Preoperative Breast MRI Does Not Improve Surgical Plan/Local Control

Breast MRI in patients with newly diagnosed breast cancer increased mastectomy rates and biopsy needs.

No definitive evidence exists showing that preoperative breast MRI in patients with newly diagnosed breast cancer (NDBC) improved surgical plan or local control, according to an oral presentation from Lisa Newman, MD, MPH, FACS, FASCO, FSSO, at the 2025 Miami Breast Cancer Conference.1 Additionally, breast MRI in this patient population was associated with additional biopsy needs and higher mastectomy rates.

Newman, chief of Breast Surgery at Weill Cornell Medicine and director of the Interdisciplinary Breast Oncology Program at New York Presbyterian Hospital Network, initially discussed what she defined as “standard” roles for breast MRI. According to Newman, breast MRI has standard roles in the following scenarios:

• Screening for women with increased breast cancer risk;
• Evaluation of the breast in women with axillary and unknown primary metastases
• Evaluation of silicone implant rupture

She then introduced a new indication for breast MRI, in which the modality is used preoperatively to improve breast conserving surgery (BCS) prospects in women with multiple breast tumors. Data assessing preoperative MRI in this patient population came from the single-arm, prospective, phase 2 ACOSOG 11102 trial (NCT01556243).2

In the trial, 204 patients with 2 or 3 biopsy-proven separate breast tumors underwent margin-negative lumpectomy and radiation therapy, of whom 70% had multiple-site lumpectomies. At a median follow-up of 66.4 months, the 5-year local recurrence (LR) rate was 3.1%; 22.6% among 15 women did not have preoperative MRI vs 1.7% among 189 women who did (P = .002).

Newman then suggested that an additional role being considered as a standard for breast MRI, routine preoperative breast MRI in those with NDBC, was controversial. To better outline the controversy, Newman proposed the following questions:

• Can MRI improve margin control and reduce rates of re-excision with BCS;
• Can MRI improve selection of patients who undergo breast conservation;
• And can MRI improve selection of patients benefitting from contralateral mastectomy?

To effectively answer these questions, Newman outlined contemporary data exhibiting the impact of preoperative breast MRI on re-excision for marginal control, local recurrence after lumpectomy and breast radiation therapy, and rates of contralateral breast cancer in patients with NDBC.

Contemporary Data on Margin Control

Regarding margin control, Newman first highlighted data from a 2014 consensus guideline, which comprised a meta-analysis of 33 studies and 28,162 patients who had provided margins data.3 At a median follow-up of 79.2 months, 1,506 cases of ipsilateral breast tumor recurrence (IBTR) were observed at a median LR rate of 5.3%.

Another multi-institution retrospective study found that patients undergoing BCS surgery experienced lower re-excision rates using the “no ink on tumor” margins––defined as the absence of cancerous cells next to an inked surface or edge of the spectrum––vs a 2 mm or greater margin standard; 14.1% with “no ink on tumor” vs 32.8% with 2 mm or greater standard.4

Furthermore, data from a population study evaluating 5 National Surgical Adjuvant Breast and Bowel Project protocols of negative disease in patients undergoing lumpectomy and breast radiotherapy with or without adjuvant therapy showed 10-year IBTR rates of 3.5%, 6.5%, and 4.3% across 3 studies evaluating patients with estrogen receptor (ER)–negative disease, as well as 3.6% and 4.3% among those with ER–positive disease.5

Additionally, another clinical trial examining temporal trends in contralateral breast cancer (CBC) incidence utilizing the Surveillance, Epidemiology, and End Results (SEER) database showed that although CBC rates stabilized from 1975 to 1985, with an estimated annual percent change (EAPC) of 0.27% per year (95% CI, –0.4 to 0.9), from 1985 to 2005, the EAPC was –3.07% (95% CI, –3.5% to –2.7%), reflecting decreasing rates of CBC.6

Newman then highlighted an additional trial that assessed MRI of the ipsilateral breast in women with percutaneously proven breast cancer.7 There, records of 70 consecutive BCS cases showed that breast MRI revealed additional cancer foci in 19 (27%) women, including 11 cases of invasive cancer and 8 cases of ductal carcinoma in situ (DCIS). Moreover, additional benign lesions were found in 17 (24%) women, including 3 high-risk lesions.

