Impact of preoperative staging with contrast-enhanced mammography for localized breast cancer management

Abstract

Objective: A precise evaluation of the disease extent is mandatory before surgery for early breast cancer (EBC). Contrast-enhanced mammography (CEDM) is a recent technique that may help define adequate surgery.

Methods: This retrospective study included consecutive patients referred to a cancer center between November 2016 and July 2017 for biopsy-confirmed invasive EBC management. The primary objective was to evaluate the rate of surgical changes after incorporating the results of the preoperative staging examination, including CEDM.

Results: A total of 231 patients were screened for inclusion, and 132 patients were included, corresponding to 134 lesions. The first surgical plan was modified for 33 patients (25%), which represented 34 lesions. For 8 patients (6%), the surgery was cancelled in preference for neoadjuvant chemotherapy; for 16 patients (12.1%), the primary tumor procedure was enlarged; and for 23 patients (17.4%) the lymph node management was modified. Surgery was changed only due to the CEDM results for 24 patients (18.5%) and consisted of a more invasive procedure due to a more extended, multifocal or multicentric lesion than seen on the standard imaging. Anatomopathological surgery piece findings were well correlated with contrast-enhanced mammography results. Overall, there was no increase in the delay between the planned date of surgery and the effective surgical procedure (median 0 days).

Conclusion: CEDM added to preoperative staging helped define better surgical management without increasing delay in the surgical procedure.

Advances in knowledge: CEDM is a reliable technique that should be considered as part of preoperative staging for EBC.

Figure 1.

Patients management when referred to our center for an ACR6 lesion

Figure 2.

– Algorithm for management of additional enhancement on CEDM

Figure 3.

Flowchart of patient enrollment

Figure 4.

A 43-year-old patient referred to the center for an invasive ductal carcinoma, grade II, evaluated at 10 mm in primary care. Contrast enhanced mammography performed in the center. (A) Low-energy images: C density, no microcalcifications focus, in the left breast an increased opacity in the suprainternal quadrant, para-areolar. (B)Recombined images corresponding, moderate background enhancement, nodular enhancement retro-areolar in the suprainternal quadrant of the left breast, extended over 43 mm in a transversal axis. (C) Recombined images only of the pathological left breast. The enhancement extends over a height of 56 mm, so additional biopsies were suggested. The patient refused additional biopsies and preferred a mastectomy immediately. On the anatomopathological evaluation, there was a grade II invasive ductal carcinoma on a 1.5 mm focus associated with extension of an in situ ductal carcinoma over 50 mm.