The Surgeon

Before breast cancer surgery, a preoperative magnetic resonance imagining (MRI) scan should be standard to determine tumor staging, researchers told the 6th European Breast Cancer Conference (EBCC) in Berlin, Germany today.

Preoperative MRI changed the surgical approach in at least 1 of every 9 patients in a series of 249 patients studied by David Martinez-Cecilia, MD, from the Hospital Universitario Reina Sofia, in Cordoba, Spain. Patients who had a malignancy on biopsy underwent an MRI, and the findings altered the surgical management of 32 patients (13%).

MRI found 20 additional malignant lesions in 18 patients (8%), he said. “That meant that for 15 patients, we were able to change the surgical treatment to one that took care of all of the tumors, as opposed to the single lesion that had originally been diagnosed.” In 11 of these patients, a planned lumpectomy was changed to a mastectomy, 3 other patients required surgery in both breasts, and 1 patient needed 2 lumpectomies in the same breast.

In other cases, the MRI showed a larger size tumor than was originally identified. This led to the management of 16 patients being changed from a lumpectomy to a mastectomy, and that of 1 patient to be changed from a lumpectomy to a quadrectomy.

After analyzing the tissue that had been removed during surgery, the researchers concluded that the change in surgical management was beneficial in 22 patients (9%), was not beneficial in 6 patients (2.4%), and was uncertain in 4 patients (1.6%). The correlation between tumor size on MRI and that from pathology was strongly positive, and was greater than that seen for mammography and for ultrasound, the researchers report.

MRI is expensive, but with results such as these it should be used as widely as possible presurgery, the researchers concluded. “It will not only improve the surgical treatment, which was our main aim, but in the long run it will probably reduce costs to healthcare systems by allowing us to identify exactly what needs to be treated, and in what way, to avoid possible recurrences of the cancer and the costs associated with its treatment,” Dr. Martinez-Cecilia said in a statement.

Asked to comment on this study, Emiel Rutgers, MD, PhD, from the Netherlands Cancer Institute and Antoni van Leeuwenhoek Hospital in Amsterdam, who chaired the EBCC meeting, said he fully agreed that breast MRI should be used preoperatively in the staging protocol. “I do feel that this investment is really worthwhile,” he told Medscape Oncology. He commented that MRI is not yet accepted as a standard procedure, but agreed with Dr. Martinez-Cecilia and colleagues that it should be.

Opponents of preoperative MRI question whether it can improve the local control rate after breast conservation, which is already good, Dr. Rutgers explained. However, work reported by his team at the same meeting suggests that it does, and “that in the long run, it really does help the patient, I am convinced of that,” he said. In a poster presented by Kenneth Pengel, MD, this research shows that preoperative MRI can lead to a lower rate of incompletely excised infiltrating ductal carcinoma (IDC) in breast-conserving surgery than that seen after conventional mammography, ultrasonography, and palpation only. The team reported on a series of 527 women, and found the rate of incompletely excised IDC to be 16/245 (6.5%) women in the non-MRI group and 3/153 (2%) women in the MRI group, a difference that was statistically significant (P = .03). However, there was no difference in the rate of incompletely excised infiltrating lobular carcinoma; it was 9/31 women (29%) in the non-MRI group and 6/21 women (29%) in the MRI group.

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