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Keywords:

  • magnetic resonance imaging (MRI);
  • breast cancer;
  • breast-conserving surgery;
  • local recurrence

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. FUNDING SUPPORT
  5. CONFLICT OF INTEREST DISCLOSURES
  6. REFERENCES

The use of magnetic resonance imaging (MRI) in patients with newly diagnosed breast cancer remains controversial. Here we review the current use of breast MRI and the impact of MRI on short-term surgical outcomes and rates of local recurrence. In addition, we address the use of MRI in specific patient populations, such as those with ductal carcinoma in situ, invasive lobular carcinoma, and occult primary breast cancer, and discuss the potential role of MRI for assessing response to neoadjuvant chemotherapy. Although MRI has improved sensitivity compared with conventional imaging, this has not translated into improved short-term surgical outcomes or long-term patient benefit, such as improved local control or survival, in any patient population. MRI is an important diagnostic test in the evaluation of patients presenting with occult primary breast cancer and has shown promise in monitoring response to neoadjuvant chemotherapy; however, the data do not support the routine use of perioperative MRI in patients with newly diagnosed breast cancer. Cancer 2014;120:120:2080–2089. © 2014 American Cancer Society.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. FUNDING SUPPORT
  5. CONFLICT OF INTEREST DISCLOSURES
  6. REFERENCES

The use of magnetic resonance imaging (MRI) in patients with newly diagnosed breast cancer requires balancing the positive and negative aspects of additional imaging and, as evidenced by the growing number of editorials and reviews arguing for or against the routine use of MRI,[1-8] remains an area of significant controversy. This debate has been fueled by inconsistent data largely comprised of small, single-institution retrospective studies, although 2 randomized controlled trials (RCTs) and several meta-analyses have provided more robust data evaluating MRI in the perioperative setting. The “pros” of perioperative MRI include improved sensitivity compared with conventional imaging and therefore increased identification of multifocal, multicentric, or contralateral disease. With improved sensitivity comes a theoretical improvement in short-term surgical management and/or long-term outcomes. The “cons” of perioperative MRI include the high false-positive rate, potential treatment delays, increased mastectomy rates and cost, and, some argue, overdiagnosis and overtreatment of MRI-only detected disease. Here we review the relevant data regarding MRI use in patients with newly diagnosed breast cancer, examining both the short-term and long-term outcomes, MRI use in populations of women with ductal carcinoma in situ (DCIS) and invasive lobular carcinoma (ILC), MRI's role in patients presenting with occult primary breast cancer, and MRI's ability to evaluate neoadjuvant chemotherapy (NAC) response.

Current MRI Use

In contrast to the well-established guidelines for MRI screening in patients with an inherited predisposition to breast cancer,[9] to our knowledge, there are no guidelines for MRI use in patients with newly diagnosed breast cancer; nevertheless, a report from Western Washington State's Surveillance, Epidemiology, and End Results (SEER) registry demonstrated that 27% of 9196 women with breast cancer underwent MRI for staging or treatment planning between 2002 and 2009,[10] and by 2009, 46% of women underwent perioperative breast MRI. MRI use varied significantly based on age, with 45% of women aged 18 years to 40 years undergoing an MRI compared with 10% of those aged ≥ 81 years (P < .001). Patients were also more likely to undergo MRI if they had commercial health care plans, lived in an urban area, lacked medical comorbidities, or had stage I to III breast cancer, lobular histology, or hormone receptor-negative tumors. The association between MRI use, young patient age, and hormone receptor-negative cancer may be attributable to the presence of known or suspected BRCA mutation carriers in the population; however, this information is not available in the SEER registry. Breslin et al reported an even higher rate of use of advanced imaging, with 53% of patients with non-stage IV breast cancer aged < 65 years undergoing breast MRI in 2008. In this cohort of 52,202 women, MRI use increased annually from 2005 to 2008 for women with both invasive and in situ carcinoma.[11]

