title: Agreement between MRI and pathologic breast tumor size after neoadjuvant chemotherapy, and comparison with alternative tests: individual patient data meta-analysis.
abstract: BACKGROUND
  Magnetic resonance imaging (MRI) may guide breast cancer surgery by measuring residual tumor size post-neoadjuvant chemotherapy (NAC). Accurate measurement may avoid overly radical surgery or reduce the need for repeat surgery. This individual patient data (IPD) meta-analysis examines MRI's agreement with pathology in measuring the longest tumor diameter and compares MRI with alternative tests.
  
  
  METHODS
  A systematic review of MEDLINE, EMBASE, PREMEDLINE, Database of Abstracts of Reviews of Effects, Heath Technology Assessment, and Cochrane databases identified eligible studies. Primary study authors supplied IPD in a template format constructed a priori. Mean differences (MDs) between tests and pathology (i.e. systematic bias) were calculated and pooled by the inverse variance method; limits of agreement (LOA) were estimated. Test measurements of 0.0 cm in the presence of pathologic residual tumor, and measurements >0.0 cm despite pathologic complete response (pCR) were described for MRI and alternative tests.
  
  
  RESULTS
  Eight studies contributed IPD (N = 300). The pooled MD for MRI was 0.0 cm (LOA: +/-3.8 cm). Ultrasound underestimated pathologic size (MD: -0.3 cm) relative to MRI (MD: 0.1 cm), with comparable LOA. MDs were similar for MRI (0.1 cm) and mammography (0.0 cm), with wider LOA for mammography. Clinical examination underestimated size (MD: -0.8 cm) relative to MRI (MD: 0.0 cm), with wider LOA. Tumors "missed" by MRI typically measured 2.0 cm or less at pathology; tumors >2.0 cm were more commonly "missed" by clinical examination (9.3 %). MRI measurements >5.0 cm occurred in 5.3 % of patients with pCR, but were more frequent for mammography (46.2 %).
  
  
  CONCLUSIONS
  There was no systematic bias in MRI tumor measurement, but LOA are large enough to be clinically important. MRI's performance was generally superior to ultrasound, mammography, and clinical examination, and it may be considered the most appropriate test in this setting. Test combinations should be explored in future studies.
authors.affