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Breast

E3: MRI to predict upstaging of DCIS to invasive cancer at the time of surgery

Introduction: Ductal carcinoma in situ (DCIS) is a pre-invasive breast cancer that is generally overtreated due to imprecise risk stratification. Clinical trials offering surveillance for “low-risk” DCIS are limited by the fact that one quarter of DCIS cases upstage at excision, raising the potential for undertreatment. Contrast-enhanced MRI is highly sensitive in the detection of breast cancer. We aimed to determine if quantitative MRI markers from contrast-enhanced MRI can identify DCIS at risk of upstaging to invasive cancer.

Methods: Prospective observational clinical trial of women diagnosed with DCIS on image-guided biopsy. All participants underwent 3T MRI. Quantitative MRI features included signal enhancement ratio (SER) and peak percent enhancement (PE), measured from routine dynamic contrast-enhanced (DCE) MR images, and Ktrans (marker of vascular permeability) measured from advanced high temporal resolution DCE MR images. Clinical, pathologic, and mammographic features were obtained from the medical record. Univariable associations with upstaging were summarized using the area under the receiver operating characteristic curve (AUC). P-values were adjusted for multiple testing. Logistic regression was used for multivariate analyses.  

Results: Of 58 DCIS lesions, 15 (26%) upstaged to invasive cancer at surgery. Forty-six of 58 lesions (79%) enhanced on MRI, though enhancement alone was not significantly associated with upstaging (p = 0.42). Among enhancing lesions, peak PE (AUC = 0.81, adj. p</span> = 0.009) and Ktrans (AUC: 0.76, adj. p = 0.034) were significantly associated with upstaging (Figure 1). Both MRI markers were correlated with each other (r = 0.70) and combining markers did not significantly improve prediction of upstaging. Both markers remained significantly associated with upstaging at surgery after adjusting for lesion size (p < 0.016 for both). None of the clinical, pathologic, or mammographic features were significantly predictive of upstaging (p > 0.24 for all), while peak PE (p < 0.007), and Ktrans (p < 0.016) remained significantly predictive of upstaging on multivariate analysis. 

Conclusions: Peak PE, measured on routine breast MRI, and the advanced DCE-MRI marker Ktrans demonstrated good performance in identifying which patients with DCIS on CNB upstage to invasive cancer at excision. These features may prove valuable for appropriate selection of active surveillance in future DCIS de-escalation trials. 

Learning Objectives:

  • Identify features on routine breast MRI that identify DCIS at risk of upstaging to invasive cancer.
  • better understand the potential for over treatment of DCIS.
  • consider the role of surveillance for "low risk" DCIS.