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USEFULNESS OF PREOPERATIVE
BREAST MAGNETIC RESONANCE
IMAGING (MRI) IN PRESURGICAL
STAGING OF BREAST CANCER
M. Ave-Seijas
M. Arias
A. Iglesias
B. Nieto
A. Tilve
C. García-Durán
HospitalXeral-CíesVigo/ES
INTRODUCTION

Breast cancer is the most frequent malignant
tumor in women

Nowadays breast tumor treatment is reaching a
more conservative approach

This new situation urges us to develop new
diagnostic techniques to obtain an accurate local
staging

A better presurgical local staging of these patients
is allowed with MRI
MAIN PURPOSE

To assess the influence of preoperative bilateral
breast magnetic resonance imaging (MRI) in
surgical management of patients with infiltrative
breast cancer susceptible of conservative
surgery, comparing the sensibility, specificity and
positive and negative predictive values for lesion
detection in breast MRI, mammography and
ultrasonography (US)
SECONDARY PURPOSES

To check the validity of MRI as a breast size tumor
predictor in invasive breast carcinomas

To determine the role of breast MRI in the detection of
multifocality/multicentricity and contralateral breast cancer

To evaluate mammography, ultrasound and breast MRI
sensitivity, specificity and predictive values in the
determination of multifocality and multicentricity in breast
tumors

To identify causes that may influence false positive and false
negative results in breast MRI studies for local staging
METHODS AND MATERIALS

TYPE OF STUDY:
 Descriptive retrospective

RM EQUIPMENT
 1.5-T magnet (Signa Horizont, General Electric, Milwakee USA)
 Dedicated phased-array breast-MR coil
METHODS AND MATERIALS

IMAGING PROTOCOL :
 Bilateral study with fat suppression
 Temporal resolution <1 min and spatial resolution 2.5mm
 Power injector and gadolinium contrast (0.15 mmol / kg)

Axial STIR and T2-weighted MR images

Dynamic axial 3D T1-weighted fat suppressed spoiled
gradient-echo images before and after injection of
gadolinium (multiple runs over 5-8 minutes, each run <2 min
for kinetics)

Sagittal T1-weighted fat suppressed images before and
after administration of gadolinium
Kuhl; Radiology August 2007
Axial STIR
Axial SE T1
Dynamic 3D GRE T1
with fat saturation after injection
of 0.15 mmol / kg of gadolinium
Sagittal SE T1
fat-sat
METHOD AND MATERIALS
PATIENTS
 Eighty patients with core needle biopsy diagnosis of
infiltrative breast cancer studied between June 2007
and May 2008, susceptible of conservative surgical
treatment after clinical examination, mammography
and US, sent for preoperative contrast-enhanced MRI
imaging
 “Second look” US and us-guided biopsy were made in
suspicious lesions only detected with RM that
involved a change in surgical treatment
 VARIABLES
 Tumor median size and multifocality, multicentricity or
contralateral disease were assessed and correlated
with histopathology findings

RESULTS

AGE: 58,88 ±13,05 years.

HISTOLOGIC TYPE: Infiltrating

TUMOR MEDIAN SIZE
Ductal
Histopathology 1,97 ± 0,76
Ductal 77 (91,25%)
Lobular 7 (8,75%)
Lobular
Total
2,70 ± 0,75
2,04 ± 0,78
Mammography
Average difference
(p)
1,56±1,12
0,450 ±1,04
(p< 0.05)
US
1,66 ± 0,67
1,87 ± 0,76
1,68 ± 0,68
0,036 ± 0,85
(p< 0.05)
MRI
1,87±0,76
3,18 ± 1,01
1,98 ± 0,79
-0,63 ± 0,49
(p>0.05)
Results
Single
Multifocal
Multicentric
Histopatology
56 (70,0%)
14 (17,5%)
10 (2,5%)
Mammograhy
77 (86,3%)
3 (3,8%)
0 (0%)
US
69 (86,2%)
9(11,25)
2(2,5)
MRI
56 (70,0%)
13 (16,2%)
11 (13,7%)

Multicentricity,
multifocality
THERE WERE NOT
CONTRALATERAL
BREAST
PATHOLOGICAL
FINDINGS IN THIS
STUDY
Sensibility
Specifity
PPV
NPV
Mammography
14%
100%
100%
75%
US
42%
98%
91%
79%
MRI
92%
96%
92%
96%
RESULTS


