|Year : 2017 | Volume
| Issue : 5 | Page : 175-180
Contralateral breast lesions detected by breast MRI study - An analysis of 735 Taiwanese women with primary operable breast cancer
Hung-Wen Lai1, Wan-Yu Hung2, Chih-Wei Lee3, Hwa-Koon Wu3, Shou-Tung Chen4, Dar-Ren Chen4, Chih-Jung Chen5, Shou-Jen Kuo4
1 Comprehensive Breast Cancer Center; Department of General Surgery; Department of Surgical Pathology, Changhua Christian Hospital, Changhua; School of Medicine, National Yang Ming University, Taipei, Taiwan
2 Department of General Surgery, Changhua Christian Hospital, Changhua, Taiwan
3 Department of Radiology, Changhua Christian Hospital, Changhua, Taiwan
4 Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan
5 Department of Surgical Pathology, Changhua Christian Hospital, Changhua, Taiwan
|Date of Submission||30-Apr-2017|
|Date of Decision||01-Jun-2017|
|Date of Acceptance||18-Aug-2017|
|Date of Web Publication||9-Oct-2017|
Comprehensive Breast Cancer Center, Changhua Christian Hospital, 135 Nanhsiao Street, Changhua 500
Source of Support: None, Conflict of Interest: None
Purpose: Women with unilateral breast cancer are at an increased risk for the development of contralateral breast cancers. In this study, we evaluated the incidence and pathology of contralateral breast cancer detection by preoperative magnetic resonance imaging (MRI) in Taiwanese women with primary operable breast cancer.
Methods: A retrospective review of patients who received preoperative breast MRI and underwent operation for breast cancer at single institution between January 2011 and December 2013 was conducted. The incidence, pathology, and management methods of MRI-detected contralateral breast lesions were reported and analyzed.
Results: A total of 735 patients enrolled in the current study, and 70 patients (9.5%) were found to have contralateral breast lesions detected by preoperative MRI. Among these 70 patients, 44 (62.9%) received surgical intervention for the MRI-detected contralateral occult lesions. Malignancy was detected in the final pathologic specimen in 21 (47.7%) patients, and benign lesions found in 23 (52.3%) patients. Among these 21 MRI-detected occult contralateral breast cancers, there were 7 (33.3%) invasive ductal carcinoma, 1 (4.8%) mucinous carcinoma, and 13 (61.9%) ductal carcinoma in situ. Compared with the pathology of the 735 primary operable breast cancers, MRI-detected contralateral breast cancer was associated with higher in situ carcinoma (61.9% vs. 15.9%, P < 0.01). The positive predictive value of MRI was 37.7%, eight of 28 MRI Breast Image Reporting and Data System(BI RADS)-4 cases had a pathological malignancy; nine of 17 MRI BI RADS-5 cases had a pathological malignancy.
Conclusion: In women with known unilateral breast cancer, 2.9% of patients were diagnosed to have synchronous contralateral breast cancer when combined with preoperative breast MRI evaluation. Adequate biopsy or surgical strategy should be discussed in patients whose preoperative breast MRI showed contralateral occult lesions with suspicious for malignancy.
Keywords: Breast magnetic resonance image, contralateral lesion, invasive breast cancer, synchronous contralateral breast cancer
|How to cite this article:|
Lai HW, Hung WY, Lee CW, Wu HK, Chen ST, Chen DR, Chen CJ, Kuo SJ. Contralateral breast lesions detected by breast MRI study - An analysis of 735 Taiwanese women with primary operable breast cancer. Formos J Surg 2017;50:175-80
|How to cite this URL:|
Lai HW, Hung WY, Lee CW, Wu HK, Chen ST, Chen DR, Chen CJ, Kuo SJ. Contralateral breast lesions detected by breast MRI study - An analysis of 735 Taiwanese women with primary operable breast cancer. Formos J Surg [serial online] 2017 [cited 2019 Sep 21];50:175-80. Available from: http://www.e-fjs.org/text.asp?2017/50/5/175/216240
Wan-Yu Hung and Hung-Wen Lai contributed equally with first author in this manuscript.
| Introduction|| |
Breast cancer is the most common type of cancer in women in most Western countries  and is the leading cause of cancer death in many Asian countries,, including Taiwan., Women with unilateral breast cancer are at an increased risk for the development of contralateral breast cancers, with a 1%–5% incidence of synchronous cancer and a 3%–13% incidence of metachronous cancer.,, Moreover, women with bilateral breast cancer were found to have worse prognoses than those with unilateral breast cancer. Methods to enhance early detection of synchronous contralateral breast cancer would be important for patients newly diagnosed with breast cancer.
