title: Detecting occult malignancy in prophylactic mastectomy: preoperative MRI versus sentinel lymph node biopsy.
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 $1,207 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 $1,420, PM with MRI and selective SLNB costs $1,774, and PM with routine MRI and SLNB costs $2,379.
  
  
  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.
authors.affiliation: Department of Surgical Oncology, Massachusetts General Hospital, Yawkey Building, 7th Floor, 55 Fruit Street, Boston, Massachusetts 02114, USA.
authors.forename: Dalliah
authors.initials: D
authors.lastname: Black
authors.forename: Michelle
authors.initials: M
authors.lastname: Specht
authors.forename: Janie M
authors.initials: JM
authors.lastname: Lee
authors.forename: Francisco
authors.initials: F
authors.lastname: Dominguez
authors.forename: Michele
authors.initials: M
authors.lastname: Gadd
authors.forename: Kevin
authors.initials: K
authors.lastname: Hughes
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Rafferty
authors.forename: Barbara
authors.initials: B
authors.lastname: Smith
mesh_terms: D000328:Adult; D001365:Axilla; D001943:Breast Neoplasms / Q000175:diagnosis* / Q000235:genetics / Q000473:pathology / Q000601:surgery; D003365:Costs and Cost Analysis; D003951:Diagnostic Errors / Q000191:economics; D005260:Female; D020022:Genetic Predisposition to Disease; D006801:Humans; D007430:Intraoperative Care / Q000191:economics; D008197:Lymph Node Excision; D008207:Lymphatic Metastasis; D008279:Magnetic Resonance Imaging / Q000191:economics / Q000379:methods*; D008408:Mastectomy; D008875:Middle Aged; D009367:Neoplasm Staging; D011300:Preoperative Care / Q000191:economics; D011322:Primary Prevention; D012189:Retrospective Studies; D012307:Risk Factors; D012680:Sensitivity and Specificity; D021701:Sentinel Lymph Node Biopsy / Q000191:economics