveness characteristics. To date, clinical image-based staging relies on conventional modalities such as digital mammography (DM), digital breast tomosynthesis (DBT), and ultrasound. Considering the phenotypic disparities of breast cancer and their relation to treatment response, other imaging techniques based on contrast-enhanced mechanisms, which highlight areas of increased neovascularity, appear indispensable in breast cancer staging. Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) offers a comprehensive 3-dimensional assessment of extent of disease and characterization of lesions, capturing both morphological and functional aspects which are crucial for treatment and monitoring of the disease. Based on this established approach, contrast-enhanced x-ray-based techniques, with high spatial resolution, such as contrast-enhanced mammography (CEM) and dedicated contrast-enhanced breast computed tomography (dCEBCT), have emerged. This review outlines the current status, limitations, and ongoing challenges associated with each one contrast-enhanced imaging modality, while emphasis is given to key breast cancer manifestations and the optimal interpretation of their imaging phenotypes, in the current era of image-based (anatomic and prognostic) breast cancer staging.

Interhospital variation in surgical treatment of screen-detected breast cancer in the South of the Netherlands

BACKGROUND

The effectiveness of the Dutch breast cancer screening programme depends on the quality of the full trajectory, from the first screening to the final treatment of a screen-detected breast cancer. Interhospital variation in breast cancer treatment has been explored by several studies, however, not specifically in a screen-detected breast cancer population. The current study compares the treatment strategies of women with screen-detected breast cancer between hospitals in the South of the Netherlands.

METHODS

A total of 1450 women with screen-detected breast cancer, who participated in the Dutch screening programme between January 2009 and July 2019, were included in this retrospective analysis of a prospectively obtained database. Breast cancer treatment (i.e. preoperative MRI, neoadjuvant systemic therapy and type and outcomes of surgery) was compared between hospitals using multivariate analysis.

RESULTS

Statistically significant interhospital variation was observed in the use of preoperative MRI (range 20.8-35.8 %, p < 0.001), neoadjuvant systemic therapy (range 4.0-13.3 %, p < 0.001) and breast conserving surgery (range 70.0-87.1 %, p < 0.001). These differences persisted after adjustment for case-mix. In patients with invasive breast cancer treated by breast conserving surgery, the mean volume of the resection specimen ranged from 381 to 541 ml between hospitals (p < 0.001). However, this was not accompanied by significant differences in the percentage of patients with positive resection margins (range 2.9-5.7 %, p = 0.34).

CONCLUSIONS

We observed significant interhospital variation in the management of women with screen-detected breast cancer. Quality assurance in screen-detected breast cancer may reduce these differences, but evolving breast cancer care and more personalised approaches should be accounted for.

Preoperative breast MRI reduces reoperations for unilateral invasive lobular carcinoma: a patient-matched analysis from the MIPA study

OBJECTIVES

To investigate the surgical impact of preoperative breast MRI in patients diagnosed with invasive lobular breast cancer (ILC) in a prospective observational study.

METHODS

The prospective MIPA observational study database was queried for patients aged 18-80 with newly diagnosed unilateral ILC at needle biopsy referred for primary surgery. Patients who underwent preoperative MRI (MRI group) were matched (1:1) with those who did not (noMRI group) according to nine confounding covariates. Surgical outcomes were compared between the matched groups with nonparametric statistics after calculating odds ratios (ORs).

RESULTS

A total of 547 women with unilateral needle biopsy-diagnosed ILC were identified (158 noMRI group, 389 MRI group). After patient matching, each group retained 103 patients, for a total of 206 matched patients. For the rate of women having a first-line mastectomy, there was no significant difference between the MRI group (21.4%, 22/103; p = 0.727; OR 1.20, 95% CI: 0.61-2.38) and the noMRI group (18.4%, 19/103). Conversely, the reoperation rate in the MRI group (1.9%, 2/103) was significantly lower (p = 0.007; OR of avoiding reoperation 7.29, 95% CI: 1.60-33.21) than in the noMRI group (12.6%, 13/103 patients). Overall mastectomy rates (first plus second-line) did not significantly differ between the MRI group (23.3%, 24/103; p = 0.867, OR 1.12, 95% CI: 0.58-2.16) and the noMRI group (21.4%, 22/103).

CONCLUSIONS

Women who had preoperative MRI after a needle biopsy diagnosis of ILC had a significant six-fold reduction in reoperations compared to those who did not have an MRI examination, with similar overall mastectomy rates.

KEY POINTS

Question No randomized controlled trials investigating the impact of preoperative MRI on surgical outcomes (mastectomy rates and reoperation) of needle-biopsy-diagnosed ILC have been conducted. Findings In a patient-matched analysis of 103 vs 103 women, preoperative MRI led to a greater than six-fold reduction of reoperations, without significant differences in first-line and overall mastectomy rates. Clinical relevance In the absence of randomized controlled trials, patient matching can be applied to mitigate confounding factors that drive the referral to preoperative MRI, showing that preoperative MRI has beneficial effects on surgical outcomes in patients with needle biopsy-diagnosed unilateral ILC.

Comparison of the Preoperative MRI Evaluation of Glandular Tissue in Subcutaneous Mastectomy and its Influence on the Implant Volume

Background/Aim

This study examined the influence of preoperative MRI on the choice of implant volume in patients undergoing subcutaneous mastectomy with immediate breast reconstruction. It was postulated that preoperative MRI scans can adequately estimate glandular tissue, which in turn correlates with implant size.

Patients and Methods

Preoperative and postoperative MRI scans were used in oncological and prophylactical subcutaneous mastectomy scenarios in 67 cases at the Department of Gynaecology, Breast Cancer Center, University of Cologne, Germany. The preoperative MRI was used to estimate the resected tissue and the postoperative MRI was used to scan for residual glandular tissue. In addition, a correlation found by Malter et al. in 2021 was evaluated with the available data.

Results

Preoperative MRIs result in an adequate estimation of resected tissue. This in turn correlates with implant volume. The correlation by Malter et al. also holds when estimating implant volume. The likelihood of residual gland was low if the preoperatively estimate volume was removed.

Conclusion

Our results indicate that the use of preoperative and postoperative MRI scans for subcutaneous mastectomies is advantageous. We suggest a routine estimation of glandular tissue, especially for small breasts.

The Role of Magnetic Resonance Imaging in the Preoperative Staging and Treatment of Invasive Lobular Carcinoma

INTRODUCTION

Invasive lobular carcinoma (ILC) is known for its diffuse growth pattern and its associated challenges in diagnosing. Magnetic resonance imaging (MRI) is the most accurate imaging modality and might aid in improving preoperative staging compared to full field digital mammography (FFDM) and ultrasound (US), however current literature is inconsistent. The aim of this paper is to evaluate the accuracy of MRI staging compared to FFDM/US and pathology results.

METHODS

In this single-centre retrospective study, all patients diagnosed with ILC between 2014 and 2019 who underwent preoperative MRI were included. Specific parameters studied were: (1) the need for second-look targeted biopsies, (2) detection of new tumors (ie, contralateral or multifocal), (3) changes in cTNM-classification, and (4) impact on final treatment plan. Bland-Altman plots were used to compare the tumor sizes measured on MRI and FFDM/US with actual pathological tumor sizes.

RESULTS

Ninety-nine patients were included. After performing preoperative MRI, 9 (9.1%) multifocal tumors were diagnosed after additional biopsies. Contralateral tumors were detected twice (2.0%) and cN classification was upgraded in 7 cases (7.1%). Surgical treatment or neoadjuvant treatment plans were changed in 16 patients (16.1%). Compared to histopathological results, FFDM/US underestimated tumor size with a mean of 0.4 cm (Limit of agreement (LoA): -2.8 cm to 2.0 cm) whereas MRI overestimated tumor size with a mean of 0.6 cm (LoA: -1.9 cm to 3.0 cm).

