The Impact of Preoperative Breast Magnetic Resonance Imaging on Surgical Management in Symptomatic Patients With Invasive Lobular Carcinoma

Abstract

Objective: Due to an insidious proliferative pattern, invasive lobular breast cancer (ILC) often fails to form a defined radiological or palpable lesion and accurate diagnosis remains challenging. This study aimed to determine the value of preoperative magnetic resonance imaging (MRI) for ILC and its impact on surgical outcomes. Methods: Consecutive symptomatic patients diagnosed with ILC in a tertiary centre over a 9-year period were reviewed. The time from diagnosis until surgery, initial type of surgery/index operation (breast-conserving surgery [BCS]/mastectomy) and the rates of reoperation (re-excision/completion mastectomy) were recorded. Patients were grouped into those who received conventional imaging and preoperative MRI (MR+) and those who received conventional imaging alone (MR–). Results: There were 218 cases of ILC, and 32.1% (n = 70) had preoperative MRI. Time from diagnosis to surgery was longer in the MR+ than the MR– group (32.5 vs 21.1 days, P < .001) even when adjusting for age and breast density. Initial BCS was performed on 71.4% (n = 50) of MR+ patients and 72.3% (n = 107) of the MR– group. While the rate of completion mastectomy following initial BCS was higher in the MR+ group (30.0%, n = 15 vs 14.0%, n = 15; χ2 = 5.63; P = .018), this association was not maintained in multivariable analysis. No difference was recorded in overall (initial and completion) mastectomy rate between the MR+ and MR– group (50.0%, n = 35 vs 37.8%, n = 56; χ2 = 2.89; P = .089). Margin re-excision following BCS was comparable between groups (8.0%, n =4, vs 9.3%, n = 10; χ2 = 0.076, P = .783) despite the selection bias for borderline conservable cases in the MR+ group. The rate of usage of MRI for ILC cases declined over the study period. Conclusion: While MRI was associated with minor delays in treatment and did not reduce overall rates of margin re-excision or completion mastectomy, it altered the choice of surgical procedure in almost a quarter of MR+ cases. The benefit of preoperative breast MRI appears to be confined to select (younger, dense breast, borderline conservable) cases in symptomatic ILC.

The Impact of Preoperative Breast MRI on Timing of Surgical Management in Newly Diagnosed Breast Cancer

“…28 A concern regarding preoperative breast MRIs is the potential for delaying definitive cancer treatment. 12,20 A potential reason for the low rate of preoperative breast MRI referrals may have been partly related to the concern of delays in surgical management. Delays are associated with both wait times to obtain the MRI and subsequent investigations of new suspicious findings.…”

“…5,20,21 Delays associated with preoperative breast MRI are related to wait times to obtain the MRI and the time required for subsequent investigations, biopsy, and pathology results for new suspicious findings. Moloney et al 12,22 found that the time from diagnosis to surgery was 11.4 days longer when a preoperative MRI was performed for patients with ILC, while another study found no associated delay. In a study by Cordeiro et al, 20 factors contributing to surgical wait times were examined and they found that additional preoperative radiologic procedures, investigations, and biopsies prolonged wait times by 6 days.…”

“…[5][6][7][8][9][10][11] The diffuse, infiltrating nature of ILC often results in disease extent underestimation on mammograms and ultrasound. 10,12 Lobular histology has been shown to be a predicting factor for positive surgical margins. 13,14 Although preoperative breast MRI is associated with higher rates of mastectomies, completing the MRI prior to surgery for patients with ILC, as well as for other breast cancer histologic subtypes, has been associated with lower rates of positive surgical margins and repeat surgeries.…”

Microwave Imaging in Breast Cancer – Results from the First-In-Human Clinical Investigation of the Wavelia System

“…In contrast to IDC which are usually well demarcated, ILC proliferation patterns are more typically diffuse with an irregular growth pattern and minimal desmoplastic reaction (24). Often, other than a slightly firm consistency, no mass may be identifiable clinically or radiologically until an advanced stage, due to the subtle insidious proliferative pattern of this subtype (25). Of the 5 cases of ILC, the Wavelia MBI system accurately identified all tumours.…”

The Wavelia Microwave Breast Imaging system–tumour discriminating features and their clinical usefulness

“…The diagnostic challenges posed by ILC are well catalogued. 23–26 Having previously demonstrated the potential to detect this frequently occult histological subtype, 19 and now demonstrated promise in estimating its size and malignancy risk, the Wavelia system could potentially compliment modern practice and be of most benefit in the detection of these lobular cases.…”