Influence of preoperative magnetic resonance imaging on the surgical management of breast cancer patients

Background

Magnetic resonance imaging (MRI) is gaining popularity in the preoperative management of breast cancer patients. However, the role of this modality remains controversial. We aimed to study the impact of preoperative MRI (pMRI) on the surgical management of breast cancer patients.

Methods

This retrospective study included 766 subjects with breast cancer treated operatively at the specialized academic center.

Results

Between those who underwent pMRI (MRI group, n = 307) and those who did not (no-MRI group, n = 458), there were no significant differences (P = .254) in the proportions of either total mastectomies (20.5% vs 17.2%, respectively) or segmental mastectomies (79.5% vs 82.8%). Patients in the MRI group were significantly more likely (P = .002) to undergo contralateral surgery (11.7% vs 5.5%). Similar results were obtained in multivariate analysis adjusting for age, with the proportions of contralateral breast operations significantly higher in the MRI group (Odds Ratio = 2.25, P = .007). pMRI had no significant effect (P = .54) on the proportion of total re-excisions (7.5% vs 8.7%) or the type of re-excision (total vs segmental mastectomy) between the groups.

Conclusions

pMRI does not have a significant impact on the type of operative intervention on the ipsilateral breast but is associated with an increase in contralateral operations. Similarly, pMRI does not change the proportion of re-excisions or the type of the re-excision performed. This study demonstrates that pMRI has little impact on the surgical management of breast cancer, and its value as a routine adjunct in the preoperative work-up of recently diagnosed breast cancer patients needs to be re-examined.     

Effect of 0.5 Tesla magnetic resonance imaging on the surgical management of breast cancer patients

BACKGROUND: This trial examines the utility of breast magnetic resonance imaging (MRI) for detection of occult breast disease and its effect on surgical treatment. METHODS: Between October 2000 and March 2002, 76 of 1289 patients underwent bilateral breast MRI within 4 months of a mammogram. The MRI scan, mammogram, pathology reports, and physicians' notes were reviewed to determine impact of MRI on surgical treatment. RESULTS: Magnetic resonance imaging detected 23 additional lesions in 19 patients not detected by mammogram. Cancer occult to mammography was detected by MRI in 6 women, constituting 7.9%. Magnetic resonance imaging impacted surgical treatment plans in 10 of 76 (13.2%) patients. CONCLUSIONS: Magnetic resonance imaging is effective at identifying new subclinical breast disease not seen on mammography. Ten of 76 patients (13.2%) who underwent MRI had their surgical management altered due to MRI findings. Specific criteria should be studied to know which subgroups would benefit most from breast MRI.     

Multiparametric magnetic resonance imaging: Current role in prostate cancer management

Digital rectal examination, serum prostate‐specific antigen screening and transrectal ultrasound‐guided biopsy are conventionally used as screening, diagnostic and surveillance tools for prostate cancer. However, they have limited sensitivity and specificity. In recent years, the role of multiparametric magnetic resonance imaging has steadily grown, and is now part of the standard clinical management in many institutions. In multiparametric magnetic resonance imaging, the morphological assessment of T2‐weighted imaging is correlated with diffusion‐weighted imaging, dynamic contrast‐enhanced imaging perfusion and/or magnetic resonance spectroscopic imaging. Multiparametric magnetic resonance imaging is currently regarded as the most sensitive and specific imaging technique for the evaluation of prostate cancer, including detection, staging, localization and aggressiveness evaluation. This article presents an overview of multiparametric magnetic resonance imaging, and discusses the current role of multiparametric magnetic resonance imaging in the different fields of prostate cancer management.     