Studies examining MRI use in older patients have reported an overall MRI receipt rate of 7% to 10% among women aged ≥ 65 years,[12-14] with significant variation based on geographic location and chronologic year (P < .01). Wang et al found that by 2007, 27% of women in the SEER-Medicare database with stage 0 to II breast cancer had undergone a perioperative MRI[13] and, as in younger patients, preoperative MRI was found to increase mastectomy rates among older patients,[14] many of whom likely would have been good candidates for breast-conserving surgery (BCS) and anti-estrogen therapy alone.[15]

A survey sent to the membership of the American Society of Breast Surgeons in 2010 sought to evaluate indications and practice patterns for MRI use among treating physicians. Of 1034 respondents, 41% reported routinely (> 75% of the time) recommending breast MRI to patients with newly diagnosed breast cancer.[16] Variation in the recommendation for MRI was noted with respect to both physician and patient factors, with academic surgeons less likely to obtain an MRI compared with private practice surgeons (P = .01). Routine recommendation for MRI was more frequent for women with a strong family history of breast cancer (73%), those with ILC (69%), in women undergoing BCS (47%), and in those with increased mammographic breast density (88%). Although physician perception is that MRI is particularly beneficial in the setting of dense breast tissue, studies have demonstrated no significant difference in the diagnostic yield, sensitivity, or negative predictive value of MRI according to breast density.[17] Similarly, studies examining the value of MRI in women with lobular cancers have generated conflicting results.

MRI for Treatment Selection

The increased sensitivity of MRI for the detection of multifocal or multicentric disease has been widely reported and summarized in a meta-analysis by Houssami et al,[18] which included 2610 patients with breast cancer who underwent perioperative MRI in addition to conventional imaging. MRI identified additional disease in 16% of patients (range, 6%-34% in individual studies), resulting in a change from wide local excision to mastectomy in 8.1% of women (95% confidence interval [CI], 5.9%-11.3%) and a larger local excision in 11.3% of women (95% CI, 6.8%-18.3%). A more recent meta-analysis by Plana et al included 10,811 women from 50 studies and found very similar results, with additional lesions identified by MRI in 20% of cases (range, 6%-71%).[19]

Although data consistently demonstrate an increased detection rate of multifocal and multicentric disease, to our knowledge, there are few data demonstrating improved outcomes based on the treatment of MRI-only detected disease. Therefore, the value of MRI in selecting local therapy remains elusive.

MRI and Short-Term Surgical Outcomes

Proponents of breast MRI argue that MRI better characterizes tumor extent and, as such, should improve surgical planning and decrease the rate of positive surgical resection margins and, therefore, the need for re-excision. However, studies have demonstrated significant variability in tumor size estimation by MRI, with underestimation reported in 8% to 59% of cases and overestimation in 11% to 70% of cases.[20-24]

Two prospective RCTs evaluated the effect of MRI on re-operation rates (both re-excision and conversion to mastectomy) in patients deemed appropriate for BCS.[25, 26] The COMICE (Comparative Effectiveness of MRI in Breast Cancer) trial multicenter collaboration included 1625 women randomized to either perioperative MRI or no additional imaging between 2002 and 2007. There was no difference noted with regard to the primary endpoint of re-operation rate, which was 19% in both the MRI and the no-MRI groups (odds ratio [OR], 0.96; 95% CI, 0.75-1.24 [P = .77]), despite the finding that 5 times as many patients in the MRI group (n = 58) converted to mastectomy before an initial attempt at BCS compared with the no-MRI group (n = 10). Among those who underwent an initial mastectomy in the MRI group, in 28% of patients (16 of 58 patients) it was considered pathologically unnecessary.[26]

Similarly, the MONET (MR mammography of non-palpable breast tumours) trial randomized 418 women with nonpalpable lesions, classified as Breast Imaging Reporting and Data System (BI-RADS) 3 to BI-RADS 5 and detected on mammogram or ultrasound, to biopsy or the addition of MRI before biopsy. In total, 163 malignant lesions were identified (83 in the MRI group and 80 in the no-MRI group). It is interesting to note that there was an increased re-excision rate for positive surgical resection margins after BCS in the MRI group (34%) compared with the no-MRI group (12%) (P = .008), and no difference was noted in the rate of conversion to mastectomy after attempted BCS in the MRI (11%) and no-MRI (14%) groups (P = .49).[25]

