Overdiagnosis by breast MRI Francesco Sardanelli Main ... - Geyseco
Overdiagnosis by breast MRI Francesco Sardanelli Main ... - Geyseco
Overdiagnosis by breast MRI Francesco Sardanelli Main ... - Geyseco
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<strong>Overdiagnosis</strong> <strong>by</strong> <strong>breast</strong> <strong>MRI</strong><br />
<strong>Francesco</strong> <strong>Sardanelli</strong><br />
<strong>Main</strong> objective. To illustrate the potential for overdiagnosis due to <strong>breast</strong> <strong>MRI</strong>.<br />
Discussion. <strong>Overdiagnosis</strong> should be considered for <strong>MRI</strong> indications in which lesions are diagnosed which<br />
would have been undetected using only conventional imaging (mammography and/or ultrasound). This is<br />
intrinsically associated with <strong>MRI</strong> screening, recommended for high-risk women. However, high-risk cohort<br />
studies showed early stage of <strong>MRI</strong>-diagnosed cancers with a high rate of negative nodal status (1-6), which<br />
plays in favor of an outcome effect (using assumptions derived from mammographic screening in the<br />
general female population). On the other hand, the relatively higher probability of triple negative cancers in<br />
these women (in particular BRCA1 mutation carriers) should be taken also into account. Meta-analyses<br />
showed that the risk of overdiagnosis is more important for preoperative <strong>MRI</strong> which changes 16.6% of<br />
surgical treatments: 9.2% increase of mastectomies due to 8.1% for true positives plus 1.1% for false<br />
positives; 7.4% wider/additional excisions due to 3.0% plus 4.4%, respectively (7). Moreover, p<strong>MRI</strong> yields a<br />
4.1% incremental detection rate of contralateral cancers (positive predictive value 48%); 35% DCIS and 65%<br />
invasive (mainly node negative) (8). To reduce overtreatment, we need needle imaging-guided needle<br />
sampling (including <strong>MRI</strong> guidance), reaching 13% of <strong>MRI</strong>-induced correct changes of surgical planning, to be<br />
compared with only about 1% annual risk of recurrences (but also with 20-40% rate of positive surgical<br />
margins). For contralateral cancers, needle biopsy can also reduce overtreatment, allowing to excise<br />
contralateral cancers with simultaneous conservative surgery in 4% of the women, to be compared with<br />
only 0.5-1% annual risk for contralateral cancer (9). A smart way to deal with <strong>MRI</strong> additional findings in the<br />
preoperative setting has been recently proposed: to ignore <strong>MRI</strong>-only findings distant from the index lesions<br />
when they cannot be detected <strong>by</strong> second look sonography which allows for needle sampling (10, 11).<br />
Preoperative <strong>MRI</strong> has also been shown to detect extensive intraductal component, but with 11-28%<br />
overestimate and 17-28% underestimate (4). Finally we should take into account that two recent<br />
randomized controlled trials failed to demonstrate advantages from preoperative <strong>MRI</strong> in terms of<br />
significantly reduced rate of reoperation for cancer involvement of surgical margins at pathology (12, 13).<br />
Even though relevant criticisms can be raised about these two trials, these results should be considered.<br />
Radiologists should be aware that the use of preoperative <strong>MRI</strong> implies a not negligible risk of overdiagnosis<br />
and overtreatment. A strict and effective relation between radiologists and surgeons is a key point in this<br />
setting.<br />
References<br />
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2. Saslow D, Boetes C, Burke W, et al; American Cancer Society Breast Cancer Advisory Group. American Cancer<br />
Society guidelines for <strong>breast</strong> screening with <strong>MRI</strong> as an adjunct to mammography. CA Cancer J Clin 2007;57(2):75-<br />
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EUSOMA working group. Eur J Cancer 2010;46(8):1296-316.<br />
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for women at elevated familial risk of <strong>breast</strong> cancer: the EVA trial. J Clin Oncol 2010;28(9):1450-7.<br />
6. <strong>Sardanelli</strong> F, Podo F, Santoro F, et al; High Breast Cancer Risk Italian 1 (HIBCRIT-1) Study. Multicenter surveillance<br />
of women at high genetic <strong>breast</strong> cancer risk using mammography, ultrasonography, and contrast-enhanced<br />
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women with newly diagnosed <strong>breast</strong> cancer: systematic review and meta-analysis of incremental cancer detection<br />
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Breast 2010 ;19(1):3-6.<br />
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<strong>MRI</strong> in patients eligible for <strong>breast</strong> conserving therapy. Breast Cancer Res Treat 2010;124(3):707-15<br />
11. <strong>Sardanelli</strong> F. Additional findings at preoperative <strong>MRI</strong>: a simple golden rule for a complex problem? Breast Cancer<br />
Res Treat 2010;124(3):717-21.<br />
12. Turnbull L, Brown S, Harvey I, et al. Comparative effectiveness of <strong>MRI</strong> in <strong>breast</strong> cancer (COMICE) trial: a<br />
randomised controlled trial. Lancet 2010;375(9714):563-71.<br />
13. Peters NH, van Esser S, van den Bosch MA, et al. Preoperative <strong>MRI</strong> and surgical management in patients with<br />
nonpalpable <strong>breast</strong> cancer: The MONET - Randomised controlled trial. Eur J Cancer 2011;47(6):879-86.