Abstract
PurposeTo establish a preoperative decision model for accurate indication of systemic therapy in early-stage breast cancer using multiparametric MRI at 7-tesla field strength.Materials and methodsPatients eligible for breast-conserving therapy were consecutively included. Patients underwent conventional diagnostic workup and one preoperative multiparametric 7-tesla breast MRI. The postoperative (gold standard) indication for systemic therapy was established from resected tumor and lymph-node tissue, based on 10-year risk-estimates of breast cancer mortality and relapse using Adjuvant! Online. Preoperative indication was estimated using similar guidelines, but from conventional diagnostic workup. Agreement was established between preoperative and postoperative indication, and MRI-characteristics used to improve agreement. MRI-characteristics included phospomonoester/phosphodiester (PME/PDE) ratio on 31-phosphorus spectroscopy (31P-MRS), apparent diffusion coefficients on diffusion-weighted imaging, and tumor size on dynamic contrast-enhanced (DCE)-MRI. A decision model was built to estimate the postoperative indication from preoperatively available data.ResultsWe included 46 women (age: 43-74yrs) with 48 invasive carcinomas. Postoperatively, 20 patients (43%) had positive, and 26 patients (57%) negative indication for systemic therapy. Using conventional workup, positive preoperative indication agreed excellently with positive postoperative indication (N = 8/8; 100%). Negative preoperative indication was correct in only 26/38 (68%) patients. However, 31P-MRS score (p = 0.030) and tumor size (p = 0.002) were associated with the postoperative indication. The decision model shows that negative indication is correct in 21/22 (96%) patients when exempting tumors larger than 2.0cm on DCE-MRI or with PME>PDE ratios at 31P-MRS.ConclusionsPreoperatively, positive indication for systemic therapy is highly accurate. Negative indication is highly accurate (96%) for tumors sized ≤2,0cm on DCE-MRI and with PME≤PDE ratios on 31P-MRS.
Highlights
In the past decades, breast cancer treatment has become less invasive, for example from mastectomy to breast conserving therapy, without compromising overall disease-free survival [1,2]
Negative indication is highly accurate (96%) for tumors sized 2,0cm on dynamic contrast-enhanced (DCE)-Magnetic resonance imaging (MRI) and with PME PDE ratios on 31P-magnetic resonance spectroscopy (MRS)
A negative preoperative indication was only accurate in tumors not larger than 2.0 cm on DCE-MRI or with a PME>PDE score at 31-Phosphorus MR spectroscopy (31P-MRS)
Summary
Breast cancer treatment has become less invasive, for example from mastectomy to breast conserving therapy, without compromising overall disease-free survival [1,2]. Preoperative tumor biopsy, combined with conventional breast imaging, and with assessment of lymph nodes with ultrasound and fineneedle aspiration, shows discordance with postoperative assessment of the resection specimen. This discordance is as high as 40% for tumor grade and mitotic count[9,10], and impacts the ability to accurately omit systemic therapy. Current guidelines for the indication of systemic therapy cannot be translated to preoperative setting for early-stage breast cancer[11]. Early-stage breast cancer patients do not benefit from the advantages of neoadjuvant treatments tailored to the response of cancer. More accurate preoperative characterization is desirable to reach the same level of confidence as that from a resection specimen
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