A meta-analysis that included 3112 patients with breast cancer from the randomized MONET and COMICE trials, as well as 7 comparative cohort studies, evaluated surgical outcomes with the addition of breast MRI and found no difference in re-excision rates after an initial attempt at BCS based on the use of MRI (11.6% vs 11.4%; P = .87). However, the use of MRI was found to significantly increase both the initial and overall mastectomy rates (16.4% and 25.5%, respectively) compared with the no-MRI group (8.1% and 18.2%, respectively), and this difference persisted after adjusting for age (initial mastectomy-adjusted OR, 3.06; 95% CI, 2.03-4.61 [P < .001]; overall mastectomy-adjusted OR, 1.51; 95% CI, 1.21-1.89 [P < .001]).[27] In addition to a lack of improvement in re-excision rates and an increase in mastectomy rates, studies have also reported an increased use of contralateral prophylactic mastectomy in women undergoing perioperative MRI.[28-30] On multivariate analysis, both King et al[28] and Sorbero et al[29] found MRI imaging to be a significant predictor of contralateral prophylactic mastectomy (ORs of 2.8 and 2.04, respectively).

Collectively, available data have failed to support MRI use for the goal of improving surgical management, and the increased rates of both unilateral and bilateral mastectomy in women undergoing perioperative MRI are concerning when considering the low rates of ipsilateral breast tumor recurrence (IBTR) and contralateral breast cancer (CBC) in the modern era.

MRI and Long-Term Outcomes: IBTR

Although breast cancer assessed by mammogram and clinical examination is found to be unicentric in > 90% of cases,[31] serial sectioning of mastectomy specimens demonstrates that 21% to 63% of clinically and mammographically detected unicentric tumors are actually multifocal or multicentric.[32-38] As such, a large percentage of patients treated with BCS will have microscopic residual disease in the breast, yet multiple prospective RCTs and the updated Early Breast Cancer Trialists' Collaborative Group overview continue to demonstrate equivalent survival between patients undergoing BCS and mastectomy,[39-41] and IBTR rates have substantially decreased over time.[42, 43]

To the best of our knowledge, the only randomized controlled data evaluating the impact of MRI on recurrence rates come from short-term follow-up in the COMICE trial, in which rates of local recurrence (LR) were assessed as a secondary endpoint. At 3 years, local recurrence-free interval rates of 94% and 96% were reported for the MRI and no-MRI groups, respectively.[44]

Several retrospective single-institution series have compared LR outcomes in women imaged with and without MRI (Table 1).45-50 Only the study by Fischer et al[45] reported a lower IBTR rate in women undergoing MRI. This study compared 121 patients with breast cancer who underwent a perioperative MRI with 225 patients who did not. At a mean follow-up of 40 months, the MRI group had an IBTR rate of 1.2% compared with 6.5% in the no-MRI group (P < .001). However, these results are difficult to interpret both because of the high rate of IBTR observed in the no-MRI group (nearly 7% at just > 3 years) and because statistical adjustments were not performed to control for differences between both groups. The MRI group had a higher percentage of small (T1) lymph node-negative tumors and fewer high-grade lesions, and, paradoxically, a higher percentage of patients in the MRI group received chemotherapy, all of which may have impacted IBTR rates. The 5 subsequent studies shown in Table 1 failed to find a significant improvement in IBTR rates with the addition of MRI when controlling for patient and tumor factors, and all reported low (0.4%-5.0%) rates of IBTR at 2 to 8 years of follow-up.[46-50] A recent individual-person data meta-analysis including 3169 women from 4 of the above-mentioned trials reported no difference in 8-year LR-free survival (97% for the MRI group vs 95% in the no-MRI group; P = .87) or 8-year distant recurrence-free survival (89% in the MRI group and 93% in the no-MRI group; P = .37). On multivariable analysis, there was no association noted between perioperative MRI and LR-free survival (hazard ratio for MRI vs no-MRI, 0.88; 95% CI, 0.52-1.51 [P = .65]).[51]

Table 1. Summary of the Literature Evaluating the Impact of MRI on IBTR Rates
ReferencePatients With MRI/Total No. of PatientsVariables Controlled For on MV AnalysisFollow-Up, YearsIBTR Rates: MRIIBTR Rates: No MRIP
  1. Abbreviations: HER2, human epidermal growth factor receptor 2; HR, hormone receptor; IBTR, ipsilateral breast tumor recurrence; LVI, lymphovascular invasion; MRI, magnetic resonance imaging; MV, multivariate.

