Abstract
Background
High-risk patients undergoing prophylactic mastectomy (PM) may have unsuspected cancers identified on pathology. The optimum way to identify and manage them is controversial. Magnetic resonance imaging (MRI) may identify occult cancer preoperatively. Sentinel lymph node biopsy (SLNB) allows intraoperative staging and axillary dissection during the same operation. We determined the efficacy and cost of MRI and/or SLNB in managing high-risk PM patients.
Methods
We reviewed 192 PMs in 173 patients from 1999 to 2005. Costs were estimated for MRI and SLNB during PM by the 2005 Medicare Resource-Based Relative Value Scale. We also estimated costs and procedures for the four strategies in a larger hypothetical cohort.
Results
A total of 19 (10%) of 192 PMs contained occult cancers, 14 ductal carcinoma-in-situ (DCIS) and 5 invasive ductal carcinoma (IDC). In 59 patients, MRI detected an IDC but missed two DCIS and an IDC. Positive MRIs generated an additional average cost of $1207 per patient. In 56 PMs with SLNB, 6 occult cancers were found, 5 DCIS and 1 IDC, all with negative SLNBs. Adding a SLNB costs an additional average of $644. A theoretical analysis demonstrated that PM alone costs $808 per patient, PM with SLNB costs $1420, PM with MRI and selective SLNB costs $1774, and PM with routine MRI and SLNB costs $2379.
Conclusions
MRI adds great cost and misses most occult cancers in PMs. SLNB allows the rare patient with occult IDC to avoid axillary dissection but adds cost. Given the low rate of unsuspected invasive cancers and the costs of MRI and SLNB, neither is recommended as standard practice for PM patients.
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References
Hartmann LC, Schaid DJ, Woods JE, et al. Efficacy of bilateral prophylactic mastectomy in women with a family history of breast cancer. N Engl J Med 1999;340:77–84
Rebbeck T, Friebel T, Lynch H, et al. Bilateral prophylactic mastectomy reduces breast cancer risk in BRCA1 and BRCA2 mutation carriers: the PROSE Study Group. J Clin Oncol 2004;22:1055–62
Rebbeck T, Lynch H, Neuhausen S, et al. Prophylactic oophorectomy in carriers of BRCA1 or BRCA2 mutations. N Engl J Med 2002;346:1616–22
Lostumbo L, Carbine N, Wallace J, Ezzo J. Prophylactic mastectomy for the prevention of breast cancer. Cochrane Database Syst Rev 2004;18:CD002748
McDonnell S, Schaid D, Myers J, et al. Efficacy of contralateral prophylactic mastectomy in women with a personal and family history of breast cancer. J Clin Oncol 2001;19:3938–43
King T, Ganaraj A, Fey J, et al. Cytokeratin-positive cells in sentinel lymph nodes in breast cancer are not random events: experience in patients undergoing prophylactic mastectomy. Cancer 2004;10:926–33
Goldflam K, Hunt K, Gershenwald J, et al. Contralateral prophylactic mastectomy. Predictors of significant histologic findings. Cancer 2004;101:1977–86
Hoogerbrugge N, Bult P, de Widt-Levert LM, et al. High prevalence of premalignant lesions in prophylactically removed breasts from women at hereditary risk for breast cancer. J Clin Oncol 2003;21:41–5
Kroll SS, Miller MJ, Schusterman MA, et al. Rationale for elective contralateral mastectomy with immediate bilateral reconstruction. Ann Surg Oncol 1994;1:457–61
Boughey J, Khakpour N, Meric-Bernstam F, et al. Selective use of sentinel lymph node surgery during prophylactic mastectomy. Cancer 2006;107:1440–7
Kriege M, Brekelmans C, Boetes C, et al. Efficacy of MRI and mammography for breast-cancer screening in women with a familial or genetic predisposition. N Engl J Med 2004;351:427–37
Stoutjesdijk M, Boetes C, Jager G, et al. Magnetic resonance imaging and mammography in women with a hereditary risk of breast cancer. J Natl Cancer Inst 2001;93:1095–102
Liberman L, Morris E, Kim C, et al. MR imaging findings in the contralateral breast of women with recently diagnosed breast cancer. Am J Roentgenol 2003;180:333–41
Lee S, Orel S, Woo I, et al. MR imaging screening of the contralateral breast in patients with newly diagnosed breast cancer: preliminary results. Radiology 2003;226:773–8
Bedrosian I, Schlencker J, Spitz F, et al. Magnetic resonance imaging-guided biopsy of mammographically and clinically occult breast lesions. Ann Surg Oncol 2002;9:457–61
Kim T, Giuliano A, Lyman G. Lymphatic mapping and sentinel lymph node biopsy in early-stage breast carcinoma: a metaanalysis. Cancer 2006;106:4–16
Wilke L, McCall L, Posther K, et al. Surgical complications associated with sentinel lymph node biopsy: results from a prospective international cooperative group trial. Ann Surg Oncol 2006;13:491–500
Temple L, Baron R, Cody H, et al. Sensory morbidity after sentinel lymph node biopsy and axillary dissection: a prospective study of 233 women. Ann Surg Oncol 2002;9:654–62
American Medical Association. Current procedural terminology code: relative value search. 2005. Available at: http://www.catalog.ama-assn.org/Catalog/cpt/cpt_search.jsp. Accessed March 20, 2006
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Black, D., Specht, M., Lee, J.M. et al. Detecting Occult Malignancy in Prophylactic Mastectomy: Preoperative MRI Versus Sentinel Lymph Node Biopsy. Ann Surg Oncol 14, 2477–2484 (2007). https://doi.org/10.1245/s10434-007-9356-1
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DOI: https://doi.org/10.1245/s10434-007-9356-1