Additional data from a retrospective review found that among 223 contralateral breast images in women with unilateral breast cancer, contralateral biopsy was recommended in 72 (32%) patients and performed in 61.8 A total of 12 patients had biopsy-proven CBC, which included 20% (n = 12/61) of the biopsy recommended group and 5.4% of the total patient population (n = 12/223). From these 2 studies, Newman concluded that breast MRI detects additional contralateral abnormalities requiring work-up and biopsies.

The Impact of Preoperative Breast MRI on Breast Surgery Planning

To outline the current state of re-excision rates after BCS with or without preoperative MRI, Newman discussed a review she conducted regarding the role of preoperative MRI in patients with NDBC.9 Results varied considerably, with 2 studies exhibiting significant increases in excision rates after MRI than without MRI, 3 studies showing significant decreases in excision rates with MRI than without, and an additional 10 studies showing non-significant results.

She supplemented these findings by exhibiting results from the UK-based comparative effectiveness of MRI in breast cancer (COMICE) parallel group trial evaluating 1623 patients with breast cancer who were eligible for lumpectomy, of whom 816 were assigned to undergo preoperative MRI and 807 were not.10 Results showed that re-excision rates were identical in each arm (19%, 19%), and that mastectomy was performed as the initial surgery in 7% (n = 58) of the MRI arm—including 15 patients triaged to “avoidable” mastectomy due to inaccurate MRI assessment of diffuse disease—and 1% (n = 10) of the no MRI arm. Newman highlighted the inexperience of the MRI radiologists as a potential limitation of the study.

An additional meta-analysis study assessed the outcomes of 3112 patients across 9 studies with breast cancer assigned to treatment with or without MRI.11 The study found statistically significant increases with MRI in mastectomy as initial surgery (16.4% vs 8.1%; P <.001) and with overall mastectomy rate (25.5% vs 18.2%; P <.001) vs no MRI. An updated follow-up including 85,975 patients found that across 15 studies, those receiving MRI had increased odds of receiving mastectomy (OR, 1.39; 95% CI, 1.23-1.57; P <.001).12

Furthermore, Newman displayed data from the SHAVE and SHAVE2 trials, which showed that among 631 patients undergoing BCS, 193 (30.6%) received preoperative MRI.13 Positive margins were identified in 31.1% of patients who received MRI vs 38.8% of those who did not (P = .073). The multivariate analysis revealed that although age and tumor size were associated with marginal status, preoperative MRI was not.

The Impact of Preoperative Breast MRI on Local Recurrence/CBC Rates

Regarding the impact on BCS outcomes with or without breast MRI, Newman highlighted 3 trials that showed significant decreases in CBC occurrence, but data from a meta-analysis on preoperative MRI studies showed that preoperative MRI did not significantly impact local recurrence or distant recurrence rates.14 An additional study revealed that preoperative breast MRI had no impact on 15-year outcomes for BCS-managed DCIS (P = .25) or early-stage breast cancer (P = .92).15 Furthermore, another study found that in women 50 years or younger, there was no significant difference in local recurrence-free survival (P =.89) or distant recurrence-free survival (P =.89) in those who underwent preoperative MRI vs those who did not.