CONCLUSIONS

In our study, mean differences in tumor size measurements using FFDM/US and MRI were comparable, with similar random errors. MRI correctly diagnosed multifocal and contralateral tumors more often and provided a better cN staging.

Discriminative Factors of Malignancy of Ipsilateral Nonmass Enhancement in Women With Newly Diagnosed Breast Cancer on Initial Staging Breast MRI

BACKGROUND

Nonmass enhancement (NME) on breast MRI impacts surgical planning.

PURPOSE

To evaluate positive predictive values (PPVs) and identify malignancy discriminators of NME ipsilateral to breast cancer on initial staging MRI.

STUDY TYPE

Retrospective.

SUBJECTS

Eighty-six women (median age, 48 years; range, 26-75 years) with 101 NME lesions (BI-RADS 4 and 5) ipsilateral to known cancers and confirmed histopathology.

FIELD STRENGTH/SEQUENCE

1.5 T and 3.0 T dynamic contrast-enhanced fat-suppressed T1-weighted fast spoiled gradient-echo.

ASSESSMENT

Three radiologists blinded to pathology independently reviewed MRI features (distribution, internal enhancement pattern, and enhancement kinetics) of NME, locations relative to index cancers (contiguous, non-contiguous, and different quadrants), associated mammographic calcifications, lymphovascular invasion (LVI), axillary node metastasis, and radiology-pathology correlations. Clinical factors, NME features, and cancer characteristics were analyzed for associations with NME malignancy.

STATISTICAL TESTS

Fisher's exact, Chi-square, Wilcoxon rank sum tests, and mixed-effect multivariable logistic regression were used. Significance threshold was set at P < 0.05.

RESULTS

Overall NME malignancy rate was 48.5% (49/101). Contiguous NME had a significantly higher malignancy rate (86.7%) than non-contiguous NME (25.0%) and NME in different quadrants (10.7%), but no significant difference was observed by distance from cancer for non-contiguous NME, P = 0.68. All calcified NME lesions contiguous to the calcified index cancer were malignant. NME was significantly more likely malignant when index cancers were masses compared to NME (52.9% vs. 21.4%), had mammographic calcifications (63.2% vs. 39.7%), LVI (81.8% vs. 44.4%), and axillary node metastasis (70.8% vs. 41.6%). NME features with highest PPVs were segmental distribution (85.7%), clumped enhancement (66.7%), and nonpersistent kinetics (77.1%). On multivariable analysis, contiguous NME, segmental distribution, and nonpersistent kinetics were associated with malignancy.

DATA CONCLUSION

Malignancy discriminators of ipsilateral NME on staging MRI included contiguous location to index cancers, segmental distribution, and nonpersistent kinetics.

EVIDENCE LEVEL

3 TECHNICAL EFFICACY: Stage 2.

Breast Magnetic Resonance Imaging for Preoperative Evaluation of Breast Cancer: A Systematic Review and Meta-Analysis

Purpose: Preoperative breast magnetic resonance imaging (MRI) is known to detect additional cancers that are occult on mammography and ultrasound. There is debate as to whether these additional lesions affect clinical outcomes. The objective of this systematic review was to summarize the evidence on whether additional information on disease extent obtained with preoperative breast MRI in patients with newly diagnosed breast cancer affects surgical management, rates of recurrence, survival, re-excision, and early detection of bilateral cancer. Methods: Embase, MEDLINE, and Cochrane Central Register of Controlled Trials were searched until January 2021 (partial update July 2022) for studies comparing outcomes with versus without pre-operative MRI. Included were both randomized controlled trials and other comparative studies provided MRI and control groups had equivalent disease and patient characteristics or methods such as multivariable analysis or propensity score matching were used to control potential confounders. Results: The search resulted in 26,399 citations, of which 8 randomized control trials, 1 prospective cohort study, and 42 retrospective studies met the inclusion criteria. Use of MRI resulted in decreased rates of reoperations (OR = 0.73, 95% CI = 0.63 to 0.85), re-excisions (OR = 0.63, 95% CI = 0.45 to 0.89), and recurrence (HR = 0.77, 95% CI = 0.65 to 0.90). Increased detection of synchronous contralateral breast cancers led to a reduction in metachronous contralateral breast cancer (HR = 0.71, 95% CI = 0.59 to 0.85). Hazard ratios for recurrence-free and overall survival were 0.77 (95% CI = 0.53 to 1.12) and 0.89 (95% CI = 0.74 to 1.07). Conclusion: This systematic review indicates substantial benefits of pre-operative breast MRI in decreasing reoperations and recurrence.

Additional occult cancers identified on staging breast MRI: imaging appearances and pathologic characteristics

INTRODUCTION

Breast magnetic resonance imaging (MRI) is increasingly being used for staging of patients with breast cancer due to its high sensitivity in detecting additional cancers (ACs). However, the clinical impact of diagnosing and treating these cancers remains unclear.

METHODS

A retrospective study was undertaken of patients with newly diagnosed breast cancer who underwent staging MRI at The American University of Beirut Medical Centre (AUBMC) between 2012 and 2020. Pathology reports and breast MRI examinations were reviewed. Eighteen breast cancer patients with 19 pathology-proven index cancers (ICs) and 19 pathology-proven MRI-detected ACs were included. Chi-square and Fisher's exact tests for categorical variables and Wilcoxon signed rank test for numerical variables were used to compare ICs to ACs.

RESULTS

The ICs consisted of four ductal carcinoma in situ (DCIS), 13 invasive ductal carcinomas (IDC), of which five with associated DCIS, and two invasive lobular carcinomas, (ILC) of which one with associated DCIS. ACs comprised 12 DCIS, five IDC, two with associated DCIS and two ILC, one with associated DCIS. Interval cancers were more frequently invasive whereas ACs were more frequently in situ (P = 0.021). ACs were more frequently nuclear grade 2 (P = 0.009). There was no statistically significant difference between ICs and ACs in lesion type (P = 0.062), shape (P = 0.073), initial enhancement (P = 1), delayed enhancement (P = 0.732), hormonal receptor profile (P = 0.68) and Ki67 (P = 0.388). Among ACs, ten (53%) were larger than 10 mm of which five (26%) were invasive cancers, and five (26%) were larger than the ICs.

CONCLUSIONS

ACs detected by breast MRI were more likely to be in situ and to show a nuclear grade 2. Although not reaching statistical significance, some ACs tend to be clinically significant by their type, size or nuclear grade. The impact on clinical management remains to be determined.

Comparing quality of breast cancer care in the Netherlands and Norway by federated propensity score analytics

PURPOSE

The aim of the study was to benchmark and compare breast cancer care quality indicators (QIs) between Norway and the Netherlands using federated analytics preventing transfer of patient-level data.

METHODS

Breast cancer patients (2017-2018) were retrieved from the Netherlands Cancer Registry and the Cancer Registry of Norway. Five European Society of Breast Cancer Specialists (EUSOMA) QIs were assessed: two on magnetic resonance imaging (MRI), two on surgical approaches, and one on postoperative radiotherapy. The QI outcomes were calculated using 'Vantage 6' federated Propensity Score Stratification (PSS). Likelihood of receiving a treatment was expressed in odds ratios (OR).

RESULTS

In total, 39,163 patients were included (32,786 from the Netherlands and 6377 from Norway). PSS scores were comparable to the crude outcomes of the QIs. The Netherlands scored higher on the QI 'proportions of patients preoperatively examined with breast MRI' [37% vs.17.5%; OR 2.8 (95% CI 2.7-2.9)], the 'proportions of patients receiving primary systemic therapy examined with breast MRI' [83.3% vs. 70.8%; OR 2.3 (95% CI 1.3-3.3)], and 'proportion of patients receiving a single breast operation' [95.2% vs. 91.5%; OR 1.8 (95% CI 1.4-2.2)]. Country scores for 'immediate breast reconstruction' and 'postoperative radiotherapy after breast-conserving surgery' were comparable. The EUSOMA standard was achieved in both countries for 4/5 indicators.

