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Feasibility of Mapping Breast Cancer with Supine Breast MRI in Patients Scheduled for Oncoplastic Surgery

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Feasibility of Mapping Breast Cancer with Supine Breast MRI in Patients Scheduled for Oncoplastic Surgery European Radiology (2019) 29:1435–1443 https://doi.org/10.1007/s00330-018-5681-y MAGNETIC RESONANCE Feasibility of mapping breast cancer with supine breast MRI in patients scheduled for oncoplastic surgery S. Joukainen1 & A. Masarwah2 & M. Könönen2 & M. Husso2 & A. Sutela2 & V. Kärjä3 & R. Vanninen2,4,5 & M. Sudah2 Received: 2 May 2018 /Revised: 9 July 2018 /Accepted: 24 July 2018 /Published online: 17 August 2018 # European Society of Radiology 2018 Abstract Objectives To prospectively determine the feasibility of preoperative supine breast MRI in breast cancer patients scheduled for oncoplastic breast-conserving surgery. Methods In addition to a diagnostic prone breast MRI, a supplementary supine MRI was performed with the patient in the surgical position including skin markers. Tumours’ locations were ink-marked on the skin according to findings obtained from supine MRI. Changes in tumours’ largest diameter and locations between prone and supine MRI were measured and compared to histology. Nipple-to-tumour and tumour-to-chest wall distances were also measured. Tumours and suspicious areas were surgi- cally removed according to skin ink-markings. The differences between MRI measurements with reference to histopathology were evaluated with the paired-sample t test. Results Fourteen consecutive patients, 15 breasts and 27 lesions were analysed. Compared to histology, prone MRI overestimated tumour size by 47.1% (p = 0.01) and supine MRI by 14.5% (p = 0.259). In supine MRI, lesions’ mean diameters and areas were smaller compared to prone MRI (– 20.9%, p = 0.009 and – 38.3%, p = 0.016, respectively). This difference in diameter was more pronounced in non-mass lesions (– 31.2%, p =0.031)comparedtomasslesions(– 9.2%, p =0.009). Tumours’ mean distance from chest wall diminished by 69.4% (p < 0.001) and from nipple by 18.2% (p < 0.001). Free microscopic margins were achieved in first operation in all patients. Conclusions Supine MRI in the surgical position is feasible and useful in the precise localisation of prone MRI-detected lesions and provides a helpful tool to implement in surgery. Supine MRI more accurately determines tumours’ size and location and might have an important role to diminish overestimations. Key Points • Breath-hold supine breast MRI is feasible using commercially available coils and sequences. • Size and area of lesions on MRI were consistently smaller when measured from the supine position as compared to the prone position. • Supine breast MRI is useful in the precise preoperative localisation of prone MRI-detected lesions. Keywords Magnetic resonance imaging/methods . Breast neoplasms/diagnosis . Breast/neoplasms/surgery . Humans Abbreviations DCIS Ductal carcinoma in situ BCS Breast-conserving surgery IDC Invasive ductal carcinoma S. Joukainen and A. Masarwah contributed equally to this work. * S. Joukainen 3 Department of Pathology, Diagnostic Imaging Centre, Kuopio [email protected] University Hospital, Puijonlaaksontie 2, 70210 Kuopio, Finland 4 Institute of Clinical Medicine, School of Medicine, Clinical 1 Department of Surgery, Division of Plastic Surgery, Kuopio Radiology, University of Eastern Finland, Yliopistonranta 1, University Hospital, Puijonlaaksontie 2, 70210 Kuopio, Finland 70210 Kuopio, Finland 5 2 Department of Clinical Radiology, Kuopio University Hospital, Cancer Center of Eastern Finland, University of Eastern Finland, Puijonlaaksontie 2, 70210 Kuopio, Finland Yliopistonranta 1, 70210 Kuopio, Finland 1436 Eur Radiol (2019) 29:1435–1443 OBCS Oncoplastic breast-conserving surgery position only, using a six-channel body array coil and volu- VIBE Volumetric interpolated breath-hold examination metric interpolated breath-hold examination (VIBE) with ac- quisition time of 20 s [7]. Carbonaro et al performed supine MRIs in 11 patients using a thoracic four-channel surface coil Introduction and VIBE with an acquisition time of 36 s [8]. Siegler et al introduced a flexible unilateral breast coil design and used Advances in our understanding of breast cancer biology and non-fat-suppressed 3D sequences with an imaging time of management have resulted in a paradigm shift towards more 85 s. Fat suppression increased imaging time from 88 s to conservative surgical treatment strategies of the disease. Breast- 190 s [9]. Gombos et al reported intraoperative supine MRI conserving surgery (BCS) with negative margins followed by using breath-hold sequences during suspended ventilation to radiotherapy and adjuvant therapy is nowadays considered the obtain high-spatial-resolution images [10]. They used a 16- standard of care for early stage breast cancer [1]. channel cardiac coil and 3D fat-suppressed imaging with a Magnetic resonance imaging (MRI) is the most sensitive scanning time of 24 s. In that study, 12 patients underwent imaging modalities for detecting breast cancer [2, 3]. Breast supine MRI after lumpectomy and only six of them had un- cancer is a heterogeneous and often multifocal disease; there- dergone presurgical supine MR imaging. fore, preoperative MRI for patients scheduled for BCS may As expected, these studies show that tumour size and loca- contain a large amount of additional information about the size, tion differ between the prone and supine position; however, shape, location and possible multifocality or multicentricity of this data has not been previously transferred in detail to the the tumour. Previous studies have shown that up to 63% of operating theatre for navigation purposes. Pallone et al per- breast cancers are multifocal, with tumour foci being found formed supine MRI with a two-element phased-array receive- more than 2 cm from the reference tumour in 43% of those only coil to segment tumours and glandular tissue and cases [4]. Intuitively, the preoperative use of MRI can help projected the tumour volume to the skin then compared it to guide the extent of surgical excision and therefore reduce reop- palpation [11]. Image-guided lesion localisation or bracketing eration rates for positive margins. is usually needed for nonpalpable lesions, yet they are per- Nevertheless, scientific evidence has consistently shown formed under mammographic or MRI guidance in positions that routine preoperative use of MRI can increase the rate of different from surgery [12, 13]. mastectomies or potentially unnecessary and extensive exci- The purpose of the present study was to prospectively eval- sions, and additionally fails to reduce the reoperation rates due uate the feasibility of preoperative supine MRI using commer- to positive margins [5, 6]. MRI is routinely performed in the cially available coils and breath-hold sequences and to create prone position, while surgery is performed with the patient accurate tools to transfer this tangible information to breast lying in the supine position. This may result in breast tumours surgeons in the operating theatre using drawing charts and being displaced or deformed secondary to changes in patient skin ink-mark projections in patients scheduled for positioning. In our opinion, the failure to show the true bene- oncoplastic breast-conserving surgery (OBCS). fits of breast MRI is not only related to the microscopic tu- mour burden but also to our inability to translate the informa- tion obtained from imaging in the prone position to surgery in the supine position. Materials and methods Supine MRI is technically challenging for two main rea- sons. Firstly, breast consistency, shape and size differ between Background patients and consequently the position of the supine breast cannot be individually predicted on the basis of prone MRI Patients from two screening centres, two district hospitals and studies alone. Therefore, in the supine position, the coils all primary health care centres within our catchment area of should be flexible so they can be adjusted to the shape of each approximately 250,000 people are referred to our tertiary uni- individual breast, avoiding breast compression at the same versity hospital for consultation and treatment. Approximately time. Secondly, chest wall movement during breathing re- 250 primary breast cancer patients are treated in our hospital quires an ultrafast sequence in order to obtain the needed annually. Prior to referral, all patients undergo a clinical breast information in one breath-hold cycle to overcome possible examination, where patients older than 30 years of age under- movement artefacts. Further challenges are related to the abil- go a minimum of a two-view mammography and whole breast ity to transfer the information obtained from imaging to the ultrasound (US). Breast MRI is not performed routinely for all surgeons in the operating theatre. patients preoperatively, but as a problem-solving ancillary ex- Thus far, reports dealing with the positioning dilemma are amination in accordance with the European Society of Breast scanty and the number of subjects is limited. Tozaki and Cancer Specialists recommendations [3]. In case additional Fukuda performed MRIs in 40 patients in the oblique supine lesions that would alter the surgical plan are found at MRI, a Eur Radiol (2019) 29:1435–1443 1437 second-look US is performed and a core biopsy obtained as MRI protocol needed. The routine MRI examination is performed in the prone posi- tion with a seven-element phased-array coil dedicated to bi- Patients lateral breast imaging (Philips Achieva 3.0-T TX, Philips). The structural prone breast MRI protocol is presented in This study was approved by the local ethics committee, and Table 1. written
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