Preoperative breast MRI in management of patients with needle biopsy-proven ductal carcinoma in situ (DCIS).

BACKGROUND: In 20-25% of patients with biopsy-proven DCIS underestimation occurs. Sentinel lymph node biopsy (SLNB) is offered to patients with biopsy-proven ductal carcinoma in situ (DCIS) and a high risk of occult invasive cancer. However, assessment of high risk is controversial. We aimed to improve selection of patients for SLNB with preoperative breast magnetic resonance imaging (MRI). METHODS: In this prospective observational study, MRI was offered to all subsequent patients with a biopsy-proven DCIS admitted to a large Dutch teaching hospital between April 2012 and March 2017. MRI images were analysed for signs of invasive cancer and the results were compared with the pathologic results after surgical treatment. The diagnostic accuracy of additional MRI in detecting occult invasive cancer was determined. RESULTS: Of 211 patients eligible for additional MRI analysis, 149 underwent breast MRI. The majority (67%) received breast-conserving therapy, and the underestimation rate was 20%. Subsequent to MRI analysis, 20 additional invasive diagnostic procedures were performed. Occult invasive cancer was suspected on MRI in 46 patients (31%) and was confirmed in 18 (12%). In this study, breast MRI had a sensitivity of 67%, a specificity of 77%, and a true negative rate of 91%. CONCLUSION: Preoperative breast MRI cannot reliably predict the presence of invasive cancer in patients with biopsy proven DCIS. Therefore, it cannot be used to in the selection of patients for a SLNB.

A prediction model for underestimation of invasive breast cancer after a biopsy diagnosis of ductal carcinoma in situ: based on 2892 biopsies and 589 invasive cancers.

BACKGROUND: Patients with a biopsy diagnosis of ductal carcinoma in situ (DCIS) might be diagnosed with invasive breast cancer at excision, a phenomenon known as underestimation. Patients with DCIS are treated based on the risk of underestimation or progression to invasive cancer. The aim of our study was to expand the knowledge on underestimation and to develop a prediction model. METHODS: Population-based data were retrieved from the Dutch Pathology Registry and the Netherlands Cancer Registry for DCIS between January 2011 and June 2012. RESULTS: Of 2892 DCIS biopsies, 21% were underestimated invasive breast cancers. In multivariable analysis, risk factors were high-grade DCIS (odds ratio (OR) 1.43, 95% confidence interval (CI): 1.05-1.95), a palpable tumour (OR 2.22, 95% CI: 1.76-2.81), a BI-RADS (Breast Imaging Reporting and Data System) score 5 (OR 2.36, 95% CI: 1.80-3.09) and a suspected invasive component at biopsy (OR 3.84, 95% CI: 2.69-5.46). The predicted risk for underestimation ranged from 9.5 to 80.2%, with a median of 14.7%. Of the 596 invasive cancers, 39% had unfavourable features. CONCLUSIONS: The risk for an underestimated diagnosis of invasive breast cancer after a biopsy diagnosis of DCIS is considerable. With our prediction model, the individual risk of underestimation can be calculated based on routinely available preoperatively known risk factors ( https://www.evidencio.com/models/show/1074 ).

Only MR can safely exclude patients from arthroscopy.

OBJECTIVE: The aim of this study was to determine in patients with subacute knee complaints and normal standardized physical examination the fraction of magnetic resonance imaging (MRI) studies showing arthroscopically treatable intra-articular pathology. MATERIAL AND METHODS: There were 290 consecutive patients (between 16 and 45 years) with at least 4 weeks of knee complaints and low clinical suspicion of intra-articular pathology based on physical exam. Two hundred seventy-four patients were included. Sixteen patients with prior knee surgery, rheumatic arthritis, or severe osteoarthritis were excluded. MRI was used to assign patients to group 1 (treatable abnormalities) or group 2 (normal or no treatable findings), depending on whether MR demonstrated treatable pathology. Arthroscopy was performed in group 1 patients. If symptoms persisted for 3 months in group 2 patients, cross over to arthroscopy was allowed. RESULTS: MR showed treatable pathology in 73 patients (26.6%). Arthroscopy was performed in 64 patients of 73 patients (group 1). In 52 patients (81.3%, 95% confidence interval (CI) 71.4-91.1%), arthroscopy was therapeutic. Of the 13 arthroscopies (6.5%) in group 2, four were therapeutic (30.8%, 95% CI 1.7-59.8). The highest fraction of MR studies showing treatable pathology was found in males, aged over 30 years, with a history of effusion (54.5%, six of 11 patients). CONCLUSION: Authors believe that the negative predictive value of clinical assessment in patients with subacute knee complaints is too low to exclude these patients from MR. MR should at least be considered in male patients aged 30 years and over with a history of effusion.

Are radiographs needed when MR imaging is performed for non-acute knee symptoms in patients younger than 45 years of age?