CONCLUSION

Both countries achieved high scores on the QIs. Differences were observed in the use of MRI and proportion of patients receiving single surgery. The federated approach supports future possibilities on benchmark QIs without transfer of privacy-sensitive data.

The performance of contrast-enhanced mammography and breast MRI in local preoperative staging of invasive lobular breast cancer

PURPOSE

Breast MRI is considered the best modality for preoperative staging of invasive lobular carcinoma (ILC). However, contrast-enhanced mammography (CEM) shows comparable diagnostic performance to MRI, but evidence of CEM's accuracy in women diagnosed with ILC is scant. We aimed to retrospectively evaluate CEM and MRI accuracy in preoperative staging of ILC.

METHODS

ILC cases diagnosed between 2013 and 2021 were collected. For both modalities, tumour diameter was extracted from the reports. Bland-Altman plots were used to assess discrepancies between size measurements according to imaging and histopathological findings. CEM and MRI's ability to detect multifocal/contralateral cancer was expressed as sensitivity, specificity, and diagnostic odds ratios (DORs). Pairwise comparison of women undergoing both CEM and MRI was not performed.

RESULTS

305 ILC-cases fulfilled preset inclusion criteria. Mean age was 63.7 years. Preoperative staging was performed using MRI or CEM in 266 (87.2%) and 77 (25.2%) cases, respectively. MRI and CEM overestimated tumour size by 1.5 and 2.1 mm, respectively. Sensitivity to detect multifocal disease was higher for MRI than for CEM (86% versus 78%), but specificity was lower for MRI (79% versus 92%). For detection of contralateral breast cancer, sensitivity for MRI was 96% versus 88% for CEM, and specificity was 92% and 99%, respectively. For both indications, DOR was higher for CEM, but differences were non-significant (p = 0.56 and p = 0.78).

CONCLUSION

CEM and MRI overestimate ILC size with comparable systematic and random errors. MRI's higher sensitivity for detection of multifocal/contralateral cancers is accompanied by lower specificity, but discriminative ability for both modalities was non-significant.

Preoperative Breast Magnetic Resonance Imaging: An Ontario Health (Cancer Care Ontario) Clinical Practice Guideline

BACKGROUND

The use of preoperative breast magnetic resonance imaging (MRI) after the diagnosis of breast cancer by mammography and/or ultrasound is inconsistent.

METHODS

After conducting a systematic review and meta-analysis comparing preoperative breast MRI versus no MRI, we reconvened to prepare a clinical practice guideline on this topic.

RESULTS

Based on the evidence that MRI improved recurrence, decreased the rates of reoperations (re-excisions or conversion mastectomy), and increased detection of synchronous contralateral breast cancer, we recommend that preoperative breast MRI should be considered on a case-by-case basis in patients diagnosed with breast cancer for whom additional information about disease extent could influence treatment. Based on stronger evidence, preoperative breast MRI is recommended in patients diagnosed with invasive lobular carcinoma for whom additional information about disease extent could influence treatment. For both recommendations, the decision to proceed with MRI would be conditional on shared decision-making between care providers and the patient, taking into account the benefits and risks of MRI as well as patient preferences. Based on the opinion of the Working Group, preoperative breast MRI is also recommended in the following more specific situations: (a) to aid in surgical planning of breast conserving surgery in patients with suspected or known multicentric or multifocal disease; (b) to identify additional lesions in patients with dense breasts; (c) to determine the presence of pectoralis major muscle/chest wall invasion in patients with posteriorly located tumours or when invasion of the pectoralis major muscle or chest wall is suspected; (d) to aid in surgical planning for skin/nipple-sparing mastectomies, autologous reconstruction, oncoplastic surgery, and breast conserving surgery with suspected nipple/areolar involvement; and (e) in patients with familial/hereditary breast cancer but who have not had recent breast MRI as part of screening or diagnosis.

Preoperative Breast MRI: Current Evidence and Patient Selection

Breast MRI is the most sensitive imaging modality for the assessment of newly diagnosed breast cancer extent and can detect additional mammographically and clinically occult breast cancers in the ipsilateral and contralateral breasts. Nonetheless, appropriate use of breast MRI in the setting of newly diagnosed breast cancer remains debated. Though highly sensitive, MRI is less specific and may result in false positives and overestimation of disease when MRI findings are not biopsied prior to surgical excision. Furthermore, improved anatomic depiction of breast cancer on MRI has not consistently translated to improved clinical outcomes, such as lower rates of re-excision or breast cancer recurrence, though there is a paucity of well-designed studies examining these issues. In addition, current treatment paradigms have been developed in the absence of this more accurate depiction of disease span, which likely has limited the value of MRI. These issues have led to inconsistent and variable utilization of preoperative MRI across practice settings and providers. In this review, we discuss the history of breast MRI and its current use and recommendations with a focus on the preoperative setting. We review the evidence surrounding the use of preoperative MRI in the evaluation of breast malignancies and discuss the data on breast MRI in the setting of specific patient factors often used to determine breast MRI eligibility, such as age, index tumor phenotype, and breast density. Finally, we review the impact of breast MRI on surgical outcomes (re-excision and mastectomy rates) and long-term breast recurrence and survival outcomes.

Invasive Lobular Carcinoma: A Review of Imaging Modalities with Special Focus on Pathology Concordance

Invasive lobular cancer (ILC) is the second most common type of breast cancer. It is characterized by a unique growth pattern making it difficult to detect on conventional breast imaging. ILC can be multicentric, multifocal, and bilateral, with a high likelihood of incomplete excision after breast-conserving surgery. We reviewed the conventional as well as newly emerging imaging modalities for detecting and determining the extent of ILC- and compared the main advantages of MRI vs. contrast-enhanced mammogram (CEM). Our review of the literature finds that MRI and CEM clearly surpass conventional breast imaging in terms of sensitivity, specificity, ipsilateral and contralateral cancer detection, concordance, and estimation of tumor size for ILC. Both MRI and CEM have each been shown to enhance surgical outcomes in patients with newly diagnosed ILC that had one of these imaging modalities added to their preoperative workup.

Clinical value of contralateral breast cancers detected by pre-operative MRI in patients diagnosed with DCIS: a population-based cohort study

OBJECTIVES

For patients with ductal carcinoma in situ (DCIS), data about the impact of breast MRI at primary diagnosis on the incidence and characteristics of contralateral breast cancers are scarce.

METHODS

We selected all 8486 women diagnosed with primary DCIS in the Netherlands in 2011-2015 from the Netherlands Cancer Registry. The synchronous and metachronous detection of contralateral DCIS (cDCIS) and contralateral invasive breast cancer (cIBC) was assessed for patients who received an MRI upon diagnosis (MRI group) and for an age-matched control group without MRI.

RESULTS

Nineteen percent of patients received an MRI, of which 0.8% was diagnosed with synchronous cDCIS and 1.3% with synchronous cIBC not found by mammography. The 5-year cumulative incidence of synchronous plus metachronous cDCIS was higher for the MRI versus age-matched control group (2.0% versus 0.9%, p = 0.02) and similar for cIBC (3.5% versus 2.3%, p = 0.17). The increased incidence of cDCIS was observed in patients aged < 50 years (sHR = 4.22, 95% CI: 1.19-14.99), but not in patients aged 50-74 years (sHR = 0.89, 95% CI: 0.41-1.93).

CONCLUSIONS

MRI at primary DCIS diagnosis detected additional synchronous cDCIS and cIBC, and was associated with a higher rate of metachronous cDCIS without decreasing the rate of metachronous cIBC. This finding was most evident in younger patients.