Contrast-enhanced breast magnetic resonance imaging: the surgical perspective

BACKGROUND: Contrast-enhanced breast magnetic resonance imaging (MRI) has shown excellent sensitivity (93%) for breast malignancies. The clinical role and value of MRI for the breast surgeon remains unresolved and controversial. METHODS: A retrospective review of clinical and imaging records was undertaken for 79 surgical patients evaluated by MRI as part of their initial assessment. RESULTS: Of 79 patients, 71 (90%) had dense mammograms, 64 (81%) had known primary breast cancer (BrCA), 42 (53%) had a family history of BrCA, and 8 (10%) had known breast atypia. MRI identified a larger than clinically suspected BrCA size in 10 (16%) patients and greater BrCA extent in 26 (41%) patients. Of 15 non-BrCA patients, 10 (67%) had a biopsy after the MRI with identification of BrCA in 6 (40%) patients. Overall, there were 20 MRI-initiated core biopsies, of which 14 (70%) identified BrCA. Of 70 BrCA patients, 13 (19%) had neoadjuvant chemotherapy, 35 (50%) had breast-conserving surgery, 36 (51%) had total mastectomy, and 14 (22%) had bilateral total mastectomy. MRI had good pathology correlation in 56 of 62 (90%) patients. In patients with known BrCA (by core biopsy), none of the 29 breast-conserving surgery resections undertaken after MRI had a positive margin or required re-excision. CONCLUSIONS: MRI is very accurate for BrCA evaluation, both for lesion size and extent. With good collaboration between the radiologist and surgeon, MRI is a powerful 3-dimensional and communication tool for the breast surgeon and the patient.     

The effect of magnetic resonance imaging in the workup of breast cancer

Background

Breast magnetic resonance imaging (MRI) is becoming an often-utilized examination in the preoperative planning for breast cancer. However, it is not yet accepted as a routine examination for all breast cancer patients due to the lack of data regarding whether breast MRI has any effect on recurrence or survival.

Methods

The charts of 76 patients referred by their surgeons for breast MRI during breast cancer workup were reviewed to determine if the breast MRI changed the preoperative clinical staging, the operative plan, or prompted additional testing.

Results

Thirty-eight of 76 patients (50%) received follow-up imaging and 22/76 (29%) received additional biopsies. The breast MRI upstaged the cancer in 14/76 patients (18%). There was a change in the surgical plan in 19 of 76 (25%) patients, all of whom received more extensive surgery than previously planned.

Conclusion

Breast MRI contributed significantly to the workup and management of breast cancer at our institution, suggesting a higher stage in 18% of the patients and changing the surgical plan in 25% of the patients.     

Evaluating the impact of preoperative breast magnetic resonance imaging on the surgical management of newly diagnosed breast cancers

HYPOTHESIS: Women with newly diagnosed breast cancers may harbor additional ipsilateral or contralateral breast malignancies that are undetected by mammography and ultrasonography. Magnetic resonance imaging (MRI) has demonstrated excellent sensitivity in the detection of breast cancers. However, the impact of routine MRI on the surgical management of new, biopsy-proven breast cancers remains unclear. DESIGN: Retrospective analysis of a prospective database. SETTING: An academic, tertiary care center in a large metropolitan area. PATIENTS: A total of 155 women with breast cancer newly diagnosed by mammography, ultrasonography, and needle biopsy underwent preoperative bilateral breast MRI in a single-institution, single-surgeon setting during 1 year. MAIN OUTCOME MEASURES: Change in surgical management based on breast MRI findings. RESULTS: The MRI demonstrated 124 additional suspicious lesions in 73 patients. Post-MRI follow-up mammograms or ultrasonograms were required in 65 patients, and 41 patients underwent additional image-guided biopsies. There was a change in surgical management as MRI discovered additional, otherwise undetected malignancies in 36 patients based on radiographic-pathologic correlation. Lumpectomy was converted to mastectomy in 10 patients (8 beneficial), wider excision was performed in 21 patients (10 beneficial), and 5 patients (2 beneficial) underwent contralateral surgery. Larger tumor size was an independent predictor of a beneficial change in surgical management (odds ratio, 1.66; 95% confidence interval, 1.04-2.66). CONCLUSIONS: Breast MRI results in a beneficial change in surgical management in 9.7% of newly diagnosed breast cancers. The detection of additional, otherwise undetected ipsilateral and contralateral breast malignancies with MRI suggests that breast MRI may have a role in the evaluation of new breast cancers.     

