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Concerns about advocating preoperative MRI on breast cancer patients
Several factors to ensure the application of breast MRI without increasing the rate of mastectomy
MRI in patients with different risks
Concerns about the role of MRI in preoperative evaluation of breast cancer
eLetter to "Review of Preoperative Magnetic Resonance Imaging (MRI) in Breast Cancer"
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Yunyou Duan Department of Ultrasound, Tangdu Hospital, the Fourth Military Medical University, Li Zhang, Lijun Yuan
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duanyy{at}fmmu.edu.cn Yunyou Duan, et al.
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Dear Editor, Recently Nehmat Houssami and colleagues recommended randomized controlled trials to establish the clinical, psychosocial, and long-term effects of preoperative MRI in newly affected breast cancer patients to see whether MRI is beneficial [1]. As suggested by Juliang Zhang et al in the eLetter to this article, hormone receptor status and human epidermal growth factor receptor 2 (HER2) status can affect the prognosis of patients with breast cancer, which should be included in the study to make sure who are the suitable candidates for preoperative MRI. However, the information about these biological traits is not available before operation. In this regard, ultrasound-guided coreneedle biopsy of the primary cancer in combination with preoperative MRI should be more informative, and do great help for the wise decision of surgery. Another concern regarding the question "Should MRI Be Performed on All Women with Newly Diagnosed, Early Stage Breast Cancer?" is that preoperative MRI should be performed on all the candidates only if it is much safer, more accurate, and cheaper than any other available examination. In other words, preoperative MRI, ultrasound-guided biopsy, X-ray and other methods should be compared to draw a full conclusion on whether preoperative MRI should be performed on all women with newly diagnosed, early stage breast cancer. Li Zhang
Department of Ultrasound, Tangdu Hospital, the Fourth Military Medical University, 710038, Xi'an, China. Correspondence should be addressed to Yunyou Duan (duanyy@fmmu.edu.cn). References 1. Houssami N, Hayes DF. Review of preoperative magnetic resonance imaging (MRI) in breast cancer: should MRI be performed on all women with newly diagnosed, early stage breast cancer? CA Cancer J Clin. 2009;59:290-302. |
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Nian-Song Qian, MD Dept of Hepatobiliary Surgery, Fourth Military Medical University, Xi'an, Shaanxi, China, Yan-Ling Yang, Yu Tang, Ke-Feng Dou, Ya-Yun Wang
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qianns2005{at}yahoo.com.cn Nian-Song Qian, et al.
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Dear Editor: As reviewed by Houssami et al. [1], pre-operative use of MRI in all women with newly diagnosed breast cancer does not improve surgical care, and it can be argued that it has a potentially harmful effect. We believe that some concerns should be addressed to avoid weakening the strength of this message. Despite the MRI's moderate specificity for distinguishing between benign and malignant lesions, it is superior to conventional imaging (such as mammography or ultrasound) for evaluating tumour size in invasive lobular carcinoma or Paget's disease owing to their multi-focal, multi-centric nature [2,3]. These findings will provide a better identification of those for whom breast-conserving therapy (BCT) is more appropriate. Mastectomy may not be adequate for every additional occult tumor deposit visible and detected by MRI because systemic therapy is able to deal with them. That is, radiotherapy and neoadjuvant chemotherapy rather than MRI-detected cancers are biologically and clinically irrelevant for the patient [4]. Although the presumption that pre-operative MRI will potentially reduce in-breast recurrence has not been confirmed, some research demonstrates that local recurrence does have an impact both on disease-free survival and on overall survival [5-7]. For this reason, avoiding and early diagnosis of recurrence is considered to have the same value as early diagnosis of the primary