KEY POINTS

• Magnetic resonance imaging at primary diagnosis of ductal carcinoma in situ detected an additional synchronous breast lesion in 2.1% of patients. • In patients aged younger than 50 years, the use of pre-operative MRI was associated with a fourfold increase in the incidence of a second contralateral DCIS without decreasing the incidence of metachronous invasive breast cancers up to 5 years after diagnosis. • In patients aged over 50 years, the use of pre-operative MRI did not result in a difference in the incidence of a second contralateral DCIS or metachronous invasive breast cancer.

MRI Breast: Current Imaging Trends, Clinical Applications, and Future Research Directions

Magnetic Resonance Imaging (MRI) is the most sensitive and advanced imaging technique in diagnosing breast cancer and is essential in improving cancer detection, lesion characterization, and determining therapy response. In addition to the dynamic contrast-enhanced (DCE) technique, functional techniques such as magnetic resonance spectroscopy (MRS), diffusion-weighted imaging (DWI), diffusion kurtosis imaging (DKI), and intravoxel incoherent motion (IVIM) further characterize and differentiate benign and malignant lesions thus, improving diagnostic accuracy. There is now an increasing clinical usage of MRI breast, including screening in high risk and supplementary screening tools in average-risk patients. MRI is becoming imperative in assisting breast surgeons in planning breast-conserving surgery for preoperative local staging and evaluation of neoadjuvant chemotherapy response. Other clinical applications for MRI breast include occult breast cancer detection, investigation of nipple discharge, and breast implant assessment. There is now an abundance of research publications on MRI Breast with several areas that still remain to be explored. This review gives a comprehensive overview of the clinical trends of MRI breast with emphasis on imaging features and interpretation using conventional and advanced techniques. In addition, future research areas in MRI breast include developing techniques to make MRI more accessible and costeffective for screening. The abbreviated MRI breast procedure and an area of focused research in the enhancement of radiologists' work with artificial intelligence have high impact for the future in MRI Breast.

Invasive Lobular Carcinoma-Correlation Between Imaging and Final Pathology: Is MRI Better?

BACKGROUND

Invasive lobular carcinoma (ILC) is associated with high re-excision rates following breast-conserving surgery (BCS). The correlation between lesion size on different imaging modalities and final tumor size has not been well characterized.

METHODS

A prospective database of patients with stage I-III breast cancer undergoing BCS between 2006 and 2016 was reviewed. Pearson correlation analysis was used to correlate tumor size on breast imaging to final pathology.

RESULTS

Of these, 111 patients with ILC were identified. Mean lesion size was 1.93 cm for MMG, 1.61 cm for US, and 2.51 cm for MRI. Mean tumor size on surgical excision was 2.64 cm. The correlation coefficient between pathology and the different imaging modalities were as follows: MMG .17, US 0.37, and MRI .58. Actual tumor size was underestimated by 1 cm in 27.1% of MMGs, 50% of USs, and in 13.3% of MRIs. 38 patients (34.2%) underwent re-excision. No differences in re-excision rates were noted in patients with and without MRI, 30.3% vs 40.0%, respectively (P = .31).

CONCLUSION

While MRI provides a better estimate of tumor size than MMG and US, the size of the tumor on imaging only weakly correlated with pathology. The use of MRI does not decrease re-excision rates.

Current and Future Directions of Breast MRI

Magnetic resonance imaging (MRI) is the most sensitive exam for detecting breast cancer. The American College of Radiology recommends women with 20% or greater lifetime risk of developing breast cancer be screened annually with MRI. However, other high-risk populations would also benefit. Hartmann et al. reported women with atypical hyperplasia have nearly a 30% incidence of breast cancer at 25-year follow-up. Women with dense breast tissue have up to a 4-fold increased risk of breast cancer when compared to average-risk women; their cancers are more likely to be mammographically occult. Because multiple cohorts of women are at high risk for developing breast cancer, there has been a movement to develop an abbreviated MRI (abMRI) protocol to expand the availability of MRI screening. Studies on abMRI effectiveness have been promising, with Weinstein et al. demonstrating a cancer detection rate of 27.4/1000 in women with dense breasts after a negative digital breast tomosynthesis. Breast MRI is also used to evaluate the extent of disease as part of preoperative assessment in women with newly diagnosed breast cancer, and to assess a patient's response to neoadjuvant chemotherapy. This paper aims to explore the current uses of MRI and propose future indications and directions.

Cost-Effectiveness of Magnetic Resonance Imaging Screening for Women With Extremely Dense Breast Tissue

BACKGROUND

Extremely dense breast tissue is associated with increased breast cancer risk and limited sensitivity of mammography. The DENSE trial showed that additional magnetic resonance imaging (MRI) screening in women with extremely dense breasts resulted in a substantial reduction in interval cancers. The cost-effectiveness of MRI screening for these women is unknown.

METHODS

We used the MISCAN-breast microsimulation model to simulate several screening protocols containing mammography and/or MRI to estimate long-term effects and costs. The model was calibrated using results of the DENSE trial and adjusted to incorporate decreases in breast density with increasing age. Screening strategies varied in the number of MRIs and mammograms offered to women ages 50-75 years. Outcomes were numbers of breast cancers, life-years, quality-adjusted life-years (QALYs), breast cancer deaths, and overdiagnosis. Incremental cost-effectiveness ratios (ICERs) were calculated (3% discounting), with a willingness-to-pay threshold of €22 000.

RESULTS

Calibration resulted in a conservative fit of the model regarding MRI detection. Both strategies of the DENSE trial were dominated (biennial mammography; biennial mammography plus MRI). MRI alone every 4 years was cost-effective with €15 620 per QALY. Screening every 3 years with MRI alone resulted in an incremental cost-effectiveness ratio of €37 181 per QALY. All strategies with mammography and/or a 2-year interval were dominated because other strategies resulted in more additional QALYs per additional euro. Alternating mammography and MRI every 2 years was close to the efficiency frontier.

CONCLUSIONS

MRI screening is cost-effective for women with extremely dense breasts, when applied at a 4-year interval. For a willingness to pay more than €22 000 per QALY gained, MRI at a 3-year interval is cost-effective as well.

Nationwide registry study on trends in localization techniques and reoperation rates in non-palpable ductal carcinoma in situ and invasive breast cancer

BACKGROUND

There is a transition from wire-guided localization (WGL) of non-palpable breast cancer to other localization techniques. Multiple prospective studies have sought to establish superior clinical outcomes for radioactive-seed localization (RSL), but consistent and congruent evidence is missing.

METHODS

In this study, female patients with breast cancer operated with breast-conserving surgery after tumour localization of a non-palpable breast cancer or ductal carcinoma in situ (DCIS) were included. The cohort was identified from the nationwide Netherlands Breast Cancer Audit conducted between 2013 and 2018. Trends in localization techniques were analysed. Univariable and multivariable analyses were performed to assess the association between the localization technique and the probability of a reoperation.

RESULTS

A total of 28 370 patients were included in the study cohort. The use of RSL increased from 15.7 to 61.1 per cent during the study years, while WGL decreased from 75.4 to 31.6 per cent. The localization technique used (RSL versus WGL) was not significantly associated with the odds of a reoperation, regardless of whether the lesion was DCIS (odds ratio 0.96 (95 per cent c.i. 0.89 to 1.03; P = 0.281)) or invasive breast cancer (OR 1.02 (95 per cent c.i. 0.96 to 1.10; P = 0.518)).

CONCLUSION

RSL is rapidly replacing WGL as the preoperative localization technique in breast surgery. This large nationwide registry study found no association between the type of localization technique and the odds of having a reoperation, thus confirming the results of previous prospective cohort studies.

