Role of MRI Screening increased sensitivity in cancer detection - - PowerPoint PPT Presentation

3/7/2015 1

When Should an MRI be Ordered?

Jasmine M. Wong, MD March 7, 2015

Role of MRI

• Screening

– increased sensitivity in cancer detection

• Pre-operative staging

– identifies additional foci of cancer not see by

• ther imaging modalities
• Surgical planning

GOAL – improve patient outcomes

Diagnostic Ability of MRI

• Sensitivity 90%
• Specificity 72%
• False positives 28%
• In 16% of cases MRI can find additional

ipsilateral focus of cancer

– 66% of these lesions were malignant

Peters, et al. Meta-analysis of MR imaging in the diagnosis of breast lesions. Radiology 2008;246:116-124 Houssami, et al. Accuracy and surgical impact of magnetic resonance imaging in breast cancer staging: Systemic review and meta-analysis in detection of multifocal and multicentric cancer.J Clin Oncol 2008;26:3248-3258

Diagnostic Ability of MRI

• MRI detected suspicious findings occult to

conventional imaging 9.3%

• Incremental cancer detection rate 4.1%
• Positive predictive value 47.9%
• MRI is limited in distinguishing between

benign and malignant lesions

Brennan, et al. Magnetic resonance imaging screening of the contralateral breast in women with newly diagnosed breast cancer: Systemic review and meta-analysis of incremental cancer detection and impact on surgical management. J Clin Oncol 2009;27:5640-5649

3/7/2015 2

MRI and Surgical Outcomes

• COMICE trial - addition of MRI to triple

assessment (clinical exam, mammography, ultrasound) was not significantly associated with a reduced re-operation rate

– Both groups had 19% of their patients needing reoperation

Turnbull, et al. Comparative effectiveness of MRI in breast cancer (COMICE) trial: randomised controlled trial. Lancet 2010;375:563-571

MRI and Surgical Outcomes

• Monet trial - randomized control trial in patients

with non-palpable suspicious breast lesions detected on mammogram or ultrasound

• Primary breast conserving surgery was similar in

both groups

• Number of conversions to mastectomy did not

differ significantly

• Number of re-excisions for positive margins

higher in the MRI group

Peters, et al. Preoperative MRI and surgical management in patients with nonpalpable breast cancer: The MONET – Randomised controlled trial Eur J Cancer 2011;47:879-886

Take Away Points

• MRI has high sensitivity, but low specificity
• MRI only incrementally increases cancer

detection rates both in the ipsilateral and contralateral breast

• MRI in the pre-operative setting does not

affect short term surgical outcomes

• MRI should not be used for routine screening
• r routine pre-operative staging

Current Clinical Indications

• High risk patients
• Invasive lobular carcinoma
• Neoadjuvant chemotherapy
• Occult primary

3/7/2015 3

High Risk Patients

• Women who are BRCA 1 or BRCA 2 gene

mutation carriers

• Untested first degree relatives of BRCA gene

mutation carriers

• Women with greater than 20-25% lifetime risk
• f developing breast cancer based on family

history

Saslow, et al. American Cancer Society guidelines for breast screening with MRI as an adjunct to Mammography. CA Cancer J Clin 2007;57:75-89

High Risk Patients

• MRI has higher sensitivity than mammography

for detecting breast cancer

– MRI not affected by breast density

• MRI has the ability to detect smaller tumors

than mammography

• No data on outcome or survival

Kriege, et al. Efficacy of MRI and mammography for breast cancer screening in women with familial or genetic predisposition. N Engl J Med2004;351:427-437

American Cancer Society Guidelines

Sensitivity of MRI in high risk patients ranges from 77- 100% compared with mammography which ranges from 16 to 40%

High Risk Patients

• Women with a history of chest radiation

before age 30

• Women with TP53 and PTEN gene mutations

Saslow, et al. American Cancer Society guidelines for bresat screening with MRI as an adjunct to Mammography. CA Cancer J Clin 2007;57:75-89

3/7/2015 4

High Risk Patients

• No consensus on when to start screening in

high risk patients

– 5 years younger than the first relative who presented with breast cancer – Starting at age 30

• No consensus on when to stop MRI screening

American Cancer Society Guidelines

• Insufficient evidence to recommend or

discourage MRI screening of women with 15- 20% lifetime risk of breast cancer or women with LCIS, ALH, ADH, dense breasts, or a personal history of cancer

High Risk Patients

• Mutation carriers (>50%)

– Cancer detection rate of 26.5 per 1000 patients

• High risk (30-49%)

– Cancer detection rate of 5.4 per 1000 patients

• Moderate risk (15-29%)

– Cancer detection rate of 7.8 per 1000 patients

Kriege, et al. Efficacy of MRI and mammography for breast cancer screening in women with familial or genetic predisposition. N Engl J Med 2004;351:427-437

Current Clinical Indications

• High risk patients
• Invasive lobular carcinoma
• Neoadjuvant chemotherapy
• Occult primary

3/7/2015 5

Invasive lobular carcinoma

• 2nd most common breast cancer, but only 5-

15% of all breast cancers

• More likely to be multi-centric, multi-focal

and/or bilateral compared to other types

• Often more difficult to detect
• Can be difficult to determine extent of disease

