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

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