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INTRODUCTION: Breast magnetic resonance imaging (MRI) is considered a more sensitive diagnostic test for detecting invasive breast cancer than mammography or breast ultrasound. Breast MRI may be particularly useful in younger premenopausal women with higher density breast tissue for differentiating between dense fibroglandular breast tissue and breast malignancies. The main objective of this study was to determine the impact of preoperative breast MRI on surgical decision-making in young women with breast cancer. METHODS: A retrospective review of patients with newly diagnosed invasive breast cancer and age of ≤50 years was performed. All patients underwent physical examination, preoperative mammogram, breast ultrasound, and bilateral breast MRI. Two breast cancer surgeons reviewed the preoperative mammogram report, breast ultrasound report, and physical examination summary and were asked if they would recommend a lumpectomy, a quandrantectomy, or a mastectomy. A few weeks later, the two surgeons were shown the same information with the breast MRI report and were asked what type of surgery they would now recommend. In each case, MRI was classified by two adjudicators as having affected the surgical outcome in a positive, negative, or neutral fashion. A positive impact was defined as the situation where breast MRI detected additional disease that was not found on physical examination, mammogram, or breast ultrasound and led to an appropriate change in surgical management. A negative impact was defined as the situation where breast MRI led the surgeon to recommend more extensive surgery, with less extensive disease actually found at pathology. No impact was defined as the situation where MRI findings did not alter surgical recommendations or outcomes. RESULTS: Of 37 patients whose charts were reviewed, five patients were deemed to be ineligible due to having received neoadjuvant chemotherapy, having previous breast implants, or having had their tumor fully excised during biopsy. In total, 32 patients met the inclusion criteria of this study and were appropriate for analysis. The median age of our study patient population was 42 years. The pathologic diagnosis was invasive ductal carcinoma in 91% (29/32) of patients and invasive lobular carcinoma in 9% (3/32) of patients. For surgeon A, clinical management was altered in 21/32 (66%) patients, and for surgeon B, management was altered in 13/32 (41%) patients. The most common change in surgical decision-making after breast MRI was from breast-conserving surgery to a mastectomy. Mastectomy rates were similar between both surgeons after breast MRI. After reviewing the pathology results and comparing them with the breast MRI results, it was determined that breast MRI led to a positive outcome in 13/32 (41%) patients. Breast MRI led to no change in surgical management in 15/32 (47%) patients and resulted in a negative change in surgical management in 4/32 (13%) patients. Bilateral breast MRI detected a contralateral breast cancer in 2/32 (6%) patients. CONCLUSIONS: Preoperative breast MRI alters surgical management in a significant proportion of younger women diagnosed with breast cancer. Prospective studies are needed to confirm these findings and to help determine if this change in surgical decision-making will result in improved local control.
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BACKGROUND AND PURPOSE: To prospectively compare diagnostic ultrasound to the 'gold standard' of surgical clips for localization of the lumpectomy site for electron boost irradiation. PATIENTS AND METHODS: Consecutive breast cancer patients referred following lumpectomy underwent diagnostic ultrasound in radiation treatment position 21-100 days post-surgery. All patients had 3-6 surgical clips defining the excision cavity. The site was marked on the skin and depth was measured. Target depth was the deepest aspect of the cavity plus a 1 cm deep margin. Treatment fields were prescribed with a 2 cm margin on the cavity, and electron energy was chosen to cover the target depth. Surgical clip position was assessed on orthogonal simulator films. RESULTS: Localizations were performed in 54 breasts (52 women). The mean interval post-surgery was 53 (SD 17) days. Overall, 35/54 (65%) of localizations were adequate, 15/54 (28%) were marginal and 4/54 (7%) were inadequate. Regression showed that lower patient weight (r=-0.37, P=0.006) predicted adequacy of localization, with better accuracy in lighter women. CONCLUSIONS: The accuracy rate for ultrasound exceeds the 20-50% reported for clinical localization. Diagnostic ultrasound may be used to improve the accuracy when surgical clips are not present.