Contrast enhanced mammography (CEM) versus magnetic resonance imaging (MRI) for staging of breast cancer: The pro CEM perspective

In women with newly diagnosed breast cancer, preoperative staging is required to assess disease extent, enabling us to decide on the most optimal treatment strategy. For locoregional staging, assessment of intramammary tumor extent and presence of axillary and perhaps also internal mammary lymph node metastases is required. Due to the similarity in the underlying principle, contrast-enhanced mammography is increasingly considered instead of breast MRI for this purpose. When considering the combination of CEM and US as a single appointment imaging strategy for preoperative staging of breast cancer, there is only limited room for an additional benefit of breast MRI. For tumor size measurements, equal performance of both CEM and MRI are observed. Sensitivity of both techniques for detecting breast cancer is comparable, meaning that both techniques are capable of detecting additional ipsilateral or contralateral tumor foci. However, specificity is in favor of CEM, meaning that there is a slightly lower chance of having false positive findings in preoperative staging of the breast. Axillary US can be performed during the same appointment as CEM, with equal performance and limitations as evaluation of the axilla on standard breast MRI examinations. Finally, there is no need to actively pursue the detection of IMLN metastases, meaning that additional MRI to do so is not required. This review provides a 'pro-CEM' perceptive on the arguments why breast MRI is hardly necessary when CEM in combination with US has been performed as a single appointment imaging strategy in breast cancer patients.

Breast-Conserving Therapy in Patients with cT3 Breast Cancer with Good Response to Neoadjuvant Systemic Therapy Results in Excellent Local Control: A Comprehensive Cancer Center Experience

BACKGROUND

Many cT3 breast cancer patients are treated with mastectomy, regardless of response to neoadjuvant systemic therapy (NST). We evaluated local control of cT3 patients undergoing breast-conserving therapy (BCT) based on magnetic resonance imaging (MRI) evaluation post-NST. In addition, we analyzed predictive characteristics for positive margins after breast-conserving surgery (BCS).

METHODS

All cT3 breast cancer patients who underwent BCS after NST between 2002 and 2015 at the Netherlands Cancer Institute were included. Local recurrence-free interval (LRFI) was estimated using the Kaplan-Meier method, and predictors for positive margins were analyzed using univariable analysis and multivariable logistic regression.

RESULTS

Of 114 patients undergoing BCS post-NST, 75 had negative margins, 16 had focally positive margins, and 23 had positive margins. Of those with (focally) positive margins, 12 underwent radiotherapy, 6 underwent re-excision, and 21 underwent mastectomy. Finally, 93/114 patients were treated with BCT (82%), with an LRFI of 95.9% (95% confidence interval [CI] 91.5-100%) after a median follow-up of 7 years. Predictors for positive margins in univariable analysis were hormone receptor-positive/human epidermal growth factor receptor 2-negative (HR+/HER2-) subtype, lobular carcinoma, and non-mass enhancement (NME) on pre-NST MRI. MRI response was not correlated to positive margins. In multivariable regression, the odds of positive margins were decreased in patients with HER2-positive (HER2+; odds ratio [OR] 0.27, 95% CI 0.10-0.73; p = 0.01) and TN tumors (OR 0.17, 95% CI 0.03-0.82; p = 0.028). A trend toward positive margins was observed in patients with NME (OR 2.38, 95% CI 0.98-5.77; p = 0.055).

CONCLUSION

BCT could be performed in 82% of cT3 patients in whom BCT appeared feasible on post-NST MRI. Local control in these patients was excellent. In those patients with HR+/HER2- tumors, NME on MRI, or invasive lobular carcinoma, the risk of positive margins should be considered preoperatively.

The Impact of Preoperative Breast MRI on Surgical Margin Status in Breast Cancer Patients Recalled at Biennial Screening Mammography: An Observational Cohort Study

Background

This study aimed to examine the association between preoperative magnetic resonance imaging (MRI) and surgical margin involvement, as well as to determine the factors associated with positive resection margins in screen-detected breast cancer patients undergoing breast-conserving surgery (BCS).

Methods

Breast cancer patients eligible for BCS and diagnosed after biennial screening mammography in the south of The Netherlands (2008–2017) were retrospectively included. Missing values were imputed and multivariable regression analyses were performed to analyze whether preoperative MRI was related to margin involvement after BCS, as well as to examine what factors were associated with positive resection margins, defined as more than focally (>4 mm) involved.

Results

Overall, 2483 patients with invasive breast cancer were enrolled, of whom 123 (5.0%) had more than focally involved resection margins. In multivariable regression analyses, preoperative MRI was associated with a reduced risk of positive resection margins after BCS (adjusted odds ratio [OR] 0.56, 95% confidence interval [CI] 0.33–0.96). Lobular histology (adjusted OR 2.86, 95% CI 1.68–4.87), large tumor size (per millimeter increase, adjusted OR 1.05, 95% CI 1.03–1.07), high (>75%) mammographic density (adjusted OR 3.61, 95% CI 1.07–12.12), and the presence of microcalcifications (adjusted OR 4.45, 95% CI 2.69–7.37) and architectural distortions (adjusted OR 1.85, 95% CI 1.01–3.40) were independently associated with positive resection margins after BCS.

Conclusions

Preoperative MRI was associated with lower risk of positive resection margins in patients with invasive breast cancer eligible for BCS using multivariable analysis. Furthermore, specific mammographic characteristics and tumor characteristics were independently associated with positive resection margins after BCS.

Retrospective Comparison of Contrast-Enhanced Spectral Mammography with Digital Mammography in Assessing Tumor Size in 668 Cases of Breast Cancer

Background

Contrast-enhanced spectral mammography (CESM) is digital mammography with contrast agent. This promising new breast imaging method can be used for planning surgical treatment. This study compared CESM versus digital mammography (MG) in evaluating tumor size in breast cancer.

Material/Methods

Comparison of tumor dimensions in CESM, MG, and histopathology was made. The correlation of these data was assessed by histopathological type, biological subtype, grading of the carcinoma, and patient age.

Results

The average difference in tumor size between CESM and histopathological examination was 5 mm. The differences in size measurement between CESM and MG were significant (p=0.00). The Pearson’s linear correlation coefficients of CESM versus HP and MG versus HP were −0.01 (p=0.79) and −0.25 (p=0.00), respectively, indicating no differences between CESM and HP based on the lesion size. A weak negative correlation between those values was observed on MG. No relationship was found between the tumor size in CESM and the biological subtype, carcinoma malignancy degree, or patient age.

Conclusions

CESM is a new diagnostic method in breast cancer. The accuracy of measurement of tumor size using CESM is independent of lesion size, but it overestimates the size by 5 mm on average. The difference is not dependent on grading, biological subtype of the carcinoma, or patient age. They concern the histopathological type, and values are significantly greater in pre-invasive carcinomas.

The effect of breast MRI on disease-free and overall survival in breast cancer patients: a retrospective population-based study

Purpose

To evaluate the effect of breast MRI on overall survival (OS) and disease-free survival (DFS) of patients with invasive breast cancer in the Netherlands.

Methods

We selected all women from the Netherlands Cancer Registry diagnosed with invasive breast cancer (a) between 2011 and 2013 for the OS-cohort and (b) in the first quarter of 2012 for the DFS-cohort. The study population was subdivided into an MRI and non-MRI group. In addition, subgroups were created according to breast cancer subtype: invasive carcinoma of no special type (NST) versus invasive lobular carcinoma (ILC). OS and DFS were compared between the MRI and non-MRI group using the Kaplan–Meier method and the log-rank test. Cox proportional hazard regression analysis was performed to estimate hazard ratios (HR) with a 95% confidence interval (CI). To account for missing data, multiple imputation was performed.

Results

Of the 31,756 patients included in the OS-cohort (70% non-MRI and 30% MRI), 27,752 (87%) were diagnosed with invasive carcinoma NST and 4004 (13%) with ILC. Of the 2464 patients included in the DFS-cohort (72% non-MRI and 28% MRI), 2161 (88%) were diagnosed with invasive carcinoma NST and 303 (12%) with ILC. The distribution of breast MRI use was significantly lower over different age categories, from 49.0% aged < 50 to 16.5% aged > 70. Multivariable Cox regression showed that breast MRI was not significantly associated with OS overall (HR 0.91, 95%-CI 0.74–1.11, p = 0.35), nor in the different histological subtypes. Multivariable Cox regression analysis showed that breast MRI was also not significantly associated with DFS (HR 1.16, 95%-CI 0.81–1.67), nor in the different histological subtypes.

Conclusion

Use of breast MRI was not significantly associated with an improved OS or DFS in patients treated with primary surgery.

Electronic supplementary material

The online version of this article (10.1007/s10549-020-05906-w) contains supplementary material, which is available to authorized users.

The Impact of Preoperative Breast Magnetic Resonance Imaging on Surgical Management in Symptomatic Patients With Invasive Lobular Carcinoma

Objective

Due to an insidious proliferative pattern, invasive lobular breast cancer (ILC) often fails to form a defined radiological or palpable lesion and accurate diagnosis remains challenging. This study aimed to determine the value of preoperative magnetic resonance imaging (MRI) for ILC and its impact on surgical outcomes.

Methods

Consecutive symptomatic patients diagnosed with ILC in a tertiary centre over a 9-year period were reviewed. The time from diagnosis until surgery, initial type of surgery/index operation (breast-conserving surgery [BCS]/mastectomy) and the rates of reoperation (re-excision/completion mastectomy) were recorded. Patients were grouped into those who received conventional imaging and preoperative MRI (MR+) and those who received conventional imaging alone (MR-).

Results

There were 218 cases of ILC, and 32.1% (n = 70) had preoperative MRI. Time from diagnosis to surgery was longer in the MR+ than the MR- group (32.5 vs 21.1 days, P < .001) even when adjusting for age and breast density. Initial BCS was performed on 71.4% (n = 50) of MR+ patients and 72.3% (n = 107) of the MR- group. While the rate of completion mastectomy following initial BCS was higher in the MR+ group (30.0%, n = 15 vs 14.0%, n = 15; χ² = 5.63; P = .018), this association was not maintained in multivariable analysis. No difference was recorded in overall (initial and completion) mastectomy rate between the MR+ and MR- group (50.0%, n = 35 vs 37.8%, n = 56; χ² = 2.89; P = .089). Margin re-excision following BCS was comparable between groups (8.0%, n =4, vs 9.3%, n = 10; χ² = 0.076, P = .783) despite the selection bias for borderline conservable cases in the MR+ group. The rate of usage of MRI for ILC cases declined over the study period.

Conclusion

While MRI was associated with minor delays in treatment and did not reduce overall rates of margin re-excision or completion mastectomy, it altered the choice of surgical procedure in almost a quarter of MR+ cases. The benefit of preoperative breast MRI appears to be confined to select (younger, dense breast, borderline conservable) cases in symptomatic ILC.

Impact of Preoperative MRI in Invasive Ductal Carcinoma With Lobular Features on Core Biopsy

BACKGROUND

Invasive breast cancer is comprised of a wide spectrum of histological types with different clinical presentations, imaging characteristics, and behaviors. Almost 10% of breast cancers with predominantly invasive ductal features have lobular components on core biopsy at primary diagnosis. Although the role of magnetic resonance imaging (MRI) in patients with purely lobular cancers is well-established, it is not clear if preoperative MRI is indicated in ductal cancer with lobular features. The aim of this study was to assess the role of preoperative MRI in patients with invasive ductal cancers with lobular features on core biopsy.

MATERIALS AND METHODS

Data regarding patients with lobular features on core biopsy who underwent a preoperative MRI from January 2015 to December 2017 were retrospectively identified and analyzed. Imaging findings, additional investigations, and changes in treatment plans following the MRI scan were reviewed.

RESULTS

The study included 120 patients, of whom 42 (35%) patients required a second-look ultrasound. Following a repeat ultrasound scan, 25 breasts and 4 axillae were biopsied. Thirty-eight percent of the breast biopsies and 50% of the axillary biopsies were malignant. Based on MRI findings, treatment plans changed in 22.5% of patients. MRI size was concordant with the histological size in 58.3% of cases, and MRI was accurate in 90% of patients in detecting multifocal disease requiring mastectomy. The majority of patients with changes in the management plans had mixed ductal and lobular cancer on final histology.

CONCLUSION

This study has demonstrated that MRI picks up additional malignancies and changes management plans in patients with lobular features on core biopsy and should be considered in the preoperative workup.

Local staging of ipsilateral breast tumor recurrence: mammography, ultrasound, or MRI?

BACKGROUND

Despite increasingly effective curative breast-conserving treatment (BCT) regimens for primary breast cancer, patients remain at risk for an ipsilateral breast tumor recurrence (IBTR). With increasing interest for repeat BCT in selected patients with IBTR, a reliable assessment of the size of IBTR is important for surgical planning.

AIM

The primary aim of this study is to establish the performance in size estimation of XMG, US, and breast MRI in patients with IBTR. The secondary aim is to compare the detection of multifocality and contralateral lesions between XMG and MRI.

PATIENTS AND METHODS

The sizes of IBTR on mammography (XMG), ultrasound (US), and magnetic resonance imaging (MRI) in 159 patients were compared to the sizes at final histopathology. The accuracy of the size estimates was addressed using Pearson's coefficient and Bland-Altman plots. Secondary outcomes were the detection of multifocality and contralateral lesions between XMG and MRI.

RESULTS

Both XMG and US significantly underestimated the tumor size by 3.5 and 4.8 mm, respectively, while MRI provided accurate tumor size estimation with a mean underestimation of 1.1 mm. The sensitivity for the detection of multifocality was significantly higher for MRI compared to XMG (25.5% vs. 5.5%). A contralateral malignancy was found in 4.4% of patients, and in 1.9%, it was detected by MRI only.

CONCLUSION

The addition of breast MRI to XMG and US in the preoperative workup of IBTR allows for more accurate size estimation. MRI provides a higher sensitivity for the detection of multifocality compared to XMG.

Performance of preoperative breast MRI based on breast cancer molecular subtype

PURPOSE

To assess the performance of preoperative breast MRI biopsy recommendations based on breast cancer molecular subtype.

METHODS

All preoperative breast MRIs at a single academic medical center from May 2010 to March 2014 were identified. Reports were reviewed for biopsy recommendations. All pathology reports were reviewed to determine biopsy recommendation outcomes. Molecular subtypes were defined as Luminal A (ER/PR+ and HER2-), Luminal B (ER/PR+ and HER2+), HER2 (ER-, PR- and HER2+), and Basal (ER-, PR-, and HER2-). Logistic regression assessed the probability of true positive versus false positive biopsy and mastectomy versus lumpectomy.

RESULTS

There were 383 patients included with a molecular subtype distribution of 253 Luminal A, 44 Luminal B, 20 HER2, and 66 Basal. Two hundred and thirteen (56%) patients and 319 sites were recommended for biopsy. Molecular subtype did not influence the recommendation for biopsy (p = 0.69) or the number of biopsy site recommendations (p = 0.30). The positive predictive value for a biopsy recommendation was 42% overall and 46% for Luminal A, 43% for Luminal B, 36% for HER2, and 29% for Basal subtype cancers. The multivariate logistic regression model showed no difference in true positive biopsy rate based on molecular subtype (p = 0.78). Fifty-one percent of patients underwent mastectomy and the multivariate model demonstrated that only a true positive biopsy (odds ratio: 5.3) was associated with higher mastectomy rates.

CONCLUSION

Breast cancer molecular subtype did not influence biopsy recommendations, positive predictive values, or surgical approaches. Only true positive biopsies increased the mastectomy rate.

Non-clinical Drivers of Variation in Preoperative MRI Utilization for Breast Cancer

BACKGROUND

Preoperative magnetic resonance imaging (MRI) utilization in breast cancer treatment has increased significantly over the past 2 decades, but its use continues to have interprovider variability and disputed clinical indications.

OBJECTIVE

The aim of this study was to evaluate non-clinical factors associated with preoperative breast MRI utilization.

METHODS

This study utilized TRICARE claims data from 2006 to 2015. TRICARE provides health benefits for active duty service members, retirees, and their dependents at both military (direct care with salaried physicians) and civilian (purchased care under fee-for-service structure) facilities. We studied patients aged 25-64 years with a breast cancer diagnosis who had undergone mammogram/ultrasound (MMG/US) alone or with subsequent breast MRI prior to surgery. Facility characteristics included urban-rural location according to the National Center for Health Statistics classification. Adjusted multivariable logistic regression tests were used to identify independent factors associated with preoperative breast MRI utilization.

RESULTS

Of the 25,392 identified patients, 64.7% (n = 16,428) received preoperative MMG/US alone, while 35.3% (n = 8964) underwent additional MRI. Younger age, Charlson Comorbidity Index score ≥ 2, active duty or retired beneficiary category, officer rank (surrogate for socioeconomic status), Air Force service branch, metropolitan location, and purchased care were associated with an increased likelihood of preoperative MRI utilization. Non-metropolitan location and Navy service branch were associated with decreased MRI use.

CONCLUSION

After controlling for expected clinical risk factors, patients were more likely to receive additional MRI when treated at metropolitan facilities or through the fee-for-service system. Both associations may point toward non-clinical incentives to perform MRI in the treatment of breast cancer.

Contrast-enhanced spectral mammography in the evaluation of breast suspicious calcifications: diagnostic accuracy and impact on surgical management

Background

Detecting pathological breast calcifications remains challenging. Based on recent studies, contrast-enhanced spectral mammography (CESM) was shown to be superior compared to full-field digital mammography (FFDM).

Purpose

To evaluate the diagnostic accuracy of CESM in suspicious breast calcifications and its impact on surgical decision-making.

Material and Methods

All screening recalled patients with suspicious calcifications that underwent CESM in the period October 2012 until September 2015 were included. One experienced radiologist provided a BI-RADS classification for the FFDM images only. The evaluation was repeated for the CESM exam. In a simulated tumor board meeting, two breast surgeons decided on the preferred surgical treatment (breast conservation therapy [BCT] versus mastectomy) for all malignant cases. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated defining BI-RADS ≥4 as being malignant. In addition, differences in surgical decision-making were analyzed and compared using McNemar’s test.

Results

In total, 147 women were included in this study (mean age = 61 years; age range = 49–75 years). Pathology showed 82 benign and 65 malignant lesions, of which 33 were ductal carcinomas in situ and 32 were invasive lesions. Diagnostic performances of CESM (differences compared to FFDM in brackets) were: sensitivity 93.8% (+3%), specificity 36.6% (−2.5%), PPV 54% (0%), and NPV 88.2% (+4%). Based on low-energy images, surgeons suggested BCT in 89% of the cases. Based on the CESM exam, no statistical changes in decisions were observed (86% BCT, P = 0.453).

Conclusion

CESM only slightly improves the diagnostic accuracy of the evaluation of breast calcifications. It is not of added value compared to FFDM in guiding surgical decision-making.

Diffusional kurtosis imaging for differentiation of additional suspicious lesions on preoperative breast MRI of patients with known breast cancer

PURPOSE

To investigate the potential of diffusional kurtosis imaging (DKI) and conventional diffusion-weighted imaging (DWI) in the evaluation of additional suspicious lesions at preoperative breast magnetic resonance imaging (MRI) in patients with breast cancer.

MATERIALS AND METHODS

Fifty-three additional suspicious lesions in 45 patients with breast cancer, which were detected on preoperative breast MRI, were examined with a 3-T MR system. DKI and DWI data were obtained using a spin-echo single-shot echo-planar imaging sequence with b-values of 0, 50, 600, 1000, and 3000 s/mm². Histogram parameters (mean, standard deviation, minimum, maximum, 10th, 25th, 50th, 75th, 90th percentiles, kurtosis, skewness and entropy) of ADC from DWI and diffusivity (D), kurtosis (K) from DKI were calculated after postprocessing. Parameters were compared between benign vs. ductal carcinoma in situ (DCIS) vs. invasive breast lesions and diagnostic performances were evaluated by receiver operating characteristic (ROC) analysis. Correlation between the mean values of D and K was analyzed according to lesion type.

RESULTS

Multiple histogram parameters of D (mean, 25th, 50th percentile, 75th percentile, and entropy) differed between benign and invasive breast lesions (all P < 0.005), but none differed between benign vs. DCIS. D-90th percentile differed between DCIS vs. invasive cancer (P = 0.040). K-10th percentile differed between benign vs. DCIS (P = 0.015). ADC-75th percentile differed between benign vs. invasive cancer and ADC-75th percentile, ADC-90th percentile differed between DCIS vs. invasive cancer, respectively (all P < 0.005). ROC curve analysis showed high specificity for discrimination between benign and invasive cancer. D-mean and K-mean showed strong correlation in benign (r_s = -0.813) and invasive lesions (r_s = -0.853), but no significant correlation in DCIS.

CONCLUSION

DKI may aid in the differentiation of additional suspicious lesions at preoperative breast MRI. Both ADC and DKI may have lower potential in differentiating DCIS from benign lesions.

Invasive lobular breast cancer: A review of pathogenesis, diagnosis, management, and future directions of early stage disease

Invasive lobular carcinoma (ILC) is the second most common type of invasive breast cancer after invasive ductal carcinoma (IDC). Invasive lobular carcinoma has unique clinical, pathologic, and radiographic features which suggest that it is a distinct clinical entity; however, it is treated with the same treatment paradigms as IDC. Information regarding the specific treatment of ILC, including response to standard therapy, is sparse. Neoadjuvant treatment considerations are of great importance in this space as ILC is often found at a locally advanced stage. In this review, we summarize the classic features of ILC and the available data regarding efficacy of both endocrine therapy and chemotherapy in curative treatment of breast cancer.

Magnetic resonance imaging for invasive lobular carcinoma: is it worth it?

Background

Invasive lobular cancer (ILC) of the breast can provide diagnostic and therapeutic challenges due to its often mammographically occult and multifocal nature. UK guidelines recommend magnetic resonance imaging (MRI) when considering breast conserving surgery (BCS) in women with a diagnosis of ILC. A small number of studies have shown that due to its low specificity, MRI can lead to additional invasive investigations whilst rarely identifying additional tumour foci that affect management. We carried out a retrospective study of patients diagnosed with ILC to assess the impact of MRI on management and to evaluate if breast density on mammography could indicate likelihood of additional disease being found on MRI.

Methods

A retrospective analysis of the electronic patient records for all cases of ILC diagnosed between January 2013 and December 2016 was carried out.

Results

A total of 110 cases of ILC were identified of which 69 women were considered for BCS and 58 (84.1%) women underwent MRI. A further abnormality was seen in 22 (37.9%) patients of whom 13 (59.1%) had a further core biopsy with 4 cases being positive for malignancy. Overall MRI changed the surgical plan from BCS to mastectomy in 7 (10.1%). Breast density did not predict the presence of additional findings on MRI.

Conclusions

MRI assessment of ILC rarely affects the management when BCS is considered. Having radiologically denser breasts did not correlate with increased reoperation rate. Larger prospective studies may provide further guidance on MRI specificity and breast density.

Long-Term Survival Differences Between T1-2 Invasive Lobular Breast Cancer and Corresponding Ductal Carcinoma After Breast-Conserving Surgery: A Propensity-Scored Matched Longitudinal Cohort Study

BACKGROUND

The role of histology subtype on the prognosis of T1-2 breast cancer patients receiving breast-conserving surgery (BCS) is not clear.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) Program was used to compare overall survival, second primary cancer-free survival (CFS), and local recurrence risk (LR) for patients with invasive lobular carcinoma (ILC) and invasive ductal carcinoma (IDC), both receiving BCS.

RESULTS

The study enrolled 196,688 patients with T1-2 disease receiving BCS, including 12,906 with ILC and 183,782 with IDC. Patients with IDC showed higher unadjusted annual rates of BCS than ILC. Five- and 10-year estimated survival rates were, respectively, 92.06% and 86.14% in ILC, compared to 90.50% and 85.26% in IDC (P = .12). In multivariable Cox regression, ILC patients showed advantage over IDC in overall survival (hazard ratio [HR] = 0.93, P = .001), whereas no significant differences in CFS (HR = 1.03, P = .33) and LR (HR = 1.17, P = .06) were found, which were consistent with results from matched cohort. In subgroup analyses, patients with grade III ILC had poorer CFS (HR = 1.23, P = .009) and higher LR (HR = 1.59, P = .01) than IDC.

CONCLUSION

Histologic type is of prognostic importance in T1-2 patients receiving BCS, and surgeons should be cautious in performing BCS for individuals with grade III ILC.

Nationwide population-based study of trends and regional variation in breast-conserving treatment for breast cancer

Background

Landmark trials have shown breast-conserving surgery (BCS) combined with radiotherapy to be as safe as mastectomy in breast cancer treatment. This population-based study aimed to evaluate trends in BCS from 1989 to 2015 in nine geographical regions in the Netherlands.

Methods

All women diagnosed between 1989 and 2015 with primary T1–2 N0–1 breast cancer, treated with BCS or mastectomy, were identified from the Netherlands Cancer Registry. Crude and case mix-adjusted rates of BCS were evaluated and compared between nine Dutch regions for two time intervals: 1989–2002 and 2003–2015. The annual percentage change in BCS per region over time was assessed by means of Joinpoint regression analyses. Explanatory variables associated with the choice of initial surgery were evaluated using multivariable logistic regression.

Results

A total of 202 934 patients were included, 82 200 treated in 1989–2002 and 120 734 in 2003–2015. During 1989–2002, the mean rate of BCS was 50·6 per cent, varying significantly from 39·0 to 71·7 per cent between the nine regions. For most regions, a marked rise in BCS was observed between 2002 and 2003. During 2003–2015, the mean rate of BCS increased to 67·4 per cent, but still varied significantly between regions from 58·5 to 75·5 per cent. A significant variation remained after case-mix correction.

Conclusion

This large nationwide study showed that the use of BCS increased from 1989 to 2015 in the Netherlands. After adjustment for explanatory variables, a large variation still existed between the nine regions. This regional variation underlines the need for implementation of a uniform treatment and decision-making strategy.

Value Added of Preoperative Contrast-Enhanced Digital Mammography in Patients With Invasive Lobular Carcinoma of the Breast

BACKGROUND

Invasive lobular carcinoma (ILC) is the second most frequently diagnosed breast cancer, accounting for 5% to 15% of all invasive breast cancers, yet it remains radiologically elusive in many cases. The goal of this study was to compare the ability to accurately assess disease extent with contrast-enhanced digital mammography (CEDM) and full-field digital mammography (FFDM) in patients with biopsy-proven ILC.

PATIENTS AND METHODS

A single-institution retrospective review of patients diagnosed with ILC with preoperative CEDM was performed. One of 3 blinded radiologist readers rereviewed cases within 1 month of another. Final size diameter was based on the largest dimension on recombined CEDM or FFDM and compared to the reference standard histopathology. Bland-Altman plots were used to visualize the differences between tumor size on imaging and pathology.

RESULTS

Thirty women were included. Mean tumor diameter was 27.0 mm (range, 7.0-118 mm) on postoperative histology, 26.0 mm on CEDM, and 16.4 mm on standard mammogram. For CEDM versus FFDM, 5 (16.7%) of 30 versus 9 (30.0%) of 30 cases underestimated pathology by > 10 mm and 5 (16.7%) of 30 versus 3 (10.0%) of 30 overestimated histopathology by > 10 mm, respectively. Two (6.7%) of 30 cases required surgical reexcision. Both Lin (0.87 vs. 0.55) and Pearson (0.87 vs. 0.70) correlation coefficient measures were higher for CEDM versus FFDM.

CONCLUSION

CEDM outperforms standard digital mammography in ability to accurately assess disease extent in patients with biopsy-proven ILC, resulting in improved surgical outcomes. Future studies should compare surgical outcomes in patients with preoperative magnetic resonance imaging and CEDM in patients with ILC.

Incidence and tumour characteristics of bilateral and unilateral interval breast cancers at screening mammography

BACKGROUND

Detected by screening mammography, bilateral breast cancer has a different pathological profile compared to unilateral breast cancer. We investigated the incidence of bilateral interval breast cancers and compared their characteristics with those of unilateral interval breast cancers.

METHODS

We included all 468,720 screening mammograms of women who underwent biennial screening mammography in the South of the Netherlands between January 2005 and January 2015. We collected breast imaging reports, biopsy results and surgical reports of all referred women and of all women who presented with interval breast cancer. The tumour with the highest tumour stage (index cancer) was used for comparison with unilateral interval cancers.

RESULTS

A total of 753 interval cancers were detected, of which 24 (3.2%) were bilateral. Among the invasive interval cancers, bilateral cancers more frequently showed a lobular histology than unilateral cancers (37.5% (9/24) vs. 16.1% (111/691), P = .01). There is a trend towards a larger proportion of bilateral than unilateral interval cancers graded 1 (45.8% (11/24) vs. 27.8% (192/691), P = .08). There were no other statistically significant differences in tumour characteristics. Also, the proportion of interval cancers showing significant mammographic abnormalities at the latest screen was comparable for unilateral and bilateral interval cancers (23.0% vs. 25.0%, P = .9).

DISCUSSION

Bilateral interval cancers comprise a small proportion of all interval cancers. Except of a higher proportion of invasive lobular cancers and a more favourable histological grade of invasive cancers, tumour characteristics are comparable for bilateral and unilateral interval breast cancers.

Breast magnetic resonance imaging use in patients undergoing neoadjuvant chemotherapy is associated with less mastectomies in large ductal cancers but not in lobular cancers

BACKGROUND

To assess the impact of breast magnetic resonance imaging (MRI) use on surgical outcome per histological breast cancer subtype in patients treated with neoadjuvant chemotherapy.

PATIENTS AND METHODS

All patients aged 18-70 years who underwent neoadjuvant chemotherapy for stage I-III invasive breast cancer in the Netherlands in the years 2011-2013 were identified from the Netherlands Cancer Registry. Patients with cT4 tumours were excluded from the analysis. Use of breast MRI and impact on surgical treatment, resection margins and detection of contralateral breast cancer were analysed by multivariable analyses.

RESULTS

Breast MRI was performed in 2879 (83.9%) out of 3433 patients treated with neoadjuvant chemotherapy. Younger age (odds ratio [OR] 1.42; 95% confidence interval [CI] 1.17-1.71 for 18-50 years compared with 50-70 years), larger tumour stage (OR 1.46 [95% CI 1.15-1.86] for cT3, compared to cT1-2 tumours) and multifocality (OR 1.30; 95% CI 1.04-1.61, versus unifocality) were associated with increased breast MRI use. In ductal breast cancer, after stratification for cT-status, breast MRI use is associated with a significant lower OR for mastectomy as final surgery in cT3 tumours (OR 0.45, 95% CI 0.21-0.99). Resection margin involvement and detection of contralateral breast cancer were not associated with breast MRI use.

CONCLUSION

In patients treated with neoadjuvant chemotherapy, the use of breast MRI was associated with a reduced mastectomy rate, particularly in patients with large invasive ductal breast tumours but not in patients with lobular breast cancer.