  2. a

    Number of patients who underwent breast-conserving therapy and were followed for IBTR.

  3. b

    For MRI group.

  4. c

    For no-MRI group.

  5. d

    Adjusted odds ratio for IBTR, 6.37 (P=.076).

Fischer 2004[45]121/346 (35%)Not done3.41.2%6.5%<.001
Solin 2008[46]215/756 (28%)Age, treatment y8.03.0%4.0%.51
Hwang 2009[47]127/463 (27%)Age, y, chemotherapy, endocrine therapy, tumor grade, LVI, HR status, HER2 status8.01.8%2.5%.67
Shin 2012[48]572/794 (72%)Not done5.01.2%2.3%.33
Miller 2012[50]125/265 (47%)aNot done for IBTR outcomes2.1b1.6%5.0%.13
4.1c
Ko 2013[49]229/615 (37%)Nuclear grade, HR status, tumor sized5.70.4%3.6%.013

The recognition that IBTR rates differ by breast cancer subtype and, notably, the significantly higher LR rates reported among patients with triple-negative and human epidermal growth factor receptor 2 (HER2)-amplified breast cancers in the pre-trastuzumab era,[52, 53] combined with ongoing controversy regarding the theoretic advantages of perioperative MRI, have led to an RCT supported by the American College of Radiology Imaging Network and the Alliance for Clinical Trials in Oncology. The objective of the trial is to assess the impact of MRI on re-operation rates, LR, quality of life, and cost-effectiveness in women with triple-negative and HER2-amplified breast cancer. Although this study may provide useful information in the cohort of patients with triple-negative breast cancer, the RCTs of adjuvant trastuzumab demonstrated significantly lower IBTR rates with the addition of trastuzumab,[54] and the low IBTR and CBC rates noted among patients with HER2-amplified cancers in more modern series will likely limit the impact of MRI among patients with HER2-amplified cancer.[55, 56]

MRI and Long-Term Outcomes: CBC

MRI has the potential to decrease metachronous CBC rates through the identification of otherwise occult contralateral disease. Table 2 summarizes 4 retrospective studies that have compared rates of metachronous CBC in women imaged with and without MRI at the time of their index breast cancer diagnosis.[45, 46, 49, 57] Criticisms of the study by Fischer et al[45] have been mentioned previously. Overall, CBC development rates were low (0.5%-6.0%) in both groups. It is important to note that the 2 studies reporting a significant difference in CBC rates both found an absolute difference of 1% to 2% in the MRI and no-MRI groups.[45, 57]

Table 2. Summary of the Literature Evaluating the Impact of MRI on the Development of CBC
ReferencePatients With MRI/Total No. of PatientsFollow-Up, YearsCBC Rates: MRICBC Rates: No MRIP
  1. Abbreviations: CBC, contralateral breast cancer; MRI, magnetic resonance imaging.

  2. a

    A total of 1771 women underwent bilateral MRI; the remaining 1323 women underwent unilateral MRI for their index breast cancer.

Fischer 2004[45]121/346 (35%)3.41.7%4.0%<.001
Solin 2008[46]215/756 (28%)8.06.0%6.0%.39
Kim 2013[57]1771/3094 (57%)a3.80.5%1.4%.02
Ko 2013[49]229/615 (37%)5.72.2%1.3%.51

A meta-analysis by Brennan et al[58] evaluating the rate of CBC detection by MRI among 3253 women presenting with unilateral cancer reported that 4.1% of patients were diagnosed with a synchronous CBC based on MRI. In comparison, a SEER population-based study from 1973 to 1996 reported the actuarial 10-year risk of metachronous CBC in women treated for unilateral stage 0 to stage II breast cancer to be 6.1%,[59] and more recent studies have demonstrated that CBC incidence has been decreasing by approximately 3% per year since 1985.[60] Together, these data suggest that either a single MRI at the time of breast cancer diagnosis will identify the majority of breast cancers that will develop over time or, conversely, that many MRI-detected contralateral cancers will be adequately treated as a by-product of appropriate systemic therapy for the index cancer and would remain clinically irrelevant.[39]