The current and future role of magnetic resonance imaging in prostate cancer detection and management

Purpose

Accurate detection of clinically significant prostate cancer (PC) and correct risk attribution are essential to individually counsel men with PC. Multiparametric MRI (mpMRI) facilitates correct localization of index lesions within the prostate and MRI-targeted prostate biopsy (TPB) helps to avoid the shortcomings of conventional biopsy such as false-negative results or underdiagnosis of aggressive PC. In this review we summarize the different sequences of mpMRI, characterize the possibilities of incorporating MRI in the biopsy workflow and outline the performance of targeted and systematic cores in significant cancer detection. Furthermore, we outline the potential of MRI in patients undergoing active surveillance (AS) and in the pre-operative setting.

Materials and methods

An electronic MEDLINE/PubMed search up to February 2015 was performed. English language articles were reviewed for inclusion ability and data were extracted, analyzed and summarized.

Results

Targeted biopsies significantly outperform conventional systematic biopsies in the detection of significant PC and are not inferior when compared to transperineal saturation biopsies. MpMRI can detect index lesions in app. 90% of cases as compared to prostatectomy specimen. The diagnostic performance of biparametric MRI (T2w + DWI) is not inferior to mpMRI, offering options to diminish cost- and time-consumption. Since app 10% of significant lesions are still MRI-invisible, systematic cores seem to be necessary. In-bore biopsy and MRI/TRUS-fusion-guided biopsy tend to be superior techniques compared to cognitive fusion. In AS, mpMRI avoids underdetection of significant PC and confirms low-risk disease accurately. In higher-risk disease, pre-surgical MRI can change the clinically-based surgical plan in up to a third of cases.

Conclusions

mpMRI and targeted biopsies are able to detect significant PC accurately and mitigate insignificant PC detection. As long as the negative predictive value (NPV) is still imperfect, systematic cores should not be omitted for optimal staging of disease. The potential to correctly classify aggressiveness of disease in AS patients and to guide and plan prostatectomy is evolving.     

Scientific Presentation Award: The impact of magnetic resonance imaging on surgical treatment of invasive breast cancer

Background

The purpose of this study was to examine the relationship between magnetic resonance imaging (MRI) and surgical treatment of invasive breast cancer (IBC).

Method

The IBC patients treated from January 2003-June 2008 were reviewed by a single institution.

Results

A total of 814 patients were treated, out of which 562 (69%) underwent breast conservation therapy (BCT), 151 (19%) chose mastectomy alone (M), and 101 (12%) chose mastectomy with reconstruction (M+ R). The mean age was comparatively low in M + R patients (P ≤ 0.001). The mean tumor size was the lowest in BCT patients (P ≤ 0.001). MRI use increased with no significant difference in type of surgery as noted by year. In multivariate analysis, type of surgery was significantly associated with tumor size, multifocality, age, and MRI use. The factors associated with MRI performance were: multifocality, younger age, tumor size, lobular histology, body mass index, and genetic testing.

Conclusions

The use of MRI in IBC patients has increased over the past 5 years, without any observable impact on surgical treatment. Similar factors are associated with mastectomy and MRI performance.     

The role of magnetic resonance imaging in the local staging of penile cancer

OBJECTIVES: To assess the accuracy of magnetic resonance imaging (MRI) as a local staging technique in penile cancer and its role in selecting patients for conservative surgical management. METHODS: Fifty-five men diagnosed with invasive penile carcinoma on biopsy were locally staged with the use of MRI. Prostaglandin E1 (alprostadil) was injected into the corpora to induce an artificial erection. Radiologic staging was compared against final histopathologic stage of the tumour. Sensitivity, specificity, and kappa agreement values were calculated for each tumour stage. Additionally, corpora cavernosa involvement was reviewed in 20 consecutive cases and suitability for conservative surgery assessed. RESULTS: A good correlation between radiologic and histologic staging was achieved with an overall kappa value of 0.75 (p<0.001). Stage-specific sensitivities and specificities were calculated: T1 (85%; 83%), T2 (75%; 89%), and T3 (88%; 98%). MRI accurately predicted corpora cavernosa invasion in all cases of pathologically proven disease. These patients were selected to undergo partial penectomy. There were no complications using this imaging technique. CONCLUSIONS: This study demonstrates that penile MRI is highly accurate in the local staging of penile cancer. Associated improvements in surgical planning allow the provision of conservative surgical treatments over more radical procedures.     

