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Use of (routine) preoperative MRI in breast cancer: current evidence

Use of (routine) preoperative MRI in breast cancer: current evidence. Joint Hospital Surgical Grand Round 22 Oct 2011. Presentation outline. Introduction Literature review Our own data. Introduction.

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Use of (routine) preoperative MRI in breast cancer: current evidence

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  1. Use of (routine)preoperative MRI in breast cancer: current evidence Joint Hospital Surgical Grand Round 22 Oct 2011

  2. Presentation outline • Introduction • Literature review • Our own data

  3. Introduction • Traditional triple assessment gives limited data on precise tumor size, location and margin • And whether there are multifocal (=several foci of tumors in the same quadrant) /multicentric (=foci of tumors in different quadrant) /contralateral disease • Breast magnetic resonance imaging (MRI) is emerging as a new clinical adjunct in this respect • Better surgical planning theoretically translates into less local recurrence and improved survival

  4. BI-RADS (= Breast Imaging Reporting and Data System) 5 Radiology (2007) 244, 356-378

  5. BI-RADS 2 Radiology (2007) 244, 356-378

  6. MR Spectroscopy Total choline (tCho) peak Radiol Clin N Am (2010) 48, 1013-1042

  7. Diffusion Weighted Imaging (DWI) Radiol Clin N Am (2010) 48, 1013-1042

  8. Clinical outcomes • Short term • Sensitivity and specificity • Alteration in management • Re-excision rate • Long term • Recurrence and survival

  9. Three reviews conducted by Nehmat Houssami • Concluded that “ Evidence consistently shows that MRI changes surgical management, usually from breast conservation to more radical surgery; however there is no evidence it improves surgical care or prognosis” J Clin Oncol (2008) 26, 3248-3258 J Clin Oncol (2009) 27, 5640-5649 CA Cancer J Clin (2009) 59, 290-302

  10. (1) Accuracy and Surgical Impact of MRI in Breast Cancer Staging: Systemic Review and Meta-Analysis in Detection of Multifocal and Multicentric Cancer • 19 studies with n=2610 • MRI detected additional disease in 16% (interquartile range 11-24%) of women with breast cancer • Summary PPV 66% (95%CI, 52-77%) • TP: FP ratio 1.91 (95%CI, 1.09-3.34) • Conversion due to MRI • Wide local excision (WLE) to mastectomy 8.1% • WLE to more extensive surgery 11.3% • Unnecessary conversion due to MRI (histology negative) • WLE to mastectomy 1.1% • WLE to more extensive surgery 5.5% J Clin Oncol (2008) 26, 3248-3258

  11. (2) MRI Screening of the Contralateral Breast in Women with Newly Diagnosed Breast Cancer: Systematic Review and Meta-Analysis of Incremental Cancer Detection and Impact on Surgical Management • 22 studies with n=3253 • Additional contralateral disease detected by MRI 9.3% (interquartile range 3.8-13.9%) • Summary PPV 47.9% (95%CI, 31.8-64.6%) • TP:FP ratio 0.92 (95%CI, 0.47-1.82) • No data on pooled management alteration J Clin Oncol (2009) 27, 5640-5649

  12. (3) Review of Preoperative MRI in Breast Cancer. Should MRI be Performed on All Women with Newly Diagnosed, Early Stage Breast Cancer? • RCTs showed equivalent survival between breast conservation therapy (WLE + radiotherapy) and mastectomy for early stage cancer • Vast majority of MRI detected additional disease are within same quadrant as the index tumor, which can be successful treated with post operative radiotherapy • COMICE trial and two additional observational studies did not show reduction in re-excision rate and on contrary higher mastectomy rate • Average of 22.4 days delay in workup CA Cancer J Clin (2009) 59, 290-302

  13. Only two observational studies provided data on long term outcome • Fischer et al study limited by imbalance of treatment between two groups • Solin et al study • Local recurrence in 8 years (MRI+ vs. MRI-ve, 3% vs. 4%, p=0.51) • Overall survival in 8 years (86% vs. 87%, p=0.51) • Significant false positive rate caused additional cost and procedure; potential impact on cosmetic outcome CA Cancer J Clin (2009) 59, 290-302

  14. Comparative effectiveness of MRI in breast cancer (COMICE) trial: a randomised controlled trial • Multi-center, randomised • 1623 women with biopsy proven breast cancer scheduled for WLE after triple therapy • MRI (n=816) vs. no further imaging (n=807) Lancet (2010) 375, 563-571

  15. 19% 19% Reoperation rate within 6 months 19% MRI group vs. 19% in no MRI group (odds ratio 0.96, 95%CI 0.75-1.24, p=0.77)

  16. Cost: MRI group £5508.4 vs. No MRI group £5213.5 (p=0.075)

  17. Our own data • No previous study conducted in Asian population whom breast density was considered higher • Retrospective review • Consecutive 712 biopsy proven breast cancer patients underwent operation by a single surgeon in Hong Kong Sanatorium and Hospital during the period 1 January 2006 till 31 December 2009 • Exclusion criteria • (1) prior surgery to ipsilateral breast except excisional biopsy for diagnosis (n=14) • (2) neoadjuvant chemo/hormonal therapy (n=37) • (3) missing data (n=2) • Total 659 cases for analysis • MRI+ 147 vs. MRI- 512

  18. Management alteration with MRI • 66.0% (97 out of 147) had change in extent of operation • From lumpectomy to wider lumpectomy (23 out of 97) • to mastectomy (47 out of 97) • to bilateral lumpectomy (15 out of 97) • to others (12 out of 97) • Within 97 alterations in management, 12 were considered inappropriately extensive due to false positive finding on MRI

  19. MRI detection of multifocal/ multicentric/ contralateral disease • False positive rate = 12.8% • False negative rate = 7.5% • Sensitivity = 95.3% • Specificity = 80.3%

  20. Conclusion • High sensitivity and moderate specificity • Neither alter short term outcome e.g. re-excision rate • Nor sufficient evidence to alter long term recurrence or survival • No concrete evidence to support its routine use

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