MRI and Long-Term Outcomes: Survival

The Early Breast Cancer Trialists' Collaborative Group overview established that there is an important relationship between local control and survival in patients with breast cancer; however, as systemic therapies continue to improve, substantially larger differences in local control will likely be needed to impact survival. Although, to the best of our knowledge, there are no prospective or RCT data evaluating the impact of MRI on survival in patients with breast cancer, in consideration of the aforementioned studies demonstrating little or no impact on LR, it is not expected that MRI would have an impact on breast cancer-related survival. Unsurprisingly, retrospective reports by Solin et al,[46] Shin et al,[48] and Ko et al[49] found no improvement in survival for women imaged with MRI compared with those who underwent conventional imaging alone.

MRI in Select Patient Populations: DCIS

Surgical outcomes, including rates of re-excision and conversion to mastectomy, in women with DCIS imaged with and without MRI have been reported in 5 retrospective single-institution studies (Table 3).[61-65] MRI did not appear to significantly decrease positive surgical resection margin or re-excision rates for women undergoing BCS in any series, yet mastectomy rates were only found to be increased in 2 of 6 studies.[62, 63]

Table 3. Summary of the Literature Evaluating the Impact of MRI on Surgical Outcomes in Patients With DCIS
ReferencePatients With MRI/Total No. of PatientsRe-excision Rate: MRIRe-excision rate: No MRIPMastectomy Rate: MRIMastectomy Rate: No MRIP
  1. Abbreviations: DCIS, ductal carcinoma in situ; MRI, magnetic resonance imaging; NS, not significant; BCS, breast-conservation surgery.

  2. a

    Overall mastectomy rate.

  3. b

    Initial mastectomy rate.

  4. c

    Mastectomy rate after attempted BCS.

Allen 2010[61]63/98 (64%)21.2%30.8%.4120.3%a25.7%a.62
Itakura 2011[62]38/149 (26%)16.0%11.0%.4245.0%b14.0%b<.001
Kropcho 2012[63]60/158 (38%)30.7%24.7%.4017.7%c4.1%c.0004
Davis 2012[65]154/218 (71%)34.1%39.2%.5227.9%a23.4%aNS
Pilewskie 2013[64]217/352 (62%)14.3%20.0%.1934.6%b27.4%b.20

Pilewskie et al compared the long-term locoregional recurrence (LRR) rates and CBC rates among 2321 women with DCIS who were treated with BCS with and without perioperative MRI.[66] Similar to the data for invasive carcinoma, there was no association noted between MRI use and improved outcomes. Eight-year rates of LRR did not significantly differ (14.6% in the MRI group vs 10.2% in the no-MRI group; P = .52), nor did rates of CBC development (3.5% in the MRI group vs 5% in the no-MRI group; P = .86). On multivariate analysis, there was no association noted between MRI use and improved LRR (hazard ratio, 1.18; 95% CI, 0.79-1.78 [P = .42]). Because women forgoing radiotherapy may derive the greatest benefit from the addition of MRI, a cohort of 904 women treated with BCS and no adjuvant radiotherapy was analyzed separately. Again, no difference was noted in the 8-year LRR rates between the MRI and no-MRI groups (P = .33).[66]

MRI in Select Patient Populations: ILC

A review of 18 studies examining MRI use in women with ILC found that MRI detected additional disease in 32% of cases (95% CI, 22%-44%) and resulted in a subsequent change in surgical management in 28% of women.[67] Three retrospective studies to date have examined the effect of perioperative MRI on surgical outcomes in women with ILC and have reported conflicting findings (Table 4).[68-70] Mann et al[68] reported a significant decrease in the re-excision rate in the MRI group (5%) compared with the no-MRI group (15%) (OR, 3.29; 95% CI, 1.22-8.85 [P = .01]), as well as a nonsignificant trend toward a lower overall mastectomy rate in the MRI group (48% vs 59%, respectively; P = .098).