cancer. Several factors can ensure the application of breast MRI without unnecessarily increasing the rate of mastectomy. The first one is selection of patients. Screening patients who have a low pretest probability of undetected foci of disease (ie, fatty, easy to mammographically image breast tissue with unifocal invasive ductal carcinoma) will lead to a higher proportion of false-positive findings and these should be excluded [8]. The second is strict histologic assessment of additional suspected lesions detected on MRI. Pathological assessment of MRI-detected lesions is mandatory before a change of surgical or medical treatment is considered. Nowadays, MR-guided vacuum-assisted breast biopsy (VAB), which is a minimally invasive, simple, and a quick alternative to surgical biopsy for evaluation of breast foci detected by MRI alone, has become widespread. Recently, more and more studies have reported that the accuracy of MR-guided VAB appears as consistent as that of surgical excision biopsy under MR-guided wire localization in diagnosing MR-detected lesions [9,10]. Further improvements will be made, including software support, improvement of patient comfort, and reduction of procedure time [11]. Although the future of pre-operative MRI may be uncertain, in our opinion, the first thing is to assess MRI's benefits and limitations before we decide whether pre-operative MRI should be used. Yours sincerely Nian-Song Qian, MD (1)
1 Department of Hepatobiliary Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China 2 Department of Ultrasound, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China 3 Department of Anatomy and K.K. Leung Brain Research Centre, Fourth Military Medical University, Xi'an, Shaanxi, China Correspondence to:
Ya-Yun Wang, MD, PhD
References: 1. Houssami N, Hayes DF. Review of preoperative magnetic resonance imaging (MRI) in breast cancer: should MRI be performed on all women with newly diagnosed, early stage breast cancer? CA Cancer J Clin. 2009;59(5):290-302. 2. Marshall JK, Griffith KA, Haffty BG, et al. Conservative management of Paget disease of the breast with radiotherapy: 10- and 15-year results. Cancer. 2003;97(9):2142-2149. 3. Caramella T, Chapellier C, Ettore F, et al. Value of MRI in the surgical planning of invasive lobular breast carcinoma: a prospective and a retrospective study of 57 cases: comparison with physical examination, conventional imaging, and histology. Clin Imaging. 2007;31(3):155-161. 4. Clarke M, Collins R, Darby S, et al. Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials. Lancet. 2005;366(9503):2087-2106. 5. Brooks JP, Danforth DN, Albert P, et al. Early ipsilateral breast tumor recurrences after breast conservation affect survival: an analysis of the National Cancer Institute randomized trial. Int J Radiat Oncol Biol Phys. 2005;62(3):785-789. 6. Poggi MM, Danforth DN, Sciuto LC, et al. Eighteen-year results in the treatment of early breast carcinoma with mastectomy versus breast conservation therapy: the National Cancer Institute Randomized Trial. Cancer. 2003;98(4):697-702. 7. Doyle T, Schultz DJ, Peters C, et al. Long-term results of local recurrence after breast conservation treatment for invasive breast cancer. Int J Radiat Oncol Biol Phys. 2001;51(1):74-80. 8. Carpenter SG, Stucky CC, Dueck AC, et al. Scientific Presentation Award: The impact of magnetic resonance imaging on surgical treatment of invasive breast cancer. Am J Surg. 2009;198(4):475-481. 9. Orel SG, Rosen M, Mies C, et al. MR imaging-guided 9-gauge vacuum-assisted breast biopsy: initial experience. Radiology. 2006;238(1):54-61. 10. Lehman CD, Deperi ER, Peacock S, et al. Clinical experience with MRI-guided vacuum-assisted breast biopsy. AJR Am J Roentgenol. 2005;184(6):1782-1787. 11. Viehweg P, Heinig A, Amaya B, et al. MR-guided interventional breast procedures considering vacuum biopsy in particular. Eur J Radiol. 2002;42(1):32-39. |
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Juliang Zhang, Surgeon, Department of Vascular and Endocrine Surgery Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China, Qing Yao, Jianghao Chen, Ting Wang, Yonggang Lv, Jing Fan, Nanlin Li, Rui Ling, Ling Wang, and Junqing Xu
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yangtz{at}tom.com Juliang Zhang, et al.
