Role of MRI in Breast Cancer Angela Kong Princess Margaret Hospital

 Introduction  Role of MRI  breast cancer screening  preoperative newly diagnosed breast cancer  Response after Neoadjuvant chemotherapy  Summary/ Conclusion Objective

 MRI breast – increasingly popular breast imaging  Contrast agent: Gandolinium  Typical rapid enhancement and washout of contrast Introduction

 Guidelines of major groups recommend annual screening of selected patients with mammography and breast MRI  BRCA mutation carriers  Untested first-degree relatives of BRCA mutation carriers  Lifetime risk of Ca breast >20-25% National Comprehensive Cancer Network (NCCN)/ACG guidelines American Cancer Society Guidelines American College of Radiology Recommendations MRI in breast cancer screening

 MRI has a higher sensitivity than MMG in BRCA mutations  Sensitivity in MMG is lower in young patients with dense breast tissue  BRCA associated breast tumours have distinct histology  “benign” features on MMG/USG MRI in breast cancer screening Mass with a pushing margin Mass with a spiculated border

 Can MRI screening in high risk group improve their outcome? MRI in breast cancer screening  No significant difference between MRI and MMG screened group  MRI significant has survival benefit compared to non screened group (P<0.002) MRI breast screening in high-risk women: cancer detection and survival analysis. Breast Cancer Res Treat Jun MRI screenedMMG screenedNo screening 10 year survival95.3%87.7%73%

 Key Message:  MRI screening is indicated in high risks population due to higher sensitivity  Long term survival benefit was unclear

Preoperative staging with MRI

: Long term: ↓ Ipsilateral breast recurrence ↑Survival Short term: ↓ Re-excision rate Higher sensitivity Preoperative staging with MRI

YearStudy design nMRI group Non MRI group P value COMICE2010RCT162519% 0.77 MONET2011RCT41834%12%0.008 Houssami2013Meta- analysis %11.4%0.87 Preoperative MRI on short term outcome  Evidence on MRI effect on surgical re-excision rate  NO significance difference in terms of the rate of re-excision  One study showed paradoxically MRI had increased the re-excision rate

YearStudy design nMRI group Non MRI group P value MONET2011RCT41811%14%o.49 Houssami2013Meta- analysis % Preoperative MRI on short term outcome  Evidence on MRI effect on overall mastectomy rate  One study showed increase in mastectomy rate

 Key message:  MRI does not reduce the re-excision rate  Potential increase in mastectomy rate without lowering the local recurrence and improving survival  Routine use is not recommended

MRI following neoadjuvant therapy

 Monitor of response:  Clinical exam  MMG  USG  ? MRI MRI following neoadjuvant therapy

 MRI has improved accuracy than MMG  Can accurately detects residual tumour or complete pathology response Meta-Analysis of Magnetic Resonance Imaging in Detecting Residual Breast Cancer After Neoadjuvant Therapy. J Natl Cancer Inst Mar 6;105(5): MRI following neoadjuvant therapy No. of studiesDiagnostic odd ratio P value MRI VS clinical MRI VS USG MRI VS MMG

 Key message:  MRI is helpful to monitor treatment response after chemotherapy  No evidence on effect on surgical management MRI following neoadjuvant therapy

 MRI breast is recommended:  High risk group as screening  Breast cancer patients who undergo neoadjuvant chemotherapy  Routine use not indicated  More evidence needed to assess long term outcome Conclusion

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