Newman then discussed potential indications where there may be a role for preoperative breast MRI:

• Dense breasts;
• Invasive lobular carcinoma (ILC);
• And ductal carcinoma in situ

Regarding preoperative breast MRI for mammographically-dense breasts, the COMICE study found no impact of mammographic density on lumpectomy re-excision rates. Furthermore, a single institute study evaluating 97 lobular cancers assigned 36 patients to preoperative MRI scans and 61 to no MRI.16 Findings revealed breast MRI underestimated tumor sizes the least compared with mammography or sonography and elicited the fewest mastectomies. Additional findings from the updated follow-up of the meta-analysis showed no difference in overall mastectomy rates related to MRI use (OR, 1.00; 95% CI, 0.75-1.33) and a nonsignificant decrease in re-excision rate (OR, 0.65; 95% CI, 0.34-1.24).17

Furthermore, regarding the effect of preoperative breast MRI on DCIS surgical management, a meta-analysis of 9 studies evaluating 1077 women with DCIS who had preoperative MRI vs 2175 who did not, preoperative MRI was found to not correlate with significant improvements in surgical outcomes.18 Notably, although MRI increased the odds of having an initial mastectomy (OR, 1.72; P = .012), no significant differences were observed in women with positive margins following BCS (OR, 0.80; P =.059) or in the necessity of reoperation for positive margins after BCS (OR, 1.06; P =.759).

An additional study revealed that similar trends emerged among locoregional recurrence (LRR) and CBC rates for DCIS treated with BCS in a retrospective analysis study.19 The hazard ratio for LRR was 1.36 (95% CI, 0.78-2.39) among patients who did not undergo radiotherapy (P = .328) and 1.18 (95% CI, 0.79-1.78) among patients who did undergo radiotherapy (P = .538). Additionally, non-significant differences in CBC rates were observed in the non-radiotherapy group (P = .871) and the radiotherapy group (P = .727).

Newman further highlighted an associated American Society of Breast Surgeons (ASBrS) Guideline, which stated that they endorse not routinely ordering breast MRI in patients with NDBC, citing “no other ASBrS guidelines or quality measures on breast MRI.”20

Overall, Newman reiterated the well-defined roles for breast MRI while noting that breast MRI in NDBC increased additional biopsy needs as well as mastectomy rates. She explained that no definitive evidence exists supporting the benefit of preoperative MRI in improving surgical planning or local control, suggesting that additional foci seen on MRI might have been controlled with adjuvant systemic therapy or radiation.

She concluded her presentation by touching upon the judicious use of breast MRI in patients with newly diagnosed disease, emphasizing the importance of shared decision-making with patients and highlighting a potentially evolving role of breast MRI with ILC.