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Dear Editor, There is no doubt that MRI plays an important role in breast cancer detection. However, it remains uncertain whether MRI will benefit prognosis of the patients, as reviewed by Houssami N and Hayes DF [1]. As we know, many factors, including tumor size, lymph node status, hormone receptor status, and human epidermal growth factor receptor 2 (HER2) status, can affect the prognosis of patients with breast cancer. So when the advances of MRI in early stage breast cancer are evaluated, some important prognostic factors should be balanced. In the only randomized controlled trial that was designed to measure the effect of MRI on re-excision rates as its primary endpoint (COMICE, Comparative Effectiveness of MRI in Breast Cancer) [2], no data were shown on whether MRI will lead to improved local outcomes in a certain subgroup, e.g. HER2 positive patients. In many other nonrandomized studies [3-5], analyses of MRI in detailed subgroups were also omitted. In China, breast cancer occurs more often in premenopausal women, who have higher recurrence and metastasis risks than postmenopausal women. Whether MRI can be of benefit also needs evidence based on randomized controlled trials. Yours Sincerely, Juliang Zhang (1)
1. Department of Vascular and Endocrine Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China 2. Department of Radiology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China Correspondence to: Ling Wang, MD, or Juliang Zhang, MD, E-mail: yangtz@tom.com References [1] Houssami N, Hayes DF. Review of preoperative magnetic resonance imaging (MRI) in breast cancer: should MRI be performed on all women with newly diagnosed, early stage breast cancer? CA Cancer J Clin. 2009;59(5):290-302. [2] Turnbull L. Magnetic resonance imaging in breast cancer: results of the COMICE trial. Breast Cancer Res. 2008;10(suppl 3):P10. [3] Houssami N, Ciatto S, Macaskill P, et al. Accuracy and surgical impact of magnetic resonance imaging in breast cancer staging: systematic review and meta-analysis in detection of multifocal and multicentric cancer. J Clin Oncol. 2008;26:3248-3258. [4] Bleicher RJ, Ciocca RM, Egleston BL, et al. The association of routine pretreatment magnetic resonance imaging with time to surgery, mastectomy rate, and margin status. J Am Coll Surg. 2009 Aug;209(2):180-7. [5] Pengel KE, Loo CE, Teertstra HJ, et al. The impact of preoperative MRI on breast-conserving surgery of invasive cancer: a comparative cohort study. Breast Cancer Res Treat. 2009 Jul;116(1):161-9. |
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Shaowei Liu, M.D. Department of Cardiology, Xijing Hospital, Fourth Military Medical University, China, Tao Yin, M.D.; Yanzhuo Ma, M.D.; Ling Tao, M.D., PhD; Tao Hu, M.D., PhD; Haichang Wang, M.D., PhD
Send letter to journal:
liushaow{at}fmmu.edu.cn Shaowei Liu, et al.
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As has been brought into notice by the authors, incremental MRI detection is contributed to a large extent by false-positive results and the consequent unnecessary surgery limits its net clinical benefit. By citing a systematic review done by Warren et al [1] examining the MRI technical parameters, including slice thickness, number of sequences after administration of contrast medium), the authors aimed to illustrate that the variability in reported data for MRI's detection of additional cancer foci is not significantly correlated with the changes in MRI technology. However, given a lack of other technical information on reported breast MRI as noted by Warren et al [1], it's premature to imply such an incorrelation. Instead, a most recent study showed that the clinically used signal enhancement ratio (SER) method produced a high rate of false positives at low enhancement thresholds and the support vector machines (SVMs) method yielded better results [2]. Therefore, technical verifications may still be accountable for the variability in reported data for MRI's detection capacity. In addition to technical perspectives that may affect the specificity of preoperative breast MRI, we believe a more fundamental characteristic of the MRI's mechanism for cancer detection might also be held responsible. The information content in the clinical MRI signal is mainly based on the density and the chemical shift properties of hydrogen molecules in a given tissue and the relaxation properties of that tissue. Theoretically, the information of cancer tissues derived from MRI images is likely to be resembled by non-cancerous changes in the breast and therefore leads to false-positive results. By contrast, a far more cost-effective tool, breast gamma imaging system (BSGI), which is based on the mechanisms of the innate property of tumor (higher cytoplasmic mitochondrial density of cancer cells than normal cells indicated by the enhanced specific binding of the radioactive tracer sestamibi to mitochondria [3] and increased pharmaceutical delivery of sestamibi to malignant tumors induced by neoangiogenesis [4]), is able to obtain equal sensitivity with much improved specificity as compared to MRI [5-7]. Therefore, although we do not challenge the necessity of conducting more large-scale, multicenter trials to eventually clarify the role of preoperative MRI in detecting residual or additional foci of breast cancer and to guide future practice, we should not be overoptimistic of a bolt-face change of current conclusion, albeit the enormous logistics and costs of conducting such trails. On the other hand, greater efforts should be directed to explore more appropriate (sensitive, specific, informative, and cost-effective) imaging modality in the preoperative evaluation of newly diagnosed breast cancer patients. Yours sincerely,
