The value of breast MRI in high‐risk patients with newly diagnosed breast cancer to exclude invasive disease in the contralateral prophylactic mastectomy: Is there a role to choose wisely patients for sentinel node biopsy?

Abstract

The aim of this study was to evaluate the presence of clinically and mammographically occult disease using breast MRI in a cohort of cancer patients undergoing contralateral prophylactic mastectomy (CPM) and the utmost indication of axillary assessment (sentinel node biopsy (SLNB)) for this side. A retrospective review of patients with unilateral invasive breast cancer or ductal carcinoma in situ (DCIS) from institutional MRI registry data (2004–2010) was conducted. Characteristics of patients undergoing CPM with breast MRI obtained less than 6 month before surgery were evaluated. A total of 2322 consecutive patients diagnosed with DCIS or stage I to III infiltrating breast cancer underwent preoperative breast MRI. Of these, 1376 patients (59.2%) had contralateral clinical breast exam and mammography without abnormalities; and 116 patients (4.9%) underwent CPM (28 excluded patients had breast MRI more than 6 months before CPM). The mean age of the 88 patients was 49 years (range 28–76 years). Two (2.3%) DCIS identified on surgical pathology specimen were not depicted by MRI and the 5 mm T1N0 invasive cancer (1.1%) was identified on MRI. Preoperative MRI showed 95% accuracy to demonstrate absence of occult disease with negative predicted value (NPV) of 98% (95% CI: 91.64–99.64%). Occult disease was present in 3.4% of CPM. MRI accurately identified the case of invasive cancer in this cohort. The high negative predictive value suggests that MRI can be used to select patients without consideration of SLNB for the contralateral side.

Influence of Risk Category and Screening Round on the Performance of an MR Imaging and Mammography Screening Program in Carriers of the BRCA Mutation and Other Women at Increased Risk

“…Hence, the overall sensitivity of the screening program is heavily dependent on the frequency of prophylactic mastectomies in the target population and the indication for prophylactic mastectomy. However, our results showed that the cancers found in prophylactic mastectomy specimens were in general small and usually noninvasive, which is in line with findings of previous studies (26,27). Consequently, the importance of detecting these cancers is unknown, even though they are most often…”

Role of Sentinel Lymph Node Biopsy During Contralateral Prophylactic Mastectomy

“…On the other hand, there are many studies in which routine SLNB during CPM is not recommended (3,6,7,9,11,13,16,17,(21)(22)(23)(24)(25)(26). In the meta-analysis by Zhou et al (23), the occult breast carcinoma rate was found to be 1.6% in 1343 PMs.…”

The Use of Sentinel Lymph Node Biopsy in BRCA1/2 Mutation Carriers Undergoing Prophylactic Mastectomy: A Retrospective Consecutive Case-Series Study

“…First of all, in what regards MRI, others have argued against its routine use in prophylactic mastectomy, because of its high cost and low sensitivity for the detection of occult carcinoma [ 22 ]. However, MRI is recommended for the surveillance of BRCA1/2 mutation carriers [ 27 , 28 ]; MRI has a high negative predictive value for invasive carcinoma [ 29 ] and can be useful for selecting women who do not need to undergo sentinel lymph node biopsy (because occult carcinomas that have not been identified using MRI have a lower probability of lymph node metastasis) [ 30 ]. Our group reinforces the importance of MRI at a short interval before surgery, since all our patients had a BRCA1/2 pathogenic mutation and, therefore, a higher risk both for occult and for interval carcinoma.…”