References

1. Newman LA. Preoperative breast MRI in patients with newly-diagnosed breast cancer. Presented at the 42nd Annual Miami Breast Cancer Conference; March 6-9, 2025; Miami, FL.
2. Boughey JC, Rosenkranz KM, Ballman KV, et al. Local recurrence after breast-conserving therapy in patients with multiple ipsilateral breast cancer: results from ACOSOG Z11102 (Alliance). J Clin Oncol. 2023;41(17):3184-3193. doi:10.1200/JCO.22.02553
3. Houssami N, Macaskill P, Marinovich ML, Morrow M. The association of surgical margins and local recurrence in women with early-stage invasive breast cancer treated with breast-conserving therapy: a meta-analysis. Ann Surg Oncol. 2014;21(3):717-730. doi:10.1245/s10434-014-3480-5
4. Kuritzky A, Reyna C, McGuire KP, et al. Evaluation of 2014 margin guidelines on re-excision and recurrence rates after breast conserving surgery: a multi-institution retrospective study. Breast. 2020;51:29-33. doi:10.1016/j.breast.2020.02.013
5. Anderson SJ, Wapnir I, Digman JJ, et al. Prognosis after ipsilateral breast tumor recurrence and locoregional recurrences in patients treated by breast-conserving therapy in five National Surgical Adjuvant Breast and Bowel Project protocols of node-negative breast cancer. J Clin Oncol. 2009;27(15):2466-2473. doi:10.1200/JCO.2008.19.8424
6. Nichols HB, Berrington de González A, Lacey JV, Rosenberg PS, Anderson WF. Declining incidence of contralateral breast cancer in the United States from 1975 to 2006. J Clin Oncol. 2011;29(12):1564-1569. doi:10.1200/JCO.2010.32.7395
7. Liberman L, Morris EA, Dershaw DD, Abramson AF, Tan LK. MR imaging of the ipsilateral breast in women with percutaneously proven breast cancer. AJR. 2012;180(4):901-910. doi:10.2214/ajr.180.4.1800901
8. Liberman L, Morris EA, Kim CM, et al. MR imaging findings in the contralateral breast of women with recently diagnosed breast cancer. AJR. 2012;180(2):333-341. doi: 10.2214/ajr.180.2.1800333
9. Newman LA. Role of preoperative MRI in the management of newly diagnosed breast cancer patients. 2020;230(3):331-339. doi:10.1016/j.jamcollsurg.2019.12.004
10. Turnbull L, Brown S, Harvey I, et al. Comparative effectiveness of MRI in breast cancer (COMICE) trial: a randomised controlled trial. Lancet. 2010;375(9714):563-571. doi:10.1016/S0140-6736(09)62070-5
11. Houssami N, Turner R, Morrow M. Preoperative magnetic resonance imaging in breast cancer: meta-analysis of surgical outcomes. Ann Surg. 2013;257(2):249-255. doi:10.1097/SLA.0b013e31827a8d17
12. Houssami N, Turner R, Morrow M. Meta-analysis of preoperative magnetic resonance imaging (MRI) and surgical treatment for breast cancer. Breast Cancer Res Treat. 2017;165(2):273-283. doi:10.1007/s10549-017-4324-3
13. Cairns A, Chagpar AB, Dupont E, et al. Does preoperative MRI reduce positive margins after breast-conserving surgery? Ann Surg Oncol. 2023;30:6053-6058. doi:10.1245/s10434-023-13884-8
14. Houssami N, Turner R, Macaskill P, et al. An individual person data meta-analysis of preoperative magnetic resonance imaging and breast cancer recurrence. J Clin Oncol. 2014;32(5):392-401. doi:10.1200/JCO.2013.52.7515
15. Vapiwala N, Hwang WT, Kushner CJ, Schnall MD, Freedman GM, Solin LJ. No impact of breast magnetic resonance imaging on 15-year outcomes in patients with ductal carcinoma in situ or early-stage invasive breast cancer managed with breast conservation therapy. Cancer. Published online December 16, 2016. doi:10.1002/cncr.30479
16. Bansal GJ, Santosh D, Davies EL. Selective magnetic resonance imaging (MRI) in invasive lobular breast cancer based on mammographic density: does it lead to an appropriate change in surgical treatment? Br J Radiol. 2016;89(1060):20150679. doi:10.1259/bjr.20150679
17. Houssami N, Turner RM, Morrow M. Meta-analysis of pre-operative magnetic resonance imaging (MRI) and surgical treatment for breast cancer. Breast Cancer Res Treat. 2017;165(2):273-283. doi:10.1007/s10549-017-4324-3
18. Fancellu A, Turner RM, Dixon JM, Pinna A, Cottu P, Houssami N. Meta-analysis of the effect of preoperative breast MRI on the surgical management of ductal carcinoma in situ. Br J Surg. 2015;102(8):883-893. doi:10.1002/bjs.9797
19. Pilewskue M, Olcese C, Eaton A, et al. Perioperative breast MRI is not associated with lower locoregional recurrence rates in DCIS patients treated with or without radiation. Ann Surg Oncol. 2014;21(5):1552-1560. doi:10.1245/s10434-013-3424-5
20. American Society of Breast Surgeons. Diagnostic and screening magnetic resonance imaging of the breast. Developed June 22, 2017. Accessed March 7, 2025. https://tinyurl.com/55v7n8aj