Assisting Community-Based Oncologists and Surgeons in Making Neoadjuvant Treatment Decisions for Patients with Early Breast CancerMRI in patients receiving neoadjuvant treatment
2:53 minutes.
TRANSCRIPTION:
DR MAMOUNAS: The MRI is very sensitive in detecting residual disease. You have to be careful, though, sometimes, because sometimes the MRI may overestimate the amount of residual disease, and vice versa. But sometimes you still see some enhancement on the MRI that could be essentially benign disease. So the bottom line with that is that before you commit somebody to a mastectomy based on a postneoadjuvant chemotherapy MRI, it would be important to actually biopsy what you think may be residual disease, if that leads you to make a different decision. You don’t always have to do it, obviously, if you know you’re going to do a lumpectomy. But if you see, like, enhancement in some parts of the breast that will necessitate you do a mastectomy, then you may want to prove it, particularly if you had the major response to neoadjuvant chemotherapy. DR LOVE: What’s seen in this MRI? DR MAMOUNAS: This MRI here is showing a patient of mine who actually presented with essentially an extensive disease in the breast with enhancement, biopsy proven, had neoadjuvant chemotherapy with very good clinical and, as you can see, radiologic response. But there were 2 areas that were remaining on the MRI that, if we took that at face value, we probably should have done a mastectomy, because the patient had the enhancement in 2 different areas. So we biopsied this disease and, essentially, it was negative. And then we went on and did the lumpectomy on the other side, finding a pathologic complete response. So we did not commit the patient to a mastectomy based on what the MRI had shown, because the major clinical and radiologic response. It ended up being a pathologic response with some residual enhancement on the MRI. DR BLACKWELL: Yes, and another approach that we’ll take, even in a circumstance like this, is the surgeons don’t always like it, but I’ll say, “Why don’t we just attempt a lumpectomy?” And if your margins are clear and there’s no invasive disease, then you’re done, as sometimes it takes us almost as long to go back and get it bracketed, and if you can’t see it well after neoadjuvant, with ultrasound, then it can lead to a delay to getting the patient to an MRI-guided biopsy. And I can tell you, I’m, most of the time, pleasantly surprised. We take these patients back with a good clinical response, a good radiologic response, and they’re done with their lumpectomy. So I absolutely agree. If anything, you’re doing the patient I think a favor in the sense that if you do take them to lumpectomy, a real, heartfelt lumpectomy — and I’m not a surgeon, but the surgeon goes in and tries to give them a good cosmetic result, good negative margins, and they just can’t get the tumor removed with a lumpectomy. Then I think the patient frequently — at least, if I was that patient — feels better about the decision, not feels great about it, but feels better in the decision-making, that a mastectomy absolutely has to happen. And the risk is, you have to go through 2 surgeries instead of one. But for many patients, that’s really what enables them to move forward in their decision-making. |