OBJECTIVE: The objective was to determine the value of radiographs in young adults with non-acute knee symptoms who are scheduled for magnetic resonance imaging (MRI). MATERIALS AND METHODS: Nine hundred and sixty-one consecutive patients aged between 16 and 45 years with knee symptoms of at least 4 weeks' duration were prospectively included in three participating hospitals. After applying exclusion criteria, 798 patients remained. Exclusion criteria were previous knee surgery (including arthroscopy) or MRI, history of rheumatoid arthritis, clinical diagnosis of retropatellar chondromalacia, contra-indication for MRI and recent trauma. We identified two groups: group A with no history of trauma (n = 332), and group B with an old (>4 weeks) history of trauma (n = 466). Patients had a standardized history taken, and underwent a physical exam, antero-posterior (AP) and lateral radiographs and MRI. We evaluated the radiographs and MRI for osseous lesions, articular surface lesions, fractures, osteoarthritis, loose bodies, bone marrow edema and incidental findings. Subsequently, patients with osseous abnormalities (Kellgren grade 1 and 2 excluded) on radiographs and a matched control group was evaluated again using MRI without radiographs. RESULTS: Median duration of symptoms was 20 weeks. In group A, radiographs showed 36 osseous abnormalities in 332 patients (10.8%). Only 13 of these, all Kellgren grade 1 osteoarthritis, were not confirmed on MRI. MRI showed 72 (21.7%) additional abnormalities not confirmed on radiographs. In group B, radiographs showed 40 osseous abnormalities (8.6%) in 466 patients. Only 15 of these, all Kellgren grade 1 osteoarthritis, were not confirmed on MRI. MRI showed 194 (41.6%) additional abnormalities not confirmed on radiographs. The second evaluation of MRI without radiographs in 34 patients was identical to the first MRI evaluation. Common lesions were significantly more often diagnosed with MRI than with radiographs. CONCLUSION: Radiographs should not be obtained routinely when MRI is being performed in young adults with non-acute knee complaints because the yield and added value to MRI are low.

Clinical consequences of bone bruise around the knee.

The aim of this study is to evaluate the relation between bone bruise and (peri-)articular derangement and to assess the impact of bone bruise on presentation and short term course of knee complaints. We recorded MR abnormalities in 664 consecutive patients with sub-acute knee complaints. Patients were divided in four groups: patients with and without intra-articular knee pathology, subdivided in patients with and without bone bruise. We assessed function and symptoms at the time of MR and 6 months thereafter. Bone bruises were diagnosed in 124 of 664 patients (18.7%). Patients with bone bruise had significantly more complete ACL, lateral meniscal, MCL and LCL tears. Both with and without intra-articular pathology patients with bone bruise had a significantly poorer function at the time of MR (Noyes score of, respectively, 313.21 versus 344.81 and 306.98 versus 341.19). Patients with bone bruise and intra-articular pathology showed significantly more decrease in activity (decrease of Tegner score from 6.28 to 2.12 versus 5.70-2.55). At 6 months there were no significant differences in clinical parameters between the four groups. We concluded that bone bruise in combination with MCL tear is an important cause of initial clinical impairment in patients with sub-acute knee complaints. Clinical improvement within 6 months is more pronounced than in patients without bone bruise.

Effectiveness of MR imaging in selection of patients for arthroscopy of the knee.

PURPOSE: To determine the effectiveness of magnetic resonance (MR) imaging in the appropriate identification of those patients with a high clinical suspicion of internal derangements of the knee who require arthroscopic therapy. MATERIALS AND METHODS: In a prospective multicenter study, MR imaging was performed at 0.5 T in 430 consecutive patients. The sensitivity and specificity of MR imaging in the patients who underwent arthroscopy and the corrected sensitivity and specificity of MR in all the study patients were calculated. For this correction, patients with negative MR and arthroscopic results were considered representative of the patients with negative MR results who were conservatively treated, and the number of the former was doubled. The standard errors of the corrected values were adjusted with the delta method. RESULTS: At MR imaging, arthroscopy was indicated in 221 patients, 200 of whom underwent arthroscopy. Two hundred nine patients with negative MR imaging results were randomized for arthroscopic (105 patients) or for conservative treatment (104 patients). Of the 105 patients randomized for arthroscopy, 93 actually underwent arthroscopy. Arthroscopic treatment was necessary in 13 of 93 patients with a negative diagnosis at MR imaging. Arthroscopic treatment was necessary in 179 of 200 patients with a positive diagnosis at MR (sensitivity, 93.2%; specificity, 79.2%). Sensitivity and specificity corrected for randomization were 87.3% and 88.4%. Sensitivity and specificity corrected for randomization, respectively, were 84.1% and 94.2% for the diagnosis of medial meniscal tears and 69.5% and 94.5% for the diagnosis of lateral meniscal tears at MR. CONCLUSION: MR imaging is an effective tool in the selection of patients for arthroscopy from among a general population.