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Impact of MRI-Evaluated Neoadjuvant Chemotherapy Response on Change of Surgical Recommendation in Breast Cancer

Chen, Jeon-Hor MD*†; Feig, Byron A. BS*; Hsiang, David J-B MD‡; Butler, John A. MD‡; Mehta, Rita S. MD§; Bahri, Shadfar MD*; Nalcioglu, Orhan PhD*; Su, Min-Ying PhD*

doi: 10.1097/SLA.0b013e31819a6e01
Original Articles

Objective: To investigate how MRI imaging of neoadjuvant chemotherapy (NAC) tumor response affects the recommendation for optimal breast cancer surgery, both before and after NAC.

Summary Background Data: Understanding how imaging findings are incorporated into surgeons' decision-making processes will help establish appropriate imaging guidelines for recommending breast conservation surgery (BCS) after the NAC.

Methods: Seventy-six breast cancer patients undergoing NAC with MRI follow-up studies were analyzed. Two experienced breast surgeons reviewed all cases. An initial surgical recommendation was made based on the pre-NAC lesion presentation; a subsequent surgical recommendation was made based on the post-NAC tumor response. Finally, the pathology results were disclosed and the surgeons were asked to decide on the optimal definitive surgical procedure. MRI findings throughout the entire course of the NAC were analyzed to understand how they affected different recommendations.

Results: Before the NAC, a large tumor size or extent of disease were the primary determinant factors for mastectomy. In this study, the mean tumor size was 5.3 ± 3.4 cm (RECIST) in the mastectomy group and 3.2 ± 1.6 cm in the lumpectomy group (P = 0.0001). After the NAC, based on consensus recommendations, 21 mastectomy candidates remained for mastectomy, with tumor size decreasing from 7.4 ± 4.5 to 1.5 ± 2.5 cm, and 22 mastectomy candidates were changed to lumpectomy, with tumor size decreasing from 4.2 ± 2.1 to 0.4 ± 0.6 cm. When the final pathology revealed pCR or minimal residual disease, the surgeons agreed that BCS is the optimal procedure. On the other hand, for a large extent of residual disease, mastectomy should be performed.

Conclusion: In patients who had more extensive pretreatment disease, despite an excellent response to NAC, the surgeons still tended to apply an aggressive approach and recommended mastectomy. Given that the confirmation of pCR or minimal residual disease would change surgeons' recommendations for less aggressive, conservation surgery, the maturity of MRI for NAC response prediction may provide reliable staging information to aid in the recommendation of the optimal surgical procedure.

This study investigated how breast MR imaging findings are incorporated into surgeons' decision-making processes in recommending the type of surgery for breast cancer patients receiving neoadjuvant chemotherapy. Surgeons agree that patients achieving pCR or near pCR can receive conservation surgery in spite of the large pre-NAC disease extent, thus the maturity of MRI for NAC response prediction may provide helpful information to aid in the recommendation of the optimal surgical procedure.

From the *Tu and Yuen Center for Functional Onco-Imaging, University of California, Irvine, California; †Department of Radiology, China Medical University Hospital, Taichung, Taiwan; ‡Department of Surgery, University of California Irvine, California; and the §Department of Medicine, University of California Irvine, California.

This study was supported in part by NIH/NCI R01 CA90437, CA127927 and California Breast Cancer Research Program # 9WB-0020.

Corresponding Author: Min-Ying Su, PhD, Tu and Yuen Center for Functional Onco-Imaging, Irvine Hall 164, University of California, Irvine, CA 92697-5020, Tel: (949) 824-4925, Fax: (949) 824-3481, E-mail: msu@uci.edu.

© 2009 Lippincott Williams & Wilkins, Inc.