Contrast-enhanced dynamic magnetic resonance imaging (MRI) has been shown to be a useful imaging modality for the diagnosis of breast cancer., MRI of the breast has been shown to be valuable in estimating tumor size , and been reported to have high sensitivity in detecting occult breast lesions.,, Some study reported that breast MRI can detect 3%–5% of occult tumors in the contralateral breast.,, However, data regarding the diagnostic performance of breast MRI in the evaluation of contralateral synchronous breast cancer detection of Taiwanese women with breast cancer were lacking.
In this study, we evaluated diagnostic performance of breast MRI in the detection of synchronous contralateral breast cancer in Taiwanese women with primary operable breast cancer. The incidence, pathology, and management of patients with MRI-detected contralateral occult breast lesions were analyzed and reported.
| Methods|| |
A retrospective review of patients who underwent operation for breast cancer from January 2011 to December 2013 was conducted at Changhua Christian Hospital (CCH), a tertiary medical center at Central Taiwan. Patients who diagnosed as primary operable breast cancer, received preoperative evaluation with conventional breast imaging combined with MRI, and received definite breast cancer at CCH were included. Patients who did not receive surgery because of distant metastasis or neoadjuvant chemotherapy were excluded. This study was approved by the Institutional Review Board (IRB) of CCH (CCH IRB No. 140404).
To evaluate the efficacy of preoperative breast MRI for contralateral breast tumor detection and the optimal management strategy of these detected contralateral occult lesions, patients' clinicopathological data and surgical methods were collected. Information recorded from patient charts included patient age, location of tumor, biopsy method, tumor size, lymph node status, tumor stage, tumor grade, estrogen receptor (ER) status, progesterone receptor (PR) status, and HER-2 status. The MRI images and reports were reviewed to identify whether contralateral breast lesions was detected. The subsequent biopsy result and surgical method after preoperative MRI study were reviewed. The data collection was performed by special trained study nurse (YLL) and verified by main principle investigator (HWL).
Diagnostic imaging equipment/conventional breast imaging
Patients enrolled in the current study were primary operable breast cancer patients, who had received preoperative conventional breast imaging with mammography and sonography. Standard mediolateral oblique and craniocaudal views of mammograms were obtained for all patients. Ultrasound procedures were performed with the patient in the supine position. Imaging was performed with a high-resolution 5–12 MHz linear array transducer, including color Doppler ultrasonography (Voluson 530D and 730D, Kretz Technik, Zipf, Austria). The sonography examinations were carried out by experienced, board-certified breast physicians.
Magnetic resonance imaging of study
The MRI protocol used in the current study was reported in previous studies ,, and summarized. MRI was performed with a Siemens (Verio) 3.0 Tesla magnet. All patients were imaged in the prone position with both breasts placed into a dedicated 16 channel breast coil. MRI protocols included bilateral axial turbo-spin-echo fat-suppressed T2-weighted image (retention time [TR]/echo time [TE] 4630/70 ms; field of view 320 mm; slice thickness 3 mm; number of excitations 1), axial turbo-spin-echo T1-weighted image (TR/TE 736/9.1 ms; field of view 320 mm; slice thickness 3 mm; number of excitations 1), diffusion-weighted images (TR/TE 5800/82 ms; field of view 360 mm; slice thickness 3 mm, with b values of 0, 400, and 800 sec/mm2) and measuring the ADC value.
Dynamic MRI using a three-dimensional fat-suppressed volumetric interpolated breath-hold examination sequence with parallel acquisition was obtained before and five times after the bolus injection of gadobenate dimeglumine (0.1 mmol/kg). Both breasts were examined in the transverse plane, with 60 s interval of each phase dynamic images. The dynamic MRI parameters were as follows: TR/TE 4.36/1.58 ms; field of view 320 mm; slice thickness 1 mm.
The interpretation principle for measurement of tumor size by MRI was based on using a commercially available MRI computer-aid diagnosis (CAD) system with computer-based tumor segmentation in volume rendering data set by DynaCAD Version 2.1 for Breast MRI (In vivo, Gainesville, FL, USA). For avoiding under estimate the tumor volume due to blooming effect and early periductal enhancement, the result was manipulated by experienced radiologist after computer-based tumor segmentation. The whole-breast MRI readings were carried out by experienced, board-certified breast radiologist (HKW).
