Dr. Julie Barone

Breast MRI and APBI Patient Selection

Increasing numbers of physicians are using preoperative breast MRI for women with early-stage breast cancer who want to pursue breast conservation therapy. Proponents of preoperative MRI say the additional imaging improves surgical planning and reduces re-excision rates. Opponents argue that it increases cost and leads to more extensive surgery without necessarily leading to better surgical outcomes.

This month, breast surgeon Julie Barone, D.O. of Oncology Associates of San Diego and Comprehensive Breast Care of San Diego explains her views on preoperative breast MRI – and why she wouldn’t recommend APBI without one.

Q: In your opinion, what role should breast MRI play in the patient selection process for APBI?

I do not recommend partial breast irradiation without a preoperative breast MRI. It is an important tool to rule out additional lesions that might not be visible on conventional imaging, which would be a contraindication for APBI.

I obtain a preoperative MRI on nearly all my breast cancer patients to rule out multicentric and contralateral disease. Breast MRI is a reliable modality that enables us to look at perfusion within the breast tissue. Without an MRI, additional occult disease could be missed. Additionally, MRI is helpful for postoperative planning of adjuvant treatment. Knowing that a patient is a potential candidate for APBI preoperatively aids in surgical planning so that the surgeon can re-approximate the cavity accordingly.

There are physicians who oppose the use of MRI for preoperative planning for a variety of reasons. Some say it increases cost, leads to more biopsies, and creates unnecessary fear in patients. In my opinion, breast MRI is an integral part of multidisciplinary care. For many patients, the information provided by the MRI may change surgical treatment. Every patient deserves a complete preoperative workup, allowing them to make an informed decision.

Q: Are there cases in which you would not recommend a preoperative MRI for a breast cancer patient?

There are several reasons for not sending a patient for an MRI – if it won’t change the treatment plan, if it causes an unsafe delay in surgery or the patient has a contraindication for MRI such as body habitus or metal implants. For instance, if a patient has already decided to have a mastectomy, the results of an MRI would not change the course of treatment. Sometimes an MRI will cause a significant delay in treatment, such as awaiting authorization for Medi-Cal patients, in which case we would likely forego the additional imaging.

Q: Research indicates up to 14% of patients initially deemed eligible for APBI were later found to be ineligible based on MRI findings. Have you observed a similar proportion?

In my practice, 15% of patients who receive a preoperative breast MRI have a change in their surgical treatment based on the MRI findings, which ultimately affects adjuvant treatments such as radiation. Either we discover they have multifocal disease, which requires a wider excision and makes them ineligible for APBI, or they have multicentric disease, which changes the surgical management from lumpectomy to mastectomy.

Q: Do you think preoperative MRI causes more women to choose mastectomy over BCT out of fear, as some studies suggest?

I believe the increase in mastectomy rates is not due to breast MRI itself, but rather the fact that patients have more options and women are very knowledgeable these days. Breast reconstruction techniques have improved significantly over time, so some patients would rather choose that route as opposed to undergoing breast conservation with a lumpectomy and radiation therapy.

In addition, MRI enables physicians to diagnose more multicentric disease, for which a mastectomy is the standard of care. While MRI has diagnosed more cases of multicentric disease, subsequently resulting in mastectomy, those mastectomies are medically indicated – it’s not necessarily something women are just choosing out of fear.

Q: Is there a particular imaging modality you find most useful for APBI patient selection?

Breast MRI is useful prior to surgery by ruling out multicentric or multifocal disease, which helps identify potential candidates for APBI and enables me to plan the lumpectomy accordingly.

Post-operatively, if the pathology report indicates a patient meets all criteria for APBI – negative nodes, unifocal tumor, clear margins, and appropriate tumor size – I then perform an ultrasound to determine the distance between the lumpectomy cavity and the skin, as well as to measure the cavity to determine the appropriate device size. At that point, the patient will follow up with the radiation oncologist who will complete the planning for partial breast irradiation.

Again, it’s all about the team approach to APBI. The patient has to want the treatment and understand its benefits and limitations compared to other radiation treatments before committing to APBI. The radiation oncologist and surgeon must coordinate the care together. This team approach is the best way to deliver the highest quality care and ensure that APBI is used safely and effectively.

What’s your opinion on preoperative breast MRI for early-stage breast cancer patients? Email jlandon@ciannamedical.com.

Dr. Julie Barone has been a Clinical Investigator for Sharp Clinical Oncology Research since 2007. In May 2009, Dr. Barone founded Comprehensive Breast Care of San Diego – a division of Oncology Associates of San Diego – which is the first program in California to receive the prestigious accreditation by the National Accreditation Program for Breast Centers (NAPBC.) Visit http://oncologysandiego.com for more information.