Invasive Lobular Carcinoma

• MRI found to more accurately determine

tumor size compared to mammography

• Mammography underestimated the tumor

size significantly more frequently than MRI

• Overestimation of the tumor size happened

with equal frequency

– Usually due to extensive LCIS around the tumor

Mann, et al. The value of MRI compared to mammography in the assessment of tumor extent in invasive lobular carcinoma of the breast. Eur J Surg Oncol 2008; 34:135-142

Scatter plots of tumor size

Mann, et al. The value of MRI compared to mammography in the assessment of tumor extent in invasive lobular carcinoma of the breast. Eur J Surg Oncol 2008; 34:135-142

Invasive Lobular Carcinoma

• Significantly fewer patients in the MRI group

had a re-excision

– Odds ratio for re-excision – 3.29

• No significant difference in initial mastectomy

rates

Mann, et al. The impact of preoperative breast MRI on the re-excision rate in invasive lobular carcinoma of the breast. Breast Cancer Res Treat 2010; 119:415- 422

3/7/2015 6

Current Clinical Indications

• Invasive lobular carcinoma
• High risk patients
• Neoadjuvant chemotherapy
• Occult primary

Neoadjuvant chemotherapy

• Increased use of neoadjuvant chemotherapy

has led to the need for a tool to assess tumor response to treatment

• MRI offers a non invasive way to assess

tumors before, during, and after neoadjuvant treatment to help determine the appropriate surgical therapy for patients

MRI Phenotypes

1—well defined, uni-centric mass 2—well defined, multi-lobulated mass 3—area enhancement with nodularity 4—area enhancement without nodularity 5—septal spreading.

3/7/2015 7

Neoadjuvant Chemotherapy

• MRI is more accurate than clinical exam,

mammography, and ultrasound for determining residual tumor size

• MRI can predict clinically meaningful tumor reduction

– Well defined MRI phenotypes have higher rates of tumor reduction than diffuse MRI phenotypes – Her2 positive and triple negative tumor have higher rates

• f tumor reduction than hormone receptor positive and

Her2 negative tumors

Lobbes, et al. The role of magnetic resonance imaging in assessing residual disease and pathologic complete response in breast cancer patients receiving neoadjuvant chemotherapy: a systemic review. Insights Imaging 2013;4:163-175 Mukhtar, et al. Clinically Meaningful Tumor Reduction Rates Vary by Prechemotherapy MRI phenotype and Tumor Subtype in the I-SPY 1 TRIAL (CALGB 150007/150012; ACRIN 6657) Ann Surg Oncol 2013;20:3823-3830

Neoadjuvant Chemotherapy

• Assessment of tumor volume with MRI has

been shown to be a strong predictor of pathologic response to neoadjuvant chemotherapy

• Multiple studies have shown that the ability of

MRI to predict pathologic complete response is related to tumor subtypes

Hylton, et al. Locally Advanced Breast Cancer: MR Imaging for Prediction of Response in Neoadjuvant Chemotherapy – Results from ACRIN 6657/I-SPY TRIAL Radiology 2012;263:663-672

Study N Findings

Hayashi et al. 2013 260

• Sensitivity/Specificity highest in TN tumors
• PPV decreased in order TN, ER-/Her2+, ER+/Her2+,ER+/Her2-

Ko et al. 2013 166

• Size prediction less accurate in ER+ tumors

Cruz et al. 2013 205

• Better correlation between MRI measured response and

pathologic response in TN and Her2+ tumors Loo et al. 2011 188

• MRI size change associated with path residual disease for TN and

Her2+ tumors; not for ER+/Her2- Kuzucan et al. 2012 54

• Among Her2- tumors, MRI accuracy higher in high-proliferation

(high Ki-67) tumors McGuire et al. 2011 203

• MRI accuracy for predicting pCR lowest in luminal tumors; highest

in TN and ER-/Her2+ tumors

Greater MRI-pathology agreement and more accurate prediction of pathologic complete response in triple negative and Her2+ hormone receptor negative breast cancers

Current Clinical Indications

• High risk patients
• Invasive lobular carcinoma
• Neoadjuvant chemotherapy
• Occult primary

3/7/2015 8

Occult Primary

• MRI recommended in case of axillary nodal

metastasis or metastatic disease with unknown primary and negative breast imaging

• MRI found on average 72% of the tumors with

a mean sensitivity of 90%

– Specificity of 31%

de Bresser, et al. Breast MRI in clinically and mammographically occult breast cancer presenting with axillary metastasis: A systemic review. Eur J Surg Oncol 2010;8:425-431

Occult Primary

• MRI found tumors in 70% of the patients with

metastatic axillary adenocarcinoma from an unknown primary site

• Of the patients who underwent surgical

excision, cancer was identified by MRI in 95%

• f the cases

Olson, et al. Magnetic resonance imaging facilitates breast conservation for occult breast cancer. Ann Surg Oncol 2000;7(6):411-15

Conclusions

• Screening with MRI should be used only in

very specific patient populations

• MRI has a role in the detection and staging of

invasive lobular carcinoma and in cases of

• ccult breast primaries.
• Interpretation of MRI findings in the setting of

neoadjuvant chemotherapy should be done in the context of MRI phenotype and tumor receptor subtypes

Thank you!