Table 4. Summary of the Literature Evaluating the Impact of MRI on Surgical Outcomes in Patients With Invasive Lobular Carcinoma
ReferencePatients With MRI/Total No. of PatientsRe-excision Rate: MRIRe-excision Rate: No MRIPMastectomy Rate: MRIMastectomy Rate: No MRIP
  1. Abbreviations: MRI, magnetic resonance imaging.

  2. a

    Overall mastectomy rate.

  3. b

    Initial mastectomy rate.

Mann 2010[68]99/267 (37%)5.0%14.9%.0148.4%a58.9%a.10
McGhan 2010[70]70/178 (39%)4.2%9.2%.2031.9%a23.9%a.23
Heil 2011[69]92/178 (52%)11.3%9.0%.3237.7%b30.3%b.12

Conversely, studies by Heil et al[69] and McGhan et al[70] found no significant decrease in re-excision rates and a nonsignificant trend toward higher mastectomy rates in women imaged with MRI. The previously mentioned meta-analysis by Houssami et al analyzed women with ILC separately and found a nonsignificant trend toward decreased re-excision rates in those women imaged with MRI (adjusted OR, 0.56; 95% CI, 0.29-1.09 [P = .09]) at the expense of an increased age-adjusted mastectomy rate with MRI (OR, 1.64; 95% CI, 1.04-2.59 [P = .034]).[27]

MRI in Select Patient Populations: Occult Primary Breast Cancer

Breast cancer presenting as an axillary lymph node metastasis without evidence of a primary breast tumor by mammogram, ultrasound, or physical examination accounts for < 1% of all breast cancers.[71] In this clinical scenario, MRI has become a standard imaging tool and is able to identify a primary breast lesion in > 67% of cases.[72] A negative MRI also provides reassurance that a large tumor burden is unlikely and that the patient may be safely treated with axillary lymph node dissection, whole-breast radiotherapy, and appropriate systemic therapy.

In a meta-analysis of 8 retrospective studies,[72] which included 220 women with occult primary breast cancer, MRI identified a suspicious breast lesion in 72% of cases, with a sensitivity of 90% and a specificity of 31%. The mean pathologic tumor size ranged from 5 mm to 16 mm, and > 90% were invasive carcinomas. When MRI identified an occult breast lesion in patients without metastatic disease, 21% to 60% of patients were able to undergo successful BCS.

MRI for Problem Solving

Similar to patients with an occult primary breast cancer, women with Paget disease or abnormal physical examination findings and negative conventional imaging may benefit from the addition of MRI for disease localization. Paget disease, which is characterized by nipple erythema, erosion, or ulceration caused by epidermal infiltration of malignant cells, is associated with an underlying breast malignancy in > 90% of cases, yet mammographic imaging may be normal in up to 50% of patients.[73] Morrogh et al[74] reviewed imaging and pathology data on 34 women with Paget disease who were treated at a single institution and 94% were found to have an underlying carcinoma. Mammography detected the underlying malignancy in 22% of cases, and supplemental MRI performed among 8 women with a negative mammogram demonstrated the underlying malignancy in 4 cases (50%).

MRI Imaging in the NAC Setting

NAC is being used with increasing enthusiasm to convert patients requiring an upfront mastectomy to BCS as well as to assess the impact of treatment on rates of pathologic complete response (pCR).[75] Multiple studies have evaluated the ability of MRI to predict response to NAC. In the American College of Radiology Imaging Network 6657 study, part of the I-SPY 1 trial, MRI was obtained at 4 time points: before the initiation of chemotherapy, after the first cycle, between the anthracycline-based regimen and taxane therapies, and at the conclusion of NAC before surgery. Compared with clinical examination, MRI was found to be a stronger predictor of both pCR and residual cancer burden, with tumor volume change measured at the time of the second MRI being the strongest predictor.[76] However, from a clinical standpoint, the comparison of MRI with physical examination is not particularly relevant, and a more practical comparison is that between MRI and conventional breast imaging.