All the breast imagings, including mammography, sonography, and MRI, were recorded according to the Breast Image Reporting and Data System (BI-RADS).
Data are expressed as mean ± standard deviation for continuous variables. Independent t tests were used for the comparison of continuous variables. Categorical variables were normally tested by the χ2-test when appropriate. All P values are two-tailed; a P < 0.05 was considered to indicate statistical significance. All statistical analyses were performed with SPSS 19.0 software (IBM, Armonk, NY, USA).
The study was conducted in accordance with the Declaration of Helsinki and was approved by the local ethics committee of the institute. Informed written consent was obtained from all patients prior to their enrollment in this study.
| Results|| |
According to the inclusion and exclusion criteria, a total of 735 Taiwanese women with primary operable breast cancer patients who received preoperative breast MRI and surgical treatment during January 2011 to December 2013 were selected from CCH Breast Cancer Database. The mean age of them was 52.7 ± 10.7 years, and mean tumor size 2.3 ± 1.6 cm. Most of them were early-stage breast cancer, with stage 0 (15.9%), stage I (32.7%), stage II (41.1%), stage III (9.9%), and stage IV (0.4%). The clinicopathological characteristics of these 735 patients are summarized in [Table 1].
|Table 1: Clinicopathologic characteristics of patients and tumors (n=735)|
Click here to view
Among the 735 primary operable breast cancer patients, 70 patients (9.5%) were found to have contralateral breast lesions detected by breast MRI. Thirty-nine (55.7%) patients underwent preoperative biopsy for the MRI-detected contralateral lesion before surgery. Seventeen patients received core needle biopsy with second-look ultrasound, and MRI-guided wire localization in 16 patients. Among these 39 patients who received biopsy, malignancy was diagnosed by biopsy in 17 (43.6%) patients and benign lesions were diagnosed in 22 (56.4%) patients. The flowchart of patients with MRI-detected contralateral breast lesions is illustrated in [Figure 1].
|Figure 1: Flowchart presented 735 primary operable breast cancer patients with preoperative breast magnetic resonance imaging and received surgery. Magnetic resonance imaging detected 70 (9.5%) synchronous contralateral lesions in 735 patients, and 21 (30%) of them were proved to be malignancy|
Click here to view
Among these 70 patients, 44 (62.9%) received surgical intervention for the MRI-detected contralateral occult lesions, and 26 (37.1%) patients did not receive operation. Malignancy was diagnosed in 21 patients in surgical specimen, and benign lesions found in 23 patients. Among these 21 MRI-detected occult contralateral breast cancers, there were 7 (33.3%) invasive ductal carcinoma, 1 (4.8%) mucinous carcinoma, and 13 (61.9%) ductal carcinoma in situ. The positive predictive value of MRI was 37.7%, eight of 28 MRI Breast Image Reporting and Data System(BI RADS)-4 cases had a pathological malignancy; nine of 17 MRI BI RADS-5 cases had a pathological malignancy. The pathology of the MRI detected breast lesions is summarized in [Table 2].
|Table 2: Pathologic result of surgical excised 44 contralateral lesion detected on preoperative breast magnetic resonance imaging|
Click here to view
Twenty-one (2.9%) out of 735 patients were diagnosed to have synchronous contralateral breast cancer when combined with preoperative breast MRI evaluation. Compared with the pathology of the 735 primary operable breast cancers, MRI-detected synchronous contralateral breast cancers were associated with higher incidence of in situ carcinoma (61.9% vs. 15.9%, P < 0.01). [Figure 2] showed examples of patients diagnosed with synchronous contralateral breast cancer who received bilateral breast conserving surgeries or bilateral nipple sparing mastectomy with immediate breast reconstruction.
|Figure 2: (a) A 75-year-old patient was core needle biopsy diagnosed with left breast infiltrating ductal carcinoma primarily but the contralateral lesion was found via magnetic resonance imaging. She underwent a magnetic resonance imaging guide wire localized wide excision for right breast lesion and the final pathology proved the infiltrating ductal carcinoma. (b) A 49-year-old patient was pathological diagnosed of infiltrating ductal carcinoma of right breast and the contralateral lesion was found via magnetic resonance imaging. The second look sonography with core needle biopsy was performed, final pathology confirmed infiltrating ductal carcinoma. According to her family history of breast cancer, she received bilateral nipple-sparing mastectomy with immediate breast reconstruction. The postoperative recovery was smooth|
Click here to view
| Discussion|| |
To evaluate the efficacy of breast MRI in the detection of synchronous contralateral breast cancer, we enrolled 735 primary operable breast cancer patients with preoperative breast MRI and received surgery in single institution. MRI detected 70 (9.5%) synchronous contralateral lesions in 735 patients, and 21 (30%) of them were proved to be malignancy. Compared with the pathology of the 735 primary operable breast cancers, MRI-detected contralateral breast cancers were associated with higher in situ carcinoma rate (61.9% vs. 15.9%, P < 0.01). These findings supported that breast MRI is a highly sensitive imaging tool, which is useful for preoperative evaluation of breast cancer.
