Response in different subtypes of breast cancer following neoadjuvant chemotherapy: correlation of MR imaging findings with final pathology

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1 Response in different subtypes of breast cancer following neoadjuvant chemotherapy: correlation of MR imaging findings with final pathology Poster No.: C-0912 Congress: ECR 2014 Type: Scientific Exhibit Authors: R. M. Lorente Ramos, J. Azpeitia Arman, M. T. Rivera García, M. A. Lara Alvarez, I. Casado Fariñas ; Madrid/ES, Madrid/ES Keywords: Cancer, Comparative studies, MR, Breast DOI: /ecr2014/C-0912 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 22

2 Aims and objectives To review and illustrate magnetic resonance (MR) imaging findings in patients with advanced breast cancer and systemic primary treatment, and correlation of MR findings with pathological response, including residual tumor features and complete remission. To analyse the differente types of radiological response to neoadjuvant therapy in different tumor subtypes. Methods and materials Study population: We retrospectively reviewed 36 patients with locally advanced breast cancer who underwent primary systemic therapy previous to surgery between January 2009 and September We exclude 5 patients with incomplete data and 1 patient who had no surgery after treatment, so our study includes 30 patients. Exams peformed: Pre and posttreatment clinical evaluation and pretreatment dynamic MR and diffusionweighted sequences were performed in all the patients. In 26 patients posttreatment dynamic and diffusion-weighted MR was performed within 10 days after treatment. Postreatment MR was not performed in 4 patients to whom mastectomy was performed, and who refused MR. After surgery, which was performed within 3 weeks from the end of treatment, pathologic evaluation of breast specimen was performed. Parameters that were evaluated: -On MR: T2 signal, lesion size, pre and posttreatment contrast enhancement kinetics, changes in size, type and percentage of response in posttreatment MR ( Fig. 1 on page 4), apparent diffusion coefficient (ADC), and response in lymph nodes. Page 2 of 22

3 Fig. 1 - On pathology tumor response was clasified according to Miller-Payne System ( Fig. 2 on page 5) based on changes in cellularity, grade and response in lymph nodes was also stated. Complete response (pcr) consists of absence of invasive disease, but intraductal tumor may be present). Page 3 of 22

4 Fig. 2 Images for this section: Page 4 of 22

5 Fig. 1 Page 5 of 22

6 Fig. 2 Page 6 of 22

7 Results MR is useful in the evaluation of response to neoadjuvant chemotherapy (NAC). It can accurately estimate the pathological size of the residual tumor and the presence of complete response. Immunohystochemical subtypes of breast cancer allow to classify patients with better outcome after neoadjuvant therapy. In our study group ages ranged from years, mean age 51 years. Out of 30 patients, tumor subtypes were Luminal A 5 patients, Luminal B 13, Her2 in 5 patients and triple negative 7 patients ( Fig. 3 on page 14 ). Based on Her 2 status eleven patients had Her 2 positive tumors, and 19 Her 2 negative ( Fig. 4 on page 14 ). Fig. 3 Page 7 of 22

8 Fig. 4 Pathologic complete response (pcr) (absence of invasive disease, but intraductal tumor may be present) appeared in 9 patients, partial in 20 and minimal response (Miller Payne 1) was found in 1 patient. Residual tumor correlation was better in MR than clinical evaluation ( Fig. 5 on page 15 ). Page 8 of 22

9 Fig. 5 MR response may be defined as complete if no lesion or enhancing area is found. Partial response may appear as lesion fragmentation, or tumor shrinkage. Both response types may be found both in masses and non-mass enhancing areas, but shrinkage is most frequent in masses and fragmentation in non-enhancing areas. On MR response was complete in 7 patients ( Fig. 6 on page 16 ), and partial in 19: fragmentation in 6, and concentric shrinkage in 13 ( Fig. 7 on page 17 ). Page 9 of 22

10 Fig. 6 Fig. 7 Page 10 of 22

11 We tried to correlate degree of response on MR with pathology. We clasified MR response as complete (no residual lesion), partial major (more than 50% response), partial minor (less than 50% response) and no response. No response was correlated with Miller Payne score 1 and 2, Partial minor and major on MR with Miller Payne score 3 and 4 and complete response with Miller Payne 5( Fig. 8 on page 17 ). Exact correlation between MR and pathologic response appeared in 18 patients, 8 Her2 positive and 10 Her2 negative tumors ( Fig. 9 on page 18 ). Mistakes in correlation MR-pathology were found mostly in patients with fragmentation response when residual tumor consists of small or scattered foci ( Fig. 10 on page 19 ). Fig. 8 Page 11 of 22

12 Fig. 9 Page 12 of 22

13 Fig. 10 Mean ADC (apparent diffusion coeficient) decreased from pretreatment to posttreatment values ( Fig. 11 on page 19 ). However we did not find a significant difference in ADC change from pre to posttreatment values between patients with complete and partial response (Fig. 12 on page 19 ). Fig. 11 Page 13 of 22

14 Fig. 12 Images for this section: Fig. 3 Page 14 of 22

15 Fig. 4 Page 15 of 22

16 Fig. 5 Page 16 of 22

17 Fig. 6 Fig. 7 Page 17 of 22

18 Fig. 8 Fig. 9 Page 18 of 22

19 Fig. 10 Fig. 11 Page 19 of 22

20 Fig. 12 Page 20 of 22

21 Conclusion MR correlation with pathology is high in the evaluation of response to neoadjuvant chemotherapy. Response may be overestimated by MR in patients with fragmentation response when residual tumor consists of small or scattered foci. We found no difference between Her-2 positive and negative tumors in MR - pathology correlation and ADC values, but due to our limited number of patients results should be further analysed with larger samples. Personal information Rosa M. Lorente Ramos. Unidad Central de Radiodiagnóstico (UCR) de la Comunidad de madrid. Department of Radiology Hospital Infanta Leonor. Madrid. Spain. rosa.lorenteramos@salud.madrid.org Javier Azpeitia Armán. Unidad Central de Radiodiagnóstico (UCR) de la Comunidad de madrid. Department of Radiology Hospital Infanta Leonor. Madrid. Spain. M. Teresa Rivera García. Department of Pathology Hospital Infanta Leonor. Madrid. Spain. Miguel Angel Lara Alvarez. Department of Oncology Hospital Infanta Leonor. Madrid. Spain. Isabel Casado Fariñas. Department of Pathology Hospital Infanta Leonor. Madrid. Spain. References - Ogston KN, Miller ID, Payne S, Hutcheon AW, Sarkar TK, Smith I, Schofield A, Heys SD. A new histological grading system to assess response of breast Page 21 of 22

22 cancers to primary chemotherapy: prognostic significance and survival. Breast 2003 Oct;12(5): Londero V, Bazzocchi M, del Frate C, Puglisi F, Di Loreto C, Francescutti G, Zuiani C. locally advanced breast cancer: comparison of mammography, sonography and MR imaging in evaluation of residual disease in women receiving neoadjuvant chemotherapy. Eur Radiol 2004;14(8):1371:9 - Park SH, Moon WK, Cho N, Song IC, Chang JM, Park IA, Han W, Noh DY. Diffusionweighted MR imaging: pretreatment prediction of response to neoadjuvant chemotherapy in patients with breast cancer. Radiology 2010;257: Le-Petross HC, Hylton N. Role of breast MR imaging in neoadjuvant chemotherapy. Magn Reson Imaging Clin N Am 2010;18: Page 22 of 22