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Yield of Surveillance Magnetic Resonance Imaging After Bilateral Mastectomy and Reconstruction: a Retrospective Cohort Study

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Yield of Surveillance Magnetic Resonance Imaging After Bilateral Mastectomy and Reconstruction: a Retrospective Cohort Study Breast Cancer Research and Treatment (2019) 174:463–468 https://doi.org/10.1007/s10549-018-05077-9 EPIDEMIOLOGY Yield of surveillance magnetic resonance imaging after bilateral mastectomy and reconstruction: a retrospective cohort study Orit Golan1 · Yoav Amitai1,5 · Yoav Barnea2,4 · Tehillah S. Menes3,4 Received: 23 November 2018 / Accepted: 28 November 2018 / Published online: 3 December 2018 © Springer Science+Business Media, LLC, part of Springer Nature 2018 Abstract Purpose There are no evidence-based guidelines for surveillance of women after bilateral mastectomy and reconstruction. Several societies recommend against routine breast imaging in this setting. Despite these recommendations, magnetic reso- nance imaging (MRI) is frequently used to follow these women. We sought to examine the findings on MRI studies done in this setting. Methods This is a retrospective cohort study including all consecutive MRI exams done after bilateral mastectomy and reconstruction between January 2010 and April 2018. Data collected included demographic information, family history, BRCA status, indication for bilateral mastectomy, type of reconstruction, findings on MRI, and work-up of MRI findings. Cancer detection rate and interval cancer rates were calculated. Results One hundred fifty-nine women had 415 surveillance MRI exams. Most (372, 90%) studies were done in women with implant-based reconstruction. Four hundred and five (98%; 95% confidence interval (CI) 96–99%) of the studies were negative. One breast recurrence was found on MRI (cancer detection rate 2.4 per 1000 MRI exams, 95% CI 0.4–13); how- ever, this woman was simultaneously diagnosed with metastatic disease. The false-positive rate was 90% (95% CI 54–99%). During follow-up three women were diagnosed with local recurrence (interval cancer rate 5 per 1000, 95% CI 1.3–17) and 4 women were diagnosed with metastatic disease. Conclusion The yield of surveillance MRI in women with bilateral mastectomy and reconstruction is very low. As most of the cohort had retro-pectoral implant-based reconstruction, it appears safe to recommend against surveillance MRI in this setting regardless of the indication for mastectomy. Keywords Breast cancer · Bilateral mastectomy · MRI · Surveillance · BRCA Introduction Women undergoing bilateral mastectomy and reconstruction represent a heterogeneous group with different indications for mastectomy, and hence different risks for developing * Tehillah S. Menes [email protected] breast cancer (recurrence or a new primary). Data on routine breast imaging in women after bilateral 1 Department of Breast Imaging, Tel Aviv Sourasky Medical mastectomy and reconstruction (for risk-reduction or a his- Center, Tel Aviv, Israel tory of breast cancer) are very limited and there is contro- 2 Department of Plastic Surgery, Tel Aviv Sourasky Medical versy regarding the role of breast imaging in this setting. Center, Tel Aviv, Israel The National Comprehensive Cancer Network (NCCN) rec- 3 Department of General Surgery, Tel Aviv Sourasky Medical ommends against routine imaging of reconstructed breasts Center, 6 Weizmann St, Tel Aviv, Israel in women with a history of breast cancer [1], as does The 4 Sackler School of Medicine, Tel Aviv University, Tel Aviv, National Institute for Health and Care Excellence (NICE) in Israel the UK [2]. As for women undergoing risk-reducing bilat- 5 Joint Department of Medical Imaging, University Health eral mastectomy, there are limited data to support routine Network, Mount Sinai Hospital, and Women’s College breast imaging [3]. The National Hereditary Cancer Task Hospital, Toronto, ON, Canada Vol.:(0123456789)1 3 464 Breast Cancer Research and Treatment (2019) 174:463–468 Force [4] recommends against any kind of routine breast Erlangen, Germany). Patients were scanned in the prone posi- imaging for surveillance. Despite these recommendations, tion. A dedicated breast coil was used for all examinations. routine imaging of patients after breast reconstruction is In premenopausal women, the scan was performed during still widely practiced, based on reports in the literature. the second week of the menstrual cycle. After obtaining Some routinely screen all women after mastectomy and axial fat saturated T2-weighted images (TR/TE 5270/89 or reconstruction regardless of the indication [5]. Madorsky- 4328/101.4), an axial T1-weighted 3D gradient-echo sequence Feldman completed a survey of 22 centers examining their was performed before and after injection of contrast mate- protocol for surveillance of BRCA mutation carriers after rial. The image parameters from January 2010 to September risk-reducing mastectomy. Most centers responding, do not 2014 were as follows: TR/TE 8.89/1.7; flip angle 10°; matrix offer routine surveillance in this setting. In the centers that size 512 × 512; field of view 38 × 38 cm2. From October 2014 offer routine surveillance, use of MRI varies