The role of mammography in the detection of breast cancer

Attempts to reach a tissue diagnosis of breast masses by the use of X-rays (mammography) proved unsuccessful and, as a consequence, the popularity of the method waned. A more natural and less radical surgical approach to the treatment of breast cancer, coupled with statistical evidence that more favourable results were obtained in early cases (stage I and II) resulted in mammography, which is one of the known methods of detecting early lesions, regaining some of its lost status. Screening programmes of asymptomatic well women by mammography in an attempt to detect early breast lesions has been instituted in many countries and the early results (5 years) have been promising. Newer techniques, including the use of special film screen combinations, microfocus tubes with enlargement techniques and grid carbonfilter cassettes, have all contributed to the improvement in diagnostic accuracy. These advances and the place of mass screening programmes in attempts to control this disease are discussed.     

磁共振在乳腺癌临床诊断中的价值

目的：评估磁共振（MRI）检查在乳腺癌中的诊治价值。方法：53例临床和（或）钼靶摄片上疑有乳腺恶性病变的女性病人，行MRI检查：所有病人都接受外科手术和病理学诊断。结果：41例乳腺癌病人中，MRI检查检出乳腺癌37例，检出率为90．24％：钼靶摄片检出乳腺癌33例，检出率为80．48％；二者有显著统计学意义（P〈0．05）；有2例乳腺癌病人．因术前MRI提示有多发病灶而未能行保乳手术。结论：增强MRI诊断乳腺病变有较高的敏感性，对钼靶摄片评价较为困难的致密（型）乳腺尤有一定独到之处。二者联合使用可大为提高乳腺癌的诊断率。MRI检查有利于乳腺癌分期并指导其临床治疗。     

Ultrasound mammography in the management of breast cancer

In this centre, ultrasound mammography has been shown to be more accurate in elucidating the nature of palpable breast lesions than X-ray mammography. A prospective study was devised to determine whether this accuracy could be translated into improved management of patients with breast carcinoma. A total of 223 patients with palpable breast masses were assessed by clinical examination, imaging (X-ray and ultrasound mammography) and aspiration cytology. Each was scored on a five-point scale and treatment was planned according to the total score. According to the protocol, an adequate total score would permit definitive surgery avoiding frozen section. By using sonography rather than radiology, the number of correct diagnoses could be improved by 25 per cent. This was because the greater sensitivity of ultrasound (92.8 per cent) compared to X-ray mammography (82.5 per cent) was reflected in a higher total score, which was sufficient to allow definitive surgical treatment without prior histological confirmation of diagnosis.     

The surgical management of breast cancer

The management of breast cancer is highly controversial. Various operations have been performed in different hospitals. This controversy may arise from an incomplete knowledge of the biology of breast cancer. At present, surgeons are highly recommended to perform an adequate surgery which gives the ultimate in local control, does not compromise the chance of cure and gives the best cosmetic and aesthetic results. Recently, the choice of conservative surgery with aggressive radiation therapy versus more adequate surgery, total mastectomy and axillary dissection, is a major controversial problem for primary treatment of operable breast cancer. However, to avoid local recurrence with attendant worry for the patient, conservative surgery should only be indicated for a select group of patients with early breast cancer. At present, there is little doubt that mastectomy and regional lymph node dissection are the most beneficial methods of treatment in all other patients. So, adequate surgery and breast reconstruction are more preferably recommended for ensuring local control and for providing a better psychological impact.