Angela Gilliam, MD University of Colorado Surgical Grand Rounds November 3, 2008

Transcription

1 Angela Gilliam, MD University of Colorado Surgical Grand Rounds November 3, 2008

2 Breast Cancer Most common cancer in American women 180,000 new cases per year Second most common cause of cancer death 44,000 cancer deaths annually Lifetime cancer risk: General population: 12.5% lifetime risk BRCA1 mutation: 55-85% BRCA2 mutation: 37-85%

3 ACS Guidelines For Screening with MRI Recommended Annually based on evidence BRCA mutation carriers Untested First-degree relatives of BRCA carrier Lifetime risk >20-25% based on family history models Recommended based on expert consensus opinion Radiation to the chest from age 10-30yr Li-Fraumeni syndrome and 1 st degree relatives Cowden syndrome and 1 st degree relatives Insufficient Evidence Lifetime risk 15-20% LCIS Dense breast on mammography Personal history of breast cancer Recommended Against based on expert consensus Lifetime risk <15% Saslow, et al. CA Cancer J Clin 57: 75-89, 2007

4 High risk patients: BRCA mutations Dr. Schnall and colleagues in association with the NCI: prospective, nonrandom with 390 patients enrolled. 4 cancers were detected MRI detected all 4 for a 1.1% cancer yield. Mammography detected 1 cancer for a 0.3% yield. Sensitivity and Specificity MRI: 100% sensitivity and 93 % specificity Mammography 25% sensitivity and 98% specificity Combined: 100% sensitive and 91% specific Lehman et al. Cancer 103: , 2005.

5 High Risk patients: BRCA mutations Warner and colleagues enrolled 236 BRCA positive women. 22 carcinomas were found (16 invasive and 6 DCIS) Clinical breast exam-9.1% Mammography 36% Ultrasound 33% MRI 77% 32% (7cancers) were detected by MRI alone Sensitivity and Specificity Mammography 36% sensitive, 100% specific MRI 77% sensitive, 99% specific Combined 86% sensitive and 95% specific Warner et al. JAMA 292: , 2004.

6 High risk patients: BRCA mutations Dr. Kuhl and colleagues enrolled 192 high risk women, 50% with BRCA mutations. 186 asymptomatic, 6 symptomatic patients 15 breast cancers were diagnosed. 9 in asymptomatic patients 6 in symptomatic patients 15/15 breast cancers were diagnosed by MRI. 100% sensitive, 97% specific 8/15 diagnosed by Mammography. 32% sensitive, 97% specific Kuhl et al. Radiology. 215: ,2000.

7

8 Surgical Treatment of Breast Cancer Mastectomy Breast Conservation Therapy Absolute contraindications Prior therapeutic irradiation to the breast region Inability to obtain negative margins First and Second trimester pregnancy Clinically or mammographically detected multicentric cancer.

9 MRI and Surgical Therapy Dr. Bedrosian and colleagues performed a retrospective review of 267 patients with breast cancer. 197patients had MR imaging prior to surgery. 95 % sensitivity 70 patients had imaging after excision with positive margins. 57% sensitivity 69/267 had a change in surgical management 16.5% were converted to mastectomy 4% underwent a wider excision 5% had a separate incision 71% had pathologically proven cancer

10 MRI and Surgical Therapy Bedrosian, cont d. 24 patients had invasive lobular carcinoma. 50% of these patients had a change in surgical management based on the MRI. 9/11 were verified by additional cancer in the specimen. Bedrosian et al. Cancer 98: , 2003.

11 MRI and Surgical Therapy Deurloo and colleagues enrolled 116 patients who were eligible for BCT. 41% of patients had additional findings by MRI. 77% had no change in management 15% were converted to mastectomy 6% underwent a larger excision 2% underwent surgery to the contralateral side Deurloo et al. Eur J of Cancer 41: , 2005.

12 MRI and Surgical Therapy Fisher and colleagues performed a retrospective review Preop MRI group: 121 patients 86 (71%)patients underwent BCT 1 (1.2%)patient had an ipsilateral recurrence 35 (29.9%)patients had a mastectomy 2(1.7%) patients had contralateral cancer on follow-up No MRI group: 225 patients 138 (61%) patients underwent BCT 9 (6.5%)patients had an ipsilateral recurrence 87 (39%)patients had a mastectomy 9 (4%)patients had contralateral cancer on follow-up Fischer et al. Eur Radiol. 14: , 2004.

13 MRI and Surgical Therapy Irwig and colleagues performed a metaanalysis of 19 studies. MRI detects additional disease in 16% of women with breast cancer. Conversion to mastectomy was 8.1% and to more extensive WLE was 11.3% 1.1 percent of women were converted to mastectomy for benign disease. Houssami et al. J of Clin Onc 26: ,2008

14 Conclusions MRI is a useful adjunct in the screening of high risk patients, such as those with BRCA mutations. MRI is beneficial for preoperative staging of breast carcinoma, especially lobular carcinoma. Other potential uses of breast MRI include evaluation of neoadjuvant therapy and screening of breast cancer survivors, but more data is needed on these subjects.