Department of Cardiology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China Correspondence: Shaowei Liu, M.D. or Haichang Wang, M.D., PhD, Department of Cardiology, Xijing Hospital, Fourth Military Medical University, Changle West Road, No.15, Xi'an, Shaanxi, China; e-mail: liushaow@fmmu.edu.cn or wanghc@fmmu.edu.cn References 1. Warren R, Ciatto S, Macaskill P, Black R, Houssami N. Technical aspects of breast MRI--do they affect outcomes? Eur Radiol. 2009;19:1629-1638. 2. Levman JE, Causer P, Warner E, Martel AL. Effect of the enhancement threshold on the computer-aided detection of breast cancer using MRI. Acad Radiol. 2009;16:1064-1069. 3. Delmon-Moingeon LI, Piwnica-Worms D, Van den Abbeele AD, Holman BL, Davison A, Jones AG. Uptake of the cation hexakis(2-methoxyisobutylisonitrile)-technetium-99m by human carcinoma cell lines in vitro. Cancer Res. 1990;50:2198-2202. 4. Sharma S, Sharma MC, Sarkar C. Morphology of angiogenesis in human cancer: a conceptual overview, histoprognostic perspective and significance of neoangiogenesis. Histopathology. 2005;46:481-489. 5. Brem RF, Petrovitch I, Rapelyea JA, Young H, Teal C, Kelly T. Breast-specific gamma imaging with 99mTc-Sestamibi and magnetic resonance imaging in the diagnosis of breast cancer--a comparative study. Breast J. 2007;13:465-469. 6. Bluemke DA, Gatsonis CA, Chen MH, et al. Magnetic resonance imaging of the breast prior to biopsy. JAMA. 2004;292:2735-2742. 7. Zhou M, Johnson N, Blanchard D, Bryn S, Nelson J. Real-world application of breast-specific gamma imaging, initial experience at a community breast center and its potential impact on clinical care. Am J Surg. 2008;195:631-635; discussion 635. |
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Lijun Yuan, MD Tangdu Hospital, the Fourth Military Medical University, Yunyou Duan, and Tiesheng Cao
Send letter to journal:
yuanlj{at}fmmu.edu.cn Lijun Yuan, et al.
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Nehmat Houssami and their colleagues in their newly published article declare that there is little high-quality evidence at present to support the routine use of preoperative MRI [1].They also recommend randomized controlled trials to establish the clinical, psychosocial, and long-term effects of MRI in newly affected breast cancer patients. One of the important questions seemed to be omitted by the authors is the right interpretation of the MRI data and the resultant alteration of the management. Reanalysis of the data from references 2, 3 and 4, reveals different outcomes of MRI-assisted surgery, especially there seeming more patients with positive margins in MRI-assisted group in reference 2. All of the above data suggest that different interpretation of MRI results might occur among different centers. In fact, MRI detection will of course provide additional information for breast cancer patients, even if there are certain false positive and negative rates. The key is how we interpret the data. Roughly changing the excision range according to the MRI data is not enough. We assume that MRI revealing additional lesions might be a sign of metastasis prone, and subsequently changing of systematic therapy might be also of benefit. Thus, it is first to reach a concordance for right interpretation and application of MRI data for breast cancer patients before we deny it or accept it. Lijun Yuan
Department of Ultrasound, Tangdu Hospital, the Fourth Military Medical University, 710038, Xi'an, China. Correspondence should be addressed to Yunyou Duan (duanyy@fmmu.edu.cn) or Tiesheng Cao (caots@fmmu.edu.cn). References 1. Houssami N, Hayes DF. Review of Preoperative Magnetic Resonance Imaging (MRI) in Breast Cancer: Should MRI Be Performed on All Women with Newly Diagnosed, Early Stage Breast Cancer? CA Cancer J Clin. 2009;59:290-302. 2. Bleicher RJ, Ciocca RM, Egleston BL, et al. The association of routine pretreatment magnetic resonance imaging with time to surgery, mastectomy rate, and margin status. J Am Coll Surg. 2009;209:180-187. 3. Warren R, Ciatto S, Macaskill P, Black R, Houssami N. Technical aspects of breast MRI: do they affect outcomes? Eur Radiol. 2009;19:1629-1638. 4. Turnbull L. Magnetic resonance imaging in breast cancer: results of the COMICE trial. Breast Cancer Res. 2008;10(suppl 3):P10. |
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