widely with onward image parameters were: TR/TE 5.3/2.4; flip angle some recommending annual MRI with or without an upper 10°; matrix size 384 × 384; field of view 38 × 38 cm2. For age limit, while others use MRI to assess residual breast tis- contrast-enhanced sequences, a rapid bolus injection of gad- sue, and limit the use of surveillance MRI to women with a olinium-based contrast agent was used with a calculated dose significant amount of residual breast tissue [6]. of 0.2 mmol/kg of body weight and at an injection rate of 2 ml Our center performs surveillance MRI after bilateral mas- per sec. Dynamic sequences included one pre-contrast and five tectomy and reconstruction. The aim of this study was to post-contrast acquisitions. The first contrast-enhanced dynamic assess the yield of MRI in this group of women, specifically sequence was performed 60 s after injection and was followed the cancer detection rate. We hypothesized that the yield of by 4 additional scans. Subtraction images were also obtained. surveillance MRI in this setting is very low. All MRI studies were processed using a commercially avail- able computed aided-detection system (CAD stream, Merge healthcare Inc., Chicago, IL, USA). Interpretation was based Methods on the American College of Radiology Breast Imaging Report- ing and Data System (BI-RADS) terminology: category 1, This retrospective cohort study was approved by our Insti- negative; 2, benign; 3, probably benign; 4, suspicious; and tutional Review Board, and the requirement for informed 5, highly suggestive of a malignancy. Patients with category consent was waived. The study cohort included all consecu- 3 lesions were recommended for short-term (6-month) MRI tive surveillance breast MRI exams done after bilateral mas- follow-up. Patients with category 4 or 5 lesions were recom- tectomy and reconstruction at our center (tertiary medical mended for second look ultrasound (US) and biopsy. Biopsy center) between January 2010 and April 2018. MRI exams of BI-RADS categories 4 and 5 lesions was performed by of women after bilateral mastectomy without reconstruction, ultrasound-guided core-needle biopsy or fine-needle aspira- and diagnostic MRI exams were excluded. A retrospective tion. Suspicious lesions not visualized on ultrasound were chart review was completed, and the data collected included: recommended for MRI guided needle or excisional biopsy. patient demographics, family history and genetic predisposi- Outcomes: The medical records were used to determine tion, indication for mastectomy, and type of reconstructive the frequency of local and distant recurrence. Based on the surgery (implant-based, autologous, or a combination). Of detection modality and time from previous MRI exam, the note, not all surgeries were done at our medical center. cancer detection rate (CDR) of surveillance MRI and inter- Data on MRI exams included indication for MRI, findings val cancer rate (defined as cancer detected within 1 year on MRI, further work-up done due to the MRI findings, and from MRI exam) were determined. post MRI follow-up (clinical or imaging). Position of the Analyses: False-positive findings were defined as cat- implants relative to the pectoralis muscle was determined egory 0, 3, 4, or 5 MRI with a benign imaging follow-up from the MRI study. All data extracted from the imaging study (for BI-RADS 0 and 3) or a benign histologic diag- studies were based on the original interpretation by experi- nosis (for BI-RADS 4 and 5). False-positive rates, CDR of enced breast radiologists. In cases in which the original MRI surveillance MRI and interval cancer rates were calculated; report was insufficient (i.e., type of reconstruction or posi- Binomial distributions were assumed and 95% confidence tion of implant not mentioned), a second breast radiologist intervals (CI) were estimated using the Wilson procedure. completed another review in order to obtain the necessary data. MRI protocol: From January 2010 to September 2014 all Results MRI studies were performed with a 1.5T imaging system (Signa, GE healthcare, Milwaukee, USA), and from October After exclusion of women undergoing bilateral mastectomy 2014 onward studies were performed in a 3T magnet (Skyra, without reconstruction (N = 34), and those undergoing diag- Siemens, Erlangen, Germany) or 1.5T magnet (Aera, Siemens, nostic MRI exams (N = 11) the study included 159 women 1 3 Breast Cancer Research and Treatment (2019) 174:463–468 465 who had in total 415 MRI exams during the study period. Most (65, 41%) women had one study, 33 had 2, 20 had 3, and 41 women had at least 4. The median number of stud- ies per patient was two (range 1–9). Characteristics of the study group are summarized in Table 1. Median age of the women at the time of the MRI exam was 47 years (range 23–82). Most (111, 70%) underwent bilateral mastectomy for a diagnosis of cancer. More than half tested positive for a pathogenic mutation in BRCA. Three hundred seventy- two (90%) of the studies were done in women with implant- based reconstruction. All implant-based reconstructions were retro-pectoral, except for two women that had on one side a retro-pectoral and on the other side, a pre-pectoral implant placed.
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