MRI and Mammography Before Surgery in Patients With Stage I-II Breast Cancer

This is a randomized trial of preoperative breast MRI in patients deemed eligible for breast conserving surgery by conventional clinical criteria will provide important information about the clinical and biologic relevance of occult disease identified by MRI alone. Patients will be assigned to standard pre-operative breast cancer disease assessment without the addition of MRI prior to breast conserving surgery or standard pre-operative breast cancer disease assessment with the use of MRI prior to breast conserving surgery.

The primary objective is to compare the rates of local-regional recurrence (LRR) following attempted breast conserving therapy in a cohort of women with triple negative or HER-2 amplified breast cancer randomized to preoperative staging with mammography (control arm) or mammography plus breast MRI (MRI arm).

Secondary objectives are:

* To compare the re-operation rates following attempted breast conserving therapy between women assessed preoperatively with breast MRI to those assessed without the use of breast MRI
* To compare local recurrence rates between women who undergo BCT on the control arm to women who undergo BCT on the MRI arm
* To compare the conversion rate to mastectomy secondary to persistent positive margins or poor cosmesis within the first 6 months of attempting BCT (prior to the administration of RT) between women assessed preoperatively with breast MRI to those assessed without the use of breast MRI
* To compare the contralateral breast cancer rates in women randomized to preoperative breast MRI to those not receiving pre-operative breast MRI
* To compare the disease-free survival rates between women assessed preoperatively with breast MRI to those assessed without the use of breast MRI
* To compare breast cancer specific and overall survival outcomes of women assessed preoperatively with breast MRI to those assessed without the use of breast MRI
* To estimate the rate of MRI-guided localization assisted surgery
* To estimate the rate of multi-centric disease in the index breast for women in the MRI arm
* To evaluate the accuracy of index lesion characteristics and other factors in predicting multi-centricity in the cohort randomized to breast MRI
* To assess the positive predictive values (PPV) of MRI in detecting ipsilateral multi-centric disease and contralateral disease in women with breast cancer undergoing preoperative breast MRI
* To estimate the false positive rate for detection of multiple foci of breast cancer by MRI

All registered patients will be monitored for relapse and survival for 5 years from the date of surgery. Patients will be followed a minimum of every 4 months for the first 2 years from diagnosis and a minimum of every 6 months during years 3-5. Patients will be monitored for local, regional, distant relapse and vital status.

• Breast surgery (Procedure)
• Magnetic resonance imaging (Procedure)
• Mammography (Procedure)

Primary outcomes

• Local-regional Recurrence (LRR) [Up to 5 years]

Secondary outcomes

• Re-operation Rate [Up to 5 years]
• Conversion Rate to Mastectomy Secondary to Persistent Positive Margins or Poor Cosmesis [Within the first 6 months]
• Time to Contralateral Breast Cancer [Up to 5 years post-randomization]
• Disease-free Survival (DFS) [Up to 5 years post-randomization]
• Overall Survival [Up to 5 years post-randomization]
• Breast Cancer Specific Survival Will be Measured [Up to 5 years post-randomization]
• Rate of MRI-guided Localization Assisted Surgery (Arm B) [Up to 5 years]
• False Positive Rate for MRI Detection of Multiple Disease Foci [Up to 5 years]

Sex: Female, ages: 18 Years to any

* Female. Men are excluded from this study because the number of men with breast cancer is insufficient to provide a statistical basis for assessment of effects in this subpopulation of people with breast cancer.
* Pathologically confirmed diagnosis of breast cancer, clinical stage I-II (T1-3 N0 M0, T0-2 N1 M0). Diagnosis must be by needle biopsy; patients diagnosed by surgical excision are excluded.
* Patients must have either:

  * Estrogen receptor (ER) negative/progesterone receptor (PR) negative (< 10% by immunohistochemistry IHC staining) and HER-2 negative breast cancer OR
  * ER negative/PR negative (< 10% by IHC staining) and HER-2 positive tumors
  * HER-2 status will be determined as per the 2013 ASCO CAP guidelines:

    * HER-2 is considered positive if there is IHC 3+ staining or ISH positive using either single probe ISH or dual probe ISH
    * HER-2 is considered negative if there is IHC 0 or 1+ staining or ISH negative using either single probe ISH or dual probe ISH
* No patients with previous ipsilateral invasive breast cancer or ductal carcinoma in situ (DCIS)
* No patients with bilateral breast cancer
* No patients with known deleterious mutations in breast cancer (BRCA) genes
* No current history of receiving hormonal therapy, tamoxifen, and or aromatase inhibitors for therapeutic measures
* No history of chemotherapy for cancer within 6 months prior to registration
* No patients scheduled to receive neoadjuvant chemotherapy or partial breast irradiation following breast conserving surgery
* Eligible for BCT based on clinical examination, mammography and, if standard practice at a given institution, ultrasound and/or tomogram. Women who cannot be appropriately selected for BCT based on these standard imaging studies, and for whom additional imaging is recommended to clarify local disease extent, will not be eligible for this trial.
* No patients with multicentric or multifocal disease scheduled to undergo multiple lumpectomies. Multifocal disease that can be encompassed in a single operative bed can be enrolled.
* Suitable to undergo MRI and receive the contrast agent gadolinium (exclusions follow):

  * No history of untreatable claustrophobia
  * No presence of metallic objects or implanted medical devices in body (i.e., cardiac pacemaker, aneurysm clips, surgical clips, prostheses, artificial hearts, valves with steel parts, metal fragments, shrapnel, tattoos near the eye, or steel implants)
  * No history of sickle cell disease
  * No contraindication to intravenous contrast administration
  * No known allergy-like reaction to gadolinium or moderate or severe allergic reactions to one or more allergens as defined by the American College of Radiology (ACR); patient may be eligible if willing to undergo pre-treatment as defined by the institution's policy and/or ACR guidance
  * No findings consistent with renal failure, as determined by glomerular filtration rate (GFR) < 30 mL/min/1.73 m\^2 based on a creatinine level obtained within 28 days prior to registration
  * Weight lower than that allowable by the MRI table
* No prior MRI of study breast within the 12 months prior to registration
* Non-pregnant and non-lactating. Patients of child-bearing potential must have a negative pregnancy test within 7 days prior to registration. Perimenopausal patients must be amenorrheic > 12 months to be considered not of child-bearing potential
* ≥ 18 years of age
* Signed study-specific informed consent prior to registration

Participant flow

Outcome results

• Local-regional Recurrence (LRR) (Primary), Number, percentage of participants: Arm 1 (Control) 95.7 (92.3 to 99.1); Arm 2 (Experimental) 93.2 (89.0 to 97.6)
• Re-operation Rate (Secondary)
• Conversion Rate to Mastectomy Secondary to Persistent Positive Margins or Poor Cosmesis (Secondary)
• Time to Contralateral Breast Cancer (Secondary)
• Disease-free Survival (DFS) (Secondary)
• Overall Survival (Secondary)
• Breast Cancer Specific Survival Will be Measured (Secondary)
• Rate of MRI-guided Localization Assisted Surgery (Arm B) (Secondary)
• False Positive Rate for MRI Detection of Multiple Disease Foci (Secondary)

Adverse events

Time frame: Up to 5 years

Serious adverse events by term

Other adverse events by term

79 more sites not listed.

• Study Protocol, Statistical Analysis Plan, and Informed Consent Form (PDF, 2019-09-18)

• Isabelle Bedrosian, MD, Study chair, M.D. Anderson Cancer Center

NIH grants: U10CA037447