In the current study, we found that, with the adding of breast MRI to conventional imaging studies, synchronous contralateral breast cancer was 2.9% (21/735), which was similar to previous literature reported 3%–5% synchronous breast cancer rate in Western countries.,, Compared to our previous study cohort, which had 1.1% (8/733) synchronous contralateral breast cancer rate in patients received conventional breast imaging (mammography and sonography) alone, combined breast MRI had superior synchronous contralateral breast cancer detection rate (2.9% vs. 1.1%, P < 0.01). Moreover, one could speculate that adding breast MRI would increase about 1.8% of synchronous contralateral breast cancer detection rate than using conventional breast imaging alone.
In Houssami's study  for the evaluation of the contralateral breast cancer detection by preoperative MRI, the incidence of suspicious MRI findings was estimated to be 9.3%, with a PPV of 48% and a false positive rate of 52%. In our current study, MRI detected 70 (9.5%) contralateral lesions in 735 patients, and 21 of them were proved to be malignancy. The PPV of the RI-detected contralateral lesion in our study was therefore 37.7%, which is compatible to other reports.
The detection of additional abnormal enhancing lesions in breast MRI might be “problematic” for subsequent patient management. The false positive rate for the additional lesion is high as observed in our current study; around 70% of the so-called “occult contralateral breast lesion” would prove to be benign neoplasms after surgical excision [Figure 1]. As shown in [Table 2], 52.3% of the 44 surgical excised suspicious lesions were found to be benign neoplasms, and most of them were fibroadenomas (34.5%) and fibrocystic change (43.5%).
Sometimes, it is confusing whether these lesions should be ignored, followed up, or referred for biopsy.,, In addition, the image-guided biopsy before surgery is increasing when breast MRI was incorporated in the preoperative evaluation., As showed in our [Figure 1], 39 of the 70 patients with MRI-detected occult synchronous contralateral lesions received preoperative biopsy. Biopsy results of proliferative lesion-like papilloma or atypia of the synchronous contralateral lesions were suggested to be excised at the same time when primary breast cancer operation is performed. As one of our patients had papilloma core needle biopsy for the contralateral breast lesion, ductal carcinoma in situ arising from papilloma was diagnosed in the final lumpectomy specimen.
Our study was limited due to its retrospective nature and possible selection bias. Patients with contralateral occult lesions detected by MRI did not receive surgical excision in every case to confirm the nature of the lesion. This might, therefore, underestimate the actual synchronous breast cancer rate or increase the false positive rate of breast MRI. Furthermore, we did not provide how many cases of contralateral malignancy could be detected by conventional breast imaging alone in the enrolled 735 patients. We did not clearly demonstrate that the adding of breast MRI would result in how many additional synchronous contralateral cancer cases being diagnosed. The 1.8% increase for detection of synchronous contralateral breast cancer detection was a rough estimation based on two different patients' cohort. However, we did collected 735 primary operable breast cancer patients with preoperative breast MRI and received surgical intervention at single institution with detailed pathologic report, which enable us to complete the current study. The result obtained from our study could reflect the synchronous breast cancer rate of Taiwanese women with breast cancer was 2.9%, which was higher than expected from previous reported series, which did not include breast MRI as preoperative imaging evaluation.
| Conclusion|| |
The risk of synchronous contralateral breast cancer, 2.9% incidence in the current study, should be kept in mind for preoperative evaluation of primary operable breast cancer patients. Biopsy procedure for tissue diagnosis or surgical strategy discussed with patients is warranted if suspicious synchronous contralateral lesion been detected by conventional imaging or breast MRI.
We would like to thank Ya-Ling Lin for the assistance in this study.
Financial support and sponsorship
This study was sponsored by research funding provided by the Changhua Christian Hospital (105-CCH-IRP-087 and 104-CCH-ICO-006).
