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Should routine breast cancer staging include MRI?

Nature Clinical Practice Oncology volume 6, pages 72–73 (2009)Cite this article

The role of imaging in patients with known breast cancer is to assess accurately the extent of disease at the primary tumor site and to identify both clinically occult multicentric disease and contralateral cancers. The clinical outcomes that can be expected from highly accurate imaging studies include a decrease in the number of excisions needed to obtain negative margins, and conversion from breast-conserving therapy (BCT) to mastectomy. In addition, a decreased incidence of local recurrence (LR) after BCT, and the synchronous diagnosis of contralateral cancers are possible.

Undoubtedly, MRI can identify cancer foci that are not evident clinically or on a mammogram. In 2008, a meta-analysis of data from 19 studies of 2,610 patients with breast cancer found that MRI detected additional disease not identified by clinical examination or other imaging modalities in 16% of cases.1 If additional disease was detected, the most common clinical outcome was more-extensive surgery than planned, with either conversion from BCT to mastectomy or a larger excision in 19% of patients.1 The fact that additional cancer is detected with MRI has been interpreted as evidence that the imaging procedure is beneficial to patients, but the available data do not support this contention. Solin and coauthors investigated the effect of MRI on the incidence of LR in a retrospective study of 756 patients with breast cancer selected for BCT with and without MRI.2 The 8-year actuarial risks of local failure were 3% and 4% in the MRI and non-MRI groups, respectively (P = 0.51). On the basis of the findings of Houssami and colleagues' meta-analysis,1 between 5.9% and 11.3% of the 541 women in this study who did not have an MRI had undetected multifocal or multicentric disease that should have been treated by mastectomy, yet only 13 experienced local failure. This fact is not particularly surprising, given what is known about the microscopic distribution of cancer in the breast and the sensitivity of MRI in detecting this disease. In a study that directly compared the findings of MRI and serial subgross sectioning, Sardanelli et al. found that in 90 patients MRI overestimated the extent of disease in about a third of cancers, and underestimated its extent in 40% of individuals with microscopic multifocal or multicentric disease.3 That apparently unifocal breast cancer is microscopically multifocal in 60% of cases has been recognized for many years.4 In spite of this finding, local failure rates in women selected for BCT without use of MRI are remarkably low. In the National Surgical Adjuvant Breast and Bowel Project trials carried out between 1984 and 1994, LR was observed in only 3.5–10% of patients regardless of nodal status. This result indicates that most of this microscopic disease is controlled with radiotherapy.5 In the Oxford Overview Analysis, 7.5% of node-positive women treated with mastectomy and chest-wall irradiation, and 8% of their node-negative counterparts treated with mastectomy alone experienced LR, which suggests that LR is also a reflection of biologically aggressive disease.6 The similarity between rates of LR after BCT and mastectomy5,6 indicates that much of the LR seen today results from tumor biology rather than a large, undetected tumor burden in the breast.

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  1. Breast Service Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA morrowm@mskcc.org

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  1. M Morrow is Chief of Breast Surgery at Memorial Sloan-Kettering Cancer Center and Professor of Surgery at Weill Cornell Medical College, New York, NY, USA.,

    Monica Morrow

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Morrow, M. Should routine breast cancer staging include MRI?. Nat Rev Clin Oncol 6, 72–73 (2009). https://doi.org/10.1038/ncponc1280

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