Diagnosis of DCIS Part II

  • Magnetic Resonance Imaging:
    • Mammography:
      • Remains the standard for radiographic evaluation of DCIS
    • The cost and accessibility of magnetic resonance imaging (MRI):
      • Make it less feasible as an effective screening method
    • However, there is evidence that patients at high risk for breast cancer or those with very dense breasts:
      • May benefit from screening with MRI
    • Contrast-enhanced MRI:
      • Is more sensitive than mammography:
        • In the detection of both DCIS and invasive cancer
    • However, fibrocystic changes and other benign findings:
      • Can mimic DCIS on MRI:
        • Leading to unnecessary biopsies
    • MRI is increasingly being utilized after initial diagnosis in the preoperative evaluation:
      • To identify multicentric and contralateral lesions:
        • Because presence of either of these may change the surgical treatment strategy
      • Hollingsworth et al. (2008):
        • Reported that MRI detected multicentric disease:
          • Defined as a separate focus of cancer more than 5 cm away from the index lesion or discontinuous growth to another breast quadrant:
        • In 4.3% of 149 patients who presented with DCIS
      • Lehman et al. (2007):
        • Reported the utility of MRI in detecting contralateral breast cancer in a group of 969 patients with unilateral breast cancer:
          • 196 of whom had DCIS
        • Of the patients with DCIS:
          • MRI prompted additional biopsies in 18 patients
        • Contralateral breast cancer was detected in five patients:
          • 28% of those biopsied and 2.6% of those with DCIS
        • The sensitivity of detecting contralateral breast cancer was:
          • 71%
        • The specificity of detecting contralateral breast cancer was:
          • 90%
        • While MRI is associated with increased likelihood of change in the surgical plan for a patient with unilateral breast cancer:
          • It is unclear whether these altered (and usually more extensive) surgical plans are actually treating clinically significant disease that might have otherwise decreased the patient’s disease-free or overall survival
  • In a review of over 2,300 patients with breast-conserving therapy (BCT, i.e., lumpectomy and radiation) for DCIS at Memorial Sloan Kettering between 1997 and 2010:
    • There was no association between receipt of preoperative MRI and risk of locoregional recurrence or contralateral breast cancer:
      • Regardless of whether the patient received radiation (Pilewskie et al., 2014)
  • The typical appearance of DCIS on MRI:
    • Is non-mass enhancement
  • Although mammography can be more sensitive than MRI for DCIS associated with calcifications:
    • Uncalcified DCIS may be better visualized by MRI
  • Kuhl and colleagues prospectively assessed 7,319 women who had undergone both preoperative mammography and MRI:
    • Of 167 women with pure DCIS on final pathology:
      • 92% (n = 153) were diagnosed by MRI and 56% (n = 93) were diagnosed by mammography:
        • Of those diagnosed with high-grade DCIS:
          • 48% were missed by mammography but diagnosed by MRI only
  • A meta-analysis looking at the association of preoperative MRI and surgical management of patients with DCIS:
    • Showed no significant difference in the proportion of women with positive margins or in the need for re-excision after BCS
    • Overall mastectomy rates did not differ significantly, whether or not preoperative MRI was performed (odds ratio [OR] 1.23; p = .34)
  • Pilewskie and colleagues reported a large series of women undergoing BCS for DCIS:
    • Found no difference in locoregional recurrence rates or contralateral breast cancer rates:
      • In women who had perioperative MRI and those who did not
  • Although MRI can be useful in assessment of extent of disease and is an adjunct to traditional imaging in patients who have discordant results or mammographically occult disease:
    • Routine use of MRI is not advocated for the perioperative management of DCIS
Contrast-enhanced, high-resolution MRI. Axial sequence, with digital subtraction (A) and sagittal MRI sequence (B), showing a linear area of enhancement (arrows) in the posterior third of the central region/junction of the medial quadrants of the left breast. The pathology study of the surgical specimen revealed DCIS, nuclear grade 2.

#Arrangoiz #CancerSurgeon #BreastSurgeon #SurgicalOncologist #BreastCancer #LCIS #DCIS #DuctalCarcinomaInsitu #LobularNeoplasia #LobularCarcinomaInsitu #Surgeon #Teacher #Miami #Mexico #MSMC #MountSinaiMedicalCenter

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