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Accuracy of MRI in the Detection of Residual Breast Cancer After Neoadjuvant Chemotherapy

¹ Department of Radiology, Breast Imaging Division, Box 3808, Duke University Medical Center, Durham, NC 27710.
² Department of Medicine, Oncology Division, Box 3893, Duke University Medical Center, Durham, NC 27710.
³ Department of Pathology, Box 3712, Duke University Medical Center, Durham, NC 27710.
⁴ Department of Biostatistics and Bioinformatics, Box 3958, Duke University Medical Center, Durham, NC 27710.
⁵ Department of Radiation Oncology, Radiation Physics Division, Box 3085, Duke University Medical Center, Durham, NC 27710.
⁶ Department of Radiation Oncology, Box 3455, Duke University Medical Center, Durham, NC 27710.

View larger version (15K): [in a new window]   Fig. 1. —Graph shows relationship between data points (• = physical examination, = MRI) and best-fit line between MRI, physical examination, and histology. Solid line = identity, dashed line = MRI, dotted line = physical examination.

View larger version (15K): [in a new window]   Fig. 2A. —Graphs show difference between histology and physical examination or MRI plotted against mean of histology and physical examination or MRI. Solid line = identity, dashed line = histology–physical examination. Difference in tumor size at histology and on physical examination increases with increasing tumor size, suggesting that physical examination becomes more inaccurate as tumor size increases, particularly when size of residual tumor exceeds 5 cm.

View larger version (13K): [in a new window]   Fig. 2B. —Graphs show difference between histology and physical examination or MRI plotted against mean of histology and physical examination or MRI. Solid line = identity, dashed line = histology–physical examination. Difference between size estimates based on histology and those based on MRI approaches zero as tumor size increases, suggesting that MRI becomes more accurate as residual tumor size increases.

View larger version (151K): [in a new window]   Fig. 3A. —35-year-old woman with invasive ductal carcinoma of left breast and overestimation by MRI after chemotherapy. Contrast-enhanced T1-weighted image acquired before initiation of neoadjuvant chemotherapy shows 3.6-cm oval mass with thin rim of peripheral enhancement and heterogeneous internal enhancement in medial and posterior left breast.

View larger version (145K): [in a new window]   Fig. 3B. —35-year-old woman with invasive ductal carcinoma of left breast and overestimation by MRI after chemotherapy. Contrast-enhanced T1-weighted image acquired after neoadjuvant chemotherapy reveals that previously shown mass has diminished in size and conspicuity. Residual abnormality (arrow) measured 1.9 cm in anteroposterior dimension, although histologic review of lumpectomy specimen showed 0.5-cm nodule containing viable and necrotic invasive ductal carcinoma. Nonneoplastic breast tissue submitted contained only "fibrocystic changes."

View larger version (152K): [in a new window]   Fig. 4A. —75-year-old woman with inflammatory carcinoma of right breast and persistent segmentally distributed abnormalities on MRI after chemotherapy. Contrast-enhanced T1-weighted image of right breast acquired before neoadjuvant chemotherapy shows segmentally distributed region of abnormal enhancement in upper slightly medial breast. Adjacent skin and areola are obscured by artifact in this image.

View larger version (142K): [in a new window]   Fig. 4B. —75-year-old woman with inflammatory carcinoma of right breast and persistent segmentally distributed abnormalities on MRI after chemotherapy. Contrast-enhanced T1-weighted image after chemotherapy reveals persistent multifocal, segmentally distributed enhancement, which measured 6.1 cm in maximum extent. Skin thickening and enhancement in periareolar region are also evident. Histology review of breast after mastectomy showed 4.0-cm gross tumor with invasive and in situ ductal carcinoma. However, no multifocal tumor was shown outside this mass, and both nipple and skin were negative for malignancy. Nonneoplastic tissue did contain intraductal papilloma and fibrocystic changes.

View larger version (67K): [in a new window]   Fig. 5A. —54-year-old woman with high-grade invasive adenocarcinoma of left breast and true-negative MRI examination after neoadjuvant chemotherapy. Contrast-enhanced T1-weighted image acquired before neoadjuvant therapy shows 3-cm mass with intense peripheral and heterogeneous internal enhancement. Abnormal lymph node is also visualized in axilla.

View larger version (78K): [in a new window]   Fig. 5B. —54-year-old woman with high-grade invasive adenocarcinoma of left breast and true-negative MRI examination after neoadjuvant chemotherapy. Contrast-enhanced T1-weighted image after chemotherapy shows complete resolution of previously seen mass. Histology review of mastectomy specimen showed area of fibrosis without residual carcinoma.

View larger version (139K): [in a new window]   Fig. 6A. —39-year-old woman with invasive ductal carcinoma and false-negative finding on MRI after neoadjuvant chemotherapy. Contrast-enhanced T1-weighted image acquired before neoadjuvant chemotherapy shows nonfocal, segmentally distributed areas of enhancement in superior and posterior breast (arrows).

View larger version (122K): [in a new window]   Fig. 6B. —39-year-old woman with invasive ductal carcinoma and false-negative finding on MRI after neoadjuvant chemotherapy. Contrast-enhanced T1-weighted image suggests area of pathologic enhancement present before neoadjuvant therapy (arrow) has resolved. At histology, however, multifocal invasive and in situ ductal carcinoma were present in seven of 31 blocks from lumpectomy specimen.

View larger version (131K): [in a new window]   Fig. 7A. —52-year-old woman with extensive left breast carcinoma and overestimation of residual tumor by MRI after chemotherapy. Contrast-enhanced T1-weighted image obtained before chemotherapy not only confirms large irregular mass, but also shows linear enhancement extending toward nipple.

View larger version (132K): [in a new window]   Fig. 7B. —52-year-old woman with extensive left breast carcinoma and overestimation of residual tumor by MRI after chemotherapy. Contrast-enhanced T1-weighted image obtained after chemotherapy shows decreased size and enhancement of mass, but persistent and extensive linear enhancement in breast, measuring 6.4 cm in anteroposterior dimension. Histologic evaluation of mastectomy specimen revealed 3.0-cm invasive and in situ ductal carcinoma. This size was smaller than predicted by MRI; however, pathologist commented that microscopic tumor deposits are present diffusely. It is very likely, therefore, that standard histologic size determination underestimated actual disease extent.

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