Conflicts of interest
There are no conflicts of interest.
| References|| |
Jemal A, Siegel R, Ward E, Murray T, Xu J, Smigal C, et al.
Cancer statistics, 2006. CA Cancer J Clin 2006;56:106-30.
Shin HR, Boniol M, Joubert C, Hery C, Haukka J, Autier P, et al.
Secular trends in breast cancer mortality in five East Asian populations: Hong Kong, Japan, Korea, Singapore and Taiwan. Cancer Sci 2010;101:1241-6.
Leong SP, Shen ZZ, Liu TJ, Agarwal G, Tajima T, Paik NS, et al.
Is breast cancer the same disease in Asian and Western countries? World J Surg 2010;34:2308-24.
Lin CH, Chen YC, Chiang CJ, Lu YS, Kuo KT, Huang CS, et al.
The emerging epidemic of estrogen-related cancers in young women in a developing Asian country. Int J Cancer 2012;130:2629-37.
Lehman CD, Gatsonis C, Kuhl CK, Hendrick RE, Pisano ED, Hanna L, et al.
MRI evaluation of the contralateral breast in women with recently diagnosed breast cancer. N
Engl J Med 2007;356:1295-303.
Plana MN, Carreira C, Muriel A, Chiva M, Abraira V, Emparanza JI, et al.
Magnetic resonance imaging in the preoperative assessment of patients with primary breast cancer: Systematic review of diagnostic accuracy and meta-analysis. Eur Radiol 2012;22:26-38.
Houssami N, Ciatto S, Macaskill P, Lord SJ, Warren RM, Dixon JM, et al.
Accuracy and surgical impact of magnetic resonance imaging in breast cancer staging: Systematic review and meta-analysis in detection of multifocal and multicentric cancer. J Clin Oncol 2008;26:3248-58.
Heywang SH, Wolf A, Pruss E, Hilbertz T, Eiermann W, Permanetter W. MR imaging of the breast with Gd-DTPA: Use and limitations. Radiology 1989;171:95-103.
Heywang SH, Fenzl G, Beck R, Hahn D, Eiermann W, Permanetter W, et al.
Use of Gd-DTPA in the nuclear magnetic resonance study of the breast. Rofo 1986;145:565-71.
Gruber IV, Rueckert M, Kagan KO, Staebler A, Siegmann KC, Hartkopf A, et al.
Measurement of tumour size with mammography, sonography and magnetic resonance imaging as compared to histological tumour size in primary breast cancer. BMC Cancer 2013;13:328.
Lai HW, Chen DR, Wu YC, Chen CJ, Lee CW, Kuo SJ, et al.
Comparison of the diagnostic accuracy of magnetic resonance imaging with sonography in the prediction of breast cancer tumor size: A concordance analysis with histopathologically determined tumor size. Ann Surg Oncol 2015;22:3816-23.
Orel SG, Schnall MD, Newman RW, Powell CM, Torosian MH, Rosato EF. MR imaging-guided localization and biopsy of breast lesions: Initial experience. Radiology 1994;193:97-102.
Lai HW, Chen CJ, Lin YJ, Chen SL, Wu HK, Wu YT, et al.
Does breast magnetic resonance imaging combined with conventional imaging modalities decrease the rates of surgical margin involvement and reoperation? A case-control comparative analysis. Medicine (Baltimore) 2016;95:e3810.
Lee CW, Wu HK, Lai HW, Wu WP, Chen ST, Chen DR, et al.
Preoperative clinicopathologic factors and breast magnetic resonance imaging features can predict ductal carcinoma in situ
with invasive components. Eur J Radiol 2016;85:780-9.
American College of Radiology. Breast Imaging Reporting and Data System (BI-RADS ®
ed. Reston, VA: American College of Radiology, 2003.
Brennan ME, Houssami N, Lord S, Macaskill P, Irwig L, Dixon JM, et al.
Magnetic resonance imaging screening of the contralateral breast in women with newly diagnosed breast cancer: Systematic review and meta-analysis of incremental cancer detection and impact on surgical management. J Clin Oncol 2009;27:5640-9.
Kuo WH, Yen AM, Lee PH, Hou MF, Chen SC, Chen KM, et al.
Incidence and risk factors associated with bilateral breast cancer in area with early age diagnosis but low incidence of primary breast cancer: Analysis of 10-year longitudinal cohort in Taiwan. Breast Cancer Res Treat 2006;99:221-8.
[Figure 1], [Figure 2]
[Table 1], [Table 2]