A meta-analysis of 2050 women from 44 NAC studies conducted between 1980 and 2008 reported that MRI correctly identified residual disease with a median sensitivity of 0.92. However, the ability of MRI to correctly identify patients who achieved a pCR in the current analysis was limited, with a median specificity of 0.60, and, expectedly, the accuracy of MRI for predicting pCR varied based on the pCR definition used. MRI was found to have a higher accuracy than mammography (P = .02), but no difference was noted between MRI and ultrasound accuracy for the identification of a pCR (P = .15).[77] Similarly, a multicenter retrospective collaboration from the Translational Breast Cancer Research Consortium (TBCRC 017), which included 746 patients treated from 2002 through 2011, reported an overall accuracy rate of 74% of MRI for predicting a pCR. Given this study's more recent timeframe, information regarding hormone receptor and HER2 status was available, and the authors demonstrated that MRI had the highest negative predictive value in patients with triple-negative and HER2-amplified tumors (60% and 62%, respectively).[78]

Although prediction of pCR is an important endpoint for therapeutic monitoring, it is not an absolute endpoint for the ability to perform lesser surgery as women with a partial response may still be good candidates for conversion to BCS after NAC. Data from the I-SPY 1 trial were analyzed to assess a “clinically meaningful tumor reduction,” defined as a change in tumor size from > 4 cm to ≤ 4 cm after NAC, as a surrogate for patients who may become candidates for BCS. Of 174 women with an initial tumor size of > 4 cm, 81% had a pathologic tumor size of ≤ 4 cm after NAC, 37% of whom were successfully treated with BCS. In 38% of the total study population, there was a discrepancy of  ≥ 2 cm between post-NAC MRI measurements and final pathologic tumor size. In this study, MRI accuracy also was found to differ by tumor pattern and receptor subtype, with improved performance noted among patients with breast cancer subtypes that are known to have higher pCR rates.[79] A meta-analysis by Marinovich et al compared the agreement in tumor size between different imaging modalities and final pathology after NAC in 958 patients from 19 studies.[80] MRI and ultrasound were found to have similar overestimations of tumor size (mean differences of 0.1 cm), whereas MRI had a lower overestimation of tumor size than mammography (mean difference of 0.4 cm). Although the pooled mean difference between MRI and final pathology was 0.1 cm, the 95% limits of agreement ranged from −4.2 cm to 4.4 cm, which is a clinically significant margin of error when planning surgical therapy.[80]

The wide margin of error in MRI estimations of post-NAC tumor response and size is likely related to both tumor subtype and treatment regimen, and requires further investigation. Important unanswered questions relate to the ability to predict successful BCS after NAC, which likely relates to the pattern of tumor response (concentric vs multicentric) (Figure 1). Given the increased cost of MRI, a direct comparison of MRI with conventional imaging in this setting may be prudent. Although the use of MRI for planning BCS after NAC is an area of future research, if a patient is known upfront to require mastectomy after NAC, such as individuals with extensive multicentric or inflammatory disease, post-treatment MRI is not indicated.

image

Figure 1. MRI assessment of neoadjuvant chemotherapy response. Images courtesy of Dr. Elizabeth Morris, Memorial Sloan Kettering Cancer Center.

Download figure to PowerPoint

Conclusions

The available literature does not appear to support the routine use of MRI for the evaluation of patients with newly diagnosed breast cancer. Data from RCTs and several retrospective series have failed to demonstrate an improvement in short-term surgical outcomes, and studies have consistently demonstrated increasing mastectomy rates with the addition of MRI. Data supporting improved long-term outcomes with the addition of perioperative breast MRI, including IBTR, CBC development, and survival, are also lacking. Multiple series demonstrating increasing trends in MRI use without a benefit in surgical or long-term outcomes require a re-evaluation of practice patterns. Although there are clinical situations in which MRI can provide valuable information, such as in patients with occult primary breast cancer and, potentially, in monitoring response to NAC, the increasing costs of advanced imaging in patients with cancer[81] highlight the need for clinicians to critically evaluate the literature and focus on spending health care dollars in an evidence-based manner.

CONFLICT OF INTEREST DISCLOSURES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. FUNDING SUPPORT
  5. CONFLICT OF INTEREST DISCLOSURES
  6. REFERENCES

The authors made no disclosures.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. FUNDING SUPPORT
  5. CONFLICT OF INTEREST DISCLOSURES
  6. REFERENCES
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