1. Role of MRI in Breast Cancer Angela Kong Princess Margaret Hospital

2.  Introduction  Role of MRI  breast cancer screening  preoperative newly diagnosed breast cancer  Response after Neoadjuvant chemotherapy  Summary/ Conclusion Objective

3.  MRI breast – increasingly popular breast imaging  Contrast agent: Gandolinium  Typical rapid enhancement and washout of contrast Introduction

4.  Guidelines of major groups recommend annual screening of selected patients with mammography and breast MRI  BRCA mutation carriers  Untested first-degree relatives of BRCA mutation carriers  Lifetime risk of Ca breast >20-25% National Comprehensive Cancer Network (NCCN)/ACG guidelines American Cancer Society Guidelines American College of Radiology Recommendations MRI in breast cancer screening

5.  MRI has a higher sensitivity than MMG in BRCA mutations  Sensitivity in MMG is lower in young patients with dense breast tissue  BRCA associated breast tumours have distinct histology  “benign” features on MMG/USG MRI in breast cancer screening Mass with a pushing margin Mass with a spiculated border

6.  Can MRI screening in high risk group improve their outcome? MRI in breast cancer screening  No significant difference between MRI and MMG screened group  MRI significant has survival benefit compared to non screened group (P<0.002) MRI breast screening in high-risk women: cancer detection and survival analysis. Breast Cancer Res Treat. 2014 Jun MRI screenedMMG screenedNo screening 10 year survival95.3%87.7%73%

7.  Key Message:  MRI screening is indicated in high risks population due to higher sensitivity  Long term survival benefit was unclear

8. Preoperative staging with MRI

9. : Long term: ↓ Ipsilateral breast recurrence ↑Survival Short term: ↓ Re-excision rate Higher sensitivity Preoperative staging with MRI

10. YearStudy design nMRI group Non MRI group P value COMICE2010RCT162519% 0.77 MONET2011RCT41834%12%0.008 Houssami2013Meta- analysis 311211.6%11.4%0.87 Preoperative MRI on short term outcome  Evidence on MRI effect on surgical re-excision rate  NO significance difference in terms of the rate of re-excision  One study showed paradoxically MRI had increased the re-excision rate

11. YearStudy design nMRI group Non MRI group P value MONET2011RCT41811%14%o.49 Houssami2013Meta- analysis 311225.5%18.20.001 Preoperative MRI on short term outcome  Evidence on MRI effect on overall mastectomy rate  One study showed increase in mastectomy rate

12.  Key message:  MRI does not reduce the re-excision rate  Potential increase in mastectomy rate without lowering the local recurrence and improving survival  Routine use is not recommended

13. MRI following neoadjuvant therapy

14.  Monitor of response:  Clinical exam  MMG  USG  ? MRI MRI following neoadjuvant therapy

15.  MRI has improved accuracy than MMG  Can accurately detects residual tumour or complete pathology response Meta-Analysis of Magnetic Resonance Imaging in Detecting Residual Breast Cancer After Neoadjuvant Therapy. J Natl Cancer Inst. 2013 Mar 6;105(5):321-33 MRI following neoadjuvant therapy No. of studiesDiagnostic odd ratio P value MRI VS clinical110.530.1 MRI VS USG100.540.15 MRI VS MMG70.270.02

16.  Key message:  MRI is helpful to monitor treatment response after chemotherapy  No evidence on effect on surgical management MRI following neoadjuvant therapy

17.  MRI breast is recommended:  High risk group as screening  Breast cancer patients who undergo neoadjuvant chemotherapy  Routine use not indicated  More evidence needed to assess long term outcome Conclusion

18. Thank you