MRI for Surgical Planning in Patients with Breast Cancer Who Undergo Preoperative Chemotherapy
Fabienne Thibault1,
Claude Nos2,
Martine Meunier1,
Carl El Khoury1,
Liliane Ollivier1,
Brigitte Sigal-Zafrani3 and
Krishna Clough2 for the Institut Curie Breast Cancer Group
1 Department of Medical Imaging, Institut Curie, 26 rue d'Ulm, 75248 Paris Cedex
05, France.
2 Department of Surgery, Institut Curie, 75248 Paris Cedex 05, France.
3 Department of Pathology, Institut Curie, 75248 Paris Cedex 05, France.
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Fig. 1A. —42-year-old woman undergoing chemotherapy who had unifocal
tumor seen on initial MR images. Initial MR images (native images) obtained
before (A) and after (B) injection of contrast medium show one
circumscribed tumor (arrows).
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Fig. 1B. —42-year-old woman undergoing chemotherapy who had unifocal
tumor seen on initial MR images. Initial MR images (native images) obtained
before (A) and after (B) injection of contrast medium show one
circumscribed tumor (arrows).
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Fig. 1C. —42-year-old woman undergoing chemotherapy who had unifocal
tumor seen on initial MR images. MR image obtained after chemotherapy shows
marked concentric shrinkage of tumor (arrow) to single residue. Such
process was considered to indicate most favorable or ideal situation for
breast-conserving surgery, allowing complete tumor excision with standard
lumpectomy.
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Fig. 2A. —67-year-old woman with unifocal tumor that fragmented while
she underwent chemotherapy. Initial digitally subtracted MR image shows single
tumor mass with spiculated margins.
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Fig. 2B. —67-year-old woman with unifocal tumor that fragmented while
she underwent chemotherapy. MR images obtained after two courses (B)
and at end of chemotherapy (C) show fragmentation of tumor, resulting
in multiple residual foci. MRI measurement of longest tumor diameter
underestimated residual 6-cm invasive ductal carcinoma tumor by 2 cm. This
type of response was considered to indicate unfavorable situation for
breast-conserving surgery. In this patient, MRI assessment would have led to
postchemotherapy mastectomy and allowed her to avoid undergoing additional
breast-conserving surgery that resulted in positive margins.
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Fig. 2C. —67-year-old woman with unifocal tumor that fragmented while
she underwent chemotherapy. MR images obtained after two courses (B)
and at end of chemotherapy (C) show fragmentation of tumor, resulting
in multiple residual foci. MRI measurement of longest tumor diameter
underestimated residual 6-cm invasive ductal carcinoma tumor by 2 cm. This
type of response was considered to indicate unfavorable situation for
breast-conserving surgery. In this patient, MRI assessment would have led to
postchemotherapy mastectomy and allowed her to avoid undergoing additional
breast-conserving surgery that resulted in positive margins.
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Fig. 3A. —In 57-year-old woman, multifocal tumor is seen on three
successive slices (shown across each row) from lateral to medial parts of
breasts. Initial MR images (A), MR images after two courses of
chemotherapy (B), and preoperative MR images after completion of
chemotherapy (C) all show two main central tumor nodules associated
with smaller peripheral nodules (arrows, A) confined in one
quadrant. B and C show nodule shrinkage in response to therapy
but persistence of two small nodules on preoperative MR images (C).
Patient is not suitable candidate for breast-conserving surgery.
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Fig. 3B. —In 57-year-old woman, multifocal tumor is seen on three
successive slices (shown across each row) from lateral to medial parts of
breasts. Initial MR images (A), MR images after two courses of
chemotherapy (B), and preoperative MR images after completion of
chemotherapy (C) all show two main central tumor nodules associated
with smaller peripheral nodules (arrows, A) confined in one
quadrant. B and C show nodule shrinkage in response to therapy
but persistence of two small nodules on preoperative MR images (C).
Patient is not suitable candidate for breast-conserving surgery.
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Fig. 3C. —In 57-year-old woman, multifocal tumor is seen on three
successive slices (shown across each row) from lateral to medial parts of
breasts. Initial MR images (A), MR images after two courses of
chemotherapy (B), and preoperative MR images after completion of
chemotherapy (C) all show two main central tumor nodules associated
with smaller peripheral nodules (arrows, A) confined in one
quadrant. B and C show nodule shrinkage in response to therapy
but persistence of two small nodules on preoperative MR images (C).
Patient is not suitable candidate for breast-conserving surgery.
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Fig. 4A. —51-year-old women who had multifocal tumor with multicentric
disease suspected on initial MR images. Tumor nodules (arrowheads)
extend widely within breast from lateral (A) to medial parts (D)
beyond quadrant of index tumor, which was localized in retroareolar region
(B) by standard evaluation. C shows section through nipple. Had
MRI been considered, this patient would have undergone direct mastectomy,
avoiding preoperative chemotherapy and unsuccessful breast-conserving
surgery.
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Fig. 4B. —51-year-old women who had multifocal tumor with multicentric
disease suspected on initial MR images. Tumor nodules (arrowheads)
extend widely within breast from lateral (A) to medial parts (D)
beyond quadrant of index tumor, which was localized in retroareolar region
(B) by standard evaluation. C shows section through nipple. Had
MRI been considered, this patient would have undergone direct mastectomy,
avoiding preoperative chemotherapy and unsuccessful breast-conserving
surgery.
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Fig. 4C. —51-year-old women who had multifocal tumor with multicentric
disease suspected on initial MR images. Tumor nodules (arrowheads)
extend widely within breast from lateral (A) to medial parts (D)
beyond quadrant of index tumor, which was localized in retroareolar region
(B) by standard evaluation. C shows section through nipple. Had
MRI been considered, this patient would have undergone direct mastectomy,
avoiding preoperative chemotherapy and unsuccessful breast-conserving
surgery.
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Fig. 4D. —51-year-old women who had multifocal tumor with multicentric
disease suspected on initial MR images. Tumor nodules (arrowheads)
extend widely within breast from lateral (A) to medial parts (D)
beyond quadrant of index tumor, which was localized in retroareolar region
(B) by standard evaluation. C shows section through nipple. Had
MRI been considered, this patient would have undergone direct mastectomy,
avoiding preoperative chemotherapy and unsuccessful breast-conserving
surgery.
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Fig. 5. —Graph shows MRI and histopathologic correlation of residual
tumor sizes after chemotherapy. MRI-measured longest diameters in centimeters
(x-axis) is compared with greatest dimensions of microscopic disease
on surgical specimens in centimeters (y-axis). Spearman rank
correlation coefficient = 0.79, p = 0.001.
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Fig. 6A. —44-year-old woman with large unifocal breast tumor. Initial
MR image shows unifocal tumor.
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Fig. 6B. —44-year-old woman with large unifocal breast tumor. MR image
obtained after two courses of chemotherapy shows marked fragmentation of tumor
but little change in its longest composite diameter.
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Fig. 6C. —44-year-old woman with large unifocal breast tumor. MR image
obtained after chemotherapy shows only two or three low-enhancing residual
foci (arrows). Patient underwent secondary mastectomy after
breast-conserving surgery resulted in positive margins. Size of residual tumor
at histology (3.5-cm invasive lobular carcinoma) was underestimated by 1.5 cm.
MRI evaluation would not have prevented additional breast-conserving surgery
in this patient.
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Copyright © 2004 by the American Roentgen Ray Society.
