Radiologic complete response (rCR) in contrast-enhanced magnetic resonance imaging (CE-MRI) after neoadjuvant chemotherapy for early breast cancer predicts recurrence-free survival but not pathologic complete response (pCR)

Abstract

Background: Patients with early breast cancer (EBC) achieving pathologic complete response (pCR) after neoadjuvant chemotherapy (NACT) have a favorable prognosis. Breast surgery might be avoided in patients in whom the presence of residual tumor can be ruled out with high confidence. Here, we investigated the diagnostic accuracy of contrast-enhanced MRI (CE-MRI) in predicting pCR and long-term outcome after NACT.

Methods: Patients with EBC, including patients with locally advanced disease, who had undergone CE-MRI after NACT, were retrospectively analyzed (n = 246). Three radiologists, blinded to clinicopathologic data, reevaluated all MRI scans regarding to the absence (radiologic complete remission; rCR) or presence (no-rCR) of residual contrast enhancement. Clinical and pathologic responses were compared categorically using Cohen's kappa statistic. The Kaplan-Meier method was used to estimate recurrence-free survival (RFS) and overall survival (OS).

Results: Overall rCR and pCR (no invasive tumor in the breast and axilla (ypT0/is N0)) rates were 45% (111/246) and 29% (71/246), respectively. Only 48% (53/111; 95% CI 38-57%) of rCR corresponded to a pCR (= positive predictive value - PPV). Conversely, in 87% (117/135; 95% CI 79-92%) of patients, residual tumor observed on MRI was pathologically confirmed (= negative predictive value - NPV). Sensitivity to detect a pCR was 75% (53/71; 95% CI 63-84%), while specificity to detect residual tumor and accuracy were 67% (117/175; 95% CI 59-74%) and 69% (170/246; 95% CI 63-75%), respectively. The PPV was significantly lower in hormone-receptor (HR)-positive compared to HR-negative tumors (17/52 = 33% vs. 36/59 = 61%; P = 0.004). The concordance between rCR and pCR was low (Cohen's kappa - 0.1), however in multivariate analysis both assessments were significantly associated with RFS (rCR P = 0.037; pCR P = 0.033) and OS (rCR P = 0.033; pCR P = 0.043).

Conclusion: Preoperative CE-MRI did not accurately predict pCR after NACT for EBC, especially not in HR-positive tumors. However, rCR was strongly associated with favorable RFS and OS.

Keywords: Breast cancer; MRI; Neoadjuvant chemotherapy; Prediction of complete pathologic response; Survival.

Fig. 1

Flow diagram. NACT, neoadjuvant chemotherapy; MRI, magnetic resonance imaging; CE-MRI, contrast-enhanced magnetic resonance imaging; pCR, pathologic complete response

Fig. 2

Cross-tabulation with numbers and percentages (in brackets) for radiologic complete response (rCR)/no rCR and pathologic complete response (pCR)/no pCR for the whole cohort

Fig. 3

Cross-tabulation with numbers and percentages (in brackets) for radiologic complete response (rCR)/no rCR and pathologic complete response (pCR)/no pCR for breast cancer subtypes

Fig. 4

Kaplan-Meier curves for recurrence-free survival according to pathologic complete response (pCR) (a) and radiologic complete response (rCR) (b) after neoadjuvant chemotherapy

Fig. 5

Kaplan-Meier curves for recurrence-free survival (RFS) (a) and oveall survival (OS) (b) according to pathologic complete response (pCR) and radiologic complete response (rCR), respectively. Patients achieving both pCR and rCR (n = 53) had an excellent prognosis for both RFS (1 event) and overall survival (0 events). Patients achieving a pCR but no rCR (n = 18) had a significantly higher risk of recurrence (4 events), but not of death (1 event)

Fig. 6

Kaplan-Meier curves for recurrence-free survival (a) and overall survival (b) according to radiologic response. rCR, radiologic complete response; rPR, radiologic partial response; rSD, radiologic stable disease; rPD, radiologic progressive disease