MRI detected additional suspicious previously unsuspected
lesions in 11 patients (21%)
MRI detected multifocality undetected on mamography/US
in 8 patients (10%):
 Surgical management was changed into a LARGER
LUMPECTOMY
C
A
B
FIGURE 1: There is a single mass in mammography (A) and US (B), resulting in
multifocal lesions in MRI (C).
RESULTS
• MRI detected multicentricity undetected on mamography/US
in 9 patients (11%):
• Surgical management was changed into MASTECTOMY
C
A
Figure 2: Mammogram (A) and US
(B) detected a single mass
which was multicentric on
MRI (C).
B
RESULTS

MRI detected additional suspicious previously
unsuspected lesions in 11 patients (21%). They all
were confirmed as malignant

MRI showed a higher sensitivity (92%) and negative
predictive value (96%) to detect multifocal and
multicentric tumor when compared to
mammography (sensibility 14% and negative
predictive value 75%) and US (sensibility 42% and
negative predictive value 79%)
RESULTS
 False
positives in MRI (n =2)
 Complex sclerosing adenosis: Initial lumpectomy was
extended
 Mastopathic focus: Treatment was not changed
 False
negatives in MRI (n=2)
 Small foci of lobular carcinoma: Treatment did not
need any change
 Small foci of Infiltrating carcinoma: Treatment was
converted into a mastectomy
RESULTS
B
A
C
Figure 3: False positive MRI (A, B): A small focus of complex sclerosing adenosis
(0,4mm) located 2 cm away from the main nodule (C) histopathology
A
B
Figure 4: False positive MRI (A, B). Close to the main lesion MRI depicted some small
enhancing nodules, that finally corresponded to pathologically proven
mastopatic areas.
RESULTS
A
B
Figure 5: False negative: (A) MRI depicted the main lesion that corresponded to
lobular carcinoma, but (B) failed to show a small peripheral lobular
carcinoma focus in the same quadrant
A
B
Figure 6: False negative: (A) MRI showed the infiltrating tumor with small areas of
intraductal carcinoma extension. (B) Histopathology proved extensive
intraductal extension. Management changed from quadrantectomy to
mastectomy
DISCUSSION
Guidelines: 80% breast tumors are subsidiary of
conservative surgery and radiotherapy
European
Accurate
local staging
PREVENTS
RECURRENCY
DECREASES REOPERATION
THE MOST SENSITIVE PREOPERATIVE DIAGNOSTIC TECNIQUE IS MRI





Tumor size
“Unseen” focus in the same breast: 6-27%
“Hidden” contralateral breast tumor: 3-9%
Intraductal extension
Cleavage plane with the chest wall
Schell et al. AJR May 2009
DISCUSSION

MRI influences patient management (15-27%)
 Larger local surgery (5-9%)
 Mastectomy (9-17%)
Schell et al AJR Mayo 2009
Kuhl Radiology September 2007
Bedrosian et al Cancer August 2003

NOWADAYS DISCUSSION
 False positives?
 Overtreatment?
 Cost-benefit?
Comstock et al RSNA 2007
MAIN CONCLUSION
1- Breast MRI depicts additional tumoral foci
unsuspected with other techniques, so it
improves the surgical management . Breast
MRI showed a higher sensitibility and negative
predictive value when compared to
mammography and breast US
CONCLUSION
2- Breast MR imaging is the best preoperative
technique to make a local staging in breast tumors
3- Breast MRI is superior to ultrasound and
mammography to depict multifocality / multicentricity
4- Breast MRI is a technique with high sensitivity,
specificity,PPV and NPV in the diagnosis of
multicentricity / multifocality in invasive breast
cancer
5- To minimize the number of false positives and
negatives in breast MRI it is essential to use a
proper technique
CONCLUSION
6- Preoperative breast MRI should not lead to a delay
in surgical planning but to a better planning
7- Preoperative breast MRI should permit a more
appropriate therapeutic management and reduce
the rate of reoperation
8- There should be a careful management and
individualized treatment decisions in patients with
lesions detected only with MRI in order to avoid
overtreatment
BIBLIOGRAFY
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