Reliability of MRI tumor size measurements for minimal invasive treatment selection in small breast cancers

Sentinel Lymph Node Biopsy in Early-Stage Breast Cancer: ASCO Guideline Update

PURPOSE

To update the ASCO evidence-based recommendations on the use of sentinel lymph node biopsy (SLNB) in patients with early-stage breast cancer treated with initial surgery.

METHODS

ASCO convened an Expert Panel to develop updated recommendations based on a systematic literature review (January 2016-May 2024).

RESULTS

Eleven randomized clinical trials (14 publications), eight meta-analyses and/or systematic reviews, and one prospective cohort study met the inclusion criteria for this systematic review. Expert Panel members used available evidence and informal consensus to develop practice recommendations.

RECOMMENDATIONS

Clinicians should not recommend routine SLNB in select patients who are postmenopausal and ≥50 years of age and with negative findings on preoperative axillary ultrasound for grade 1-2, small (≤2 cm), hormone receptor-positive, human epidermal growth factor receptor 2-negative breast cancer and who undergo breast-conserving therapy. Clinicians may offer postmastectomy radiation (RT) with regional nodal irradiation (RNI) and omit axillary lymph node dissection (ALND) in patients with clinically node-negative invasive breast cancer ≤5 cm who receive mastectomy and have one to two positive sentinel nodes. Clinicians may offer SLNB in patients who have cT3-T4c or multicentric tumors (clinically node-negative) or ductal carcinoma in situ treated with mastectomy, and in patients who are obese, male, or pregnant, or who have had prior breast or axillary surgery. Clinicians should not recommend ALND for patients with early-stage breast cancer who do not have nodal metastases, and clinicians should not recommend ALND for patients with early-stage breast cancer who have one or two sentinel lymph node metastases and will receive breast-conserving surgery and whole-breast RT with or without RNI.Additional information is available at www.asco.org/breast-cancer-guidelines.This guideline has been endorsed by the American Society for Radiation Oncology (ASTRO).

Tumor size and stage assessment accuracy of MRI and ultrasound versus pathological measurements in early breast cancer patients

BACKGROUND

Accurate size and stage estimation is important to monitor tumor response and plan further treatment in breast cancer patients undergoing neoadjuvant chemotherapy. To evaluate the accuracy of imaging findings [ultrasound (US) and magnetic resonance imaging (MRI)] for tumor size and stage estimations in early breast cancer patients and to elucidate the factors influencing tumor stage assessment.

METHODS

We retrospectively enrolled consecutive women having pathologically confirmed breast cancer (stage T1/T2, 199 patients and 201 lesions) and preoperative records available for both US and MRI. The concordance between imaging-determined and pathological tumor size and stage was explored. The McNemar's test was conducted to compare the concordance between imaging-determined tumor size and imaging-determined tumor stage. Multivariate logistic regression was used to analyze the factors that influenced the accuracy.

RESULTS

The concordance between US-determined and pathological tumor size (71.1%) was comparable to MRI-pathology concordance (72.6%). MRI-determined stage concordance (73.6%) was comparable to US-determined stage concordance (69.2%). Tumors with a larger pathological size, were more likely to be underestimated by US or MRI in terms of tumor size and stage (all P < 0.05).

CONCLUSION

Tumor size and tumor stage concordance did not significantly differ between US and MRI in early breast cancer patients; US could be the first choice for tumor size estimation and tumor staging.

ACR Appropriateness Criteria® Imaging of Invasive Breast Cancer

As the proportion of women diagnosed with invasive breast cancer increases, the role of imaging for staging and surveillance purposes should be determined based on evidence-based guidelines. It is important to understand the indications for extent of disease evaluation and staging, as unnecessary imaging can delay care and even result in adverse outcomes. In asymptomatic patients that received treatment for curative intent, there is no role for imaging to screen for distant recurrence. Routine surveillance with an annual 2-D mammogram and/or tomosynthesis is recommended to detect an in-breast recurrence or a new primary breast cancer in women with a history of breast cancer, and MRI is increasingly used as an additional screening tool in this population, especially in women with dense breasts. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Target volumes comparison between postoperative simulation magnetic resonance imaging and preoperative diagnostic magnetic resonance imaging for prone breast radiotherapy after breast-conserving surgery

BACKGROUND

This study investigated the differences in target volumes between preoperative magnetic resonance imaging (MRIpre) and postoperative MRI (MRIpost) for breast radiotherapy after breast-conserving surgery (BCS) using deformable image registration (DIR).

METHODS AND MATERIALS

Seventeen eligible patients who underwent whole-breast irradiation in the prone position after BCS were enrolled. On MRIpre, the gross tumor volume (GTV) was delineated as GTVpre, which was then expanded by 10 mm to represent the preoperative lumpectomy cavity (LC), denoted as LCpre. The LC was expanded to the clinical target volume (CTV) and planning target volume (PTV) on the MRIpre and MRIpost, denoted as CTVpre, CTVpost, PTVpre, and PTVpost, respectively. The MIM software system was used to register the MRIpre and MRIpost using DIR. Differences were evaluated regarding target volume, distance between the centers of mass (dCOM), conformity index (CI), and degree of inclusion (DI). The relationship between CILC /CIPTV and the clinical factors was also assessed.

RESULTS

Significant differences were observed in LC and PTV volumes between MRIpre and MRIpost (p < 0.0001). LCpre was 0.85 cm3 larger than LCpost, while PTVpre was 29.38 cm3 smaller than PTVpost. The dCOM between LCpre and LCpost was 1.371 cm, while that between PTVpre and PTVpost reduced to 1.348 cm. There were statistically significant increases in CI and DI for LCpost-LCpre and PTVpost-PTVpre (CI = 0.221, 0.470; DI = 0.472, 0.635). No obvious linear correlations (p > 0.05) were found between CI and GTV, primary tumor volume-to-breast volume ratio, distance from the primary tumor to the nipple and chest wall, and body mass index.

CONCLUSIONS

Despite using DIR technology, the spatial correspondence of target volumes between MRIpre and MRIpost was suboptimal. Therefore, relying solely on preoperative diagnostic MRI with DIR for postoperative LC delineation is not recommended.

The accuracy of magnetic resonance imaging in predicting the size of pure ductal carcinoma in situ: a systematic review and meta-analysis

Ductal carcinoma in situ (DCIS) is a putative precursor of invasive breast cancer and MRI is considered the most sensitive imaging technique for its detection. This study aims to evaluate the accuracy of MRI measuring the pure DCIS size, against pathology, to better understand the role of MRI in the management of this intraductal neoplasm.Potentially eligible studies in MEDLINE, Embase and Google Scholar, up to January 2021 were considered, and a systematic review and meta-analysis according to the published protocol (Prospero-CRD42021232228) was performed. Outcomes of mean differences and accuracy rates were analysed using IBM^® SPSS^® v26 and random-effect models in platform R v3.3.Twenty-two cross-sectional studies were selected and 15 proceeded to meta-analysis. MRI accurately predicted 55% of the tumours' sizes and, according to Bland-Altman plots, concordance between MRI and pathology was greater for smaller tumours. In the meta-analysis, difference of the means between MRI and pathology was 3.85 mm (CI 95% [-0.92;8.60]) with considerable heterogeneity (I2 = 96.7%). Subgroup analysis showed similar results for sizes between different MRI fields, temporal resolution, slice thickness and acquisition times, but lower heterogeneity in studies using 3-T MRI (I2 = 57.2%). Results were concordant with low risk of bias studies (2.46, CI 95% [0.57-4.36]), without heterogeneity (I2 = 0%).Therefore, MRI is shown to be an accurate method in pure DCIS size assessment. Once the best MRI protocol is established, evaluation of the impact of pure DCIS size in predicting treatment outcomes will contribute to clarifying current issues related to intraductal breast carcinoma.

Evaluation of Breast Cancer Size Measurement by Computer-Aided Diagnosis (CAD) and a Radiologist on Breast MRI

Purpose: This study aimed to evaluate cancer size measurement by computer-aided diagnosis (CAD) and radiologist on breast magnetic resonance imaging (MRI) relative to histopathology and to determine clinicopathologic and MRI factors that may affect measurements. Methods: Preoperative MRI of 208 breast cancers taken between January 2017 and March 2021 were included. We evaluated correlation between CAD-generated size and pathologic size as well as that between radiologist-measured size and pathologic size. We classified size discrepancies into accurate and inaccurate groups. For both CAD and radiologist, clinicopathologic and imaging factors were compared between accurate and inaccurate groups. Results: The mean sizes as predicted by CAD, radiologist and pathology were 2.66 ± 1.68 cm, 2.54 ± 1.68 cm, and 2.30 ± 1.61 cm, with significant difference (p < 0.001). Correlation coefficients of cancer size measurement by radiologist and CAD in reference to pathology were 0.898 and 0.823. Radiologist’s measurement was more accurate than CAD, with statistical significance (p < 0.001). CAD-generated measurement was significantly more inaccurate for cancers of larger pathologic size (>2 cm), in the presence of an extensive intraductal component (EIC), with positive progesterone receptor (PR), and of non-mass enhancement (p = 0.045, 0.045, 0.03 and 0.002). Radiologist-measured size was significantly more inaccurate for cancers in presence of an in situ component, EIC, positive human epidermal growth factor receptor 2 (HER2), and non-mass enhancement (p = 0.017, 0.008, 0.003 and <0.001). Conclusion: Breast cancer size measurement showed a very strong correlation between CAD and pathology and radiologist and pathology. Radiologist-measured size was significantly more accurate than CAD size. Cancer size measurement by CAD and radiologist can both be inaccurate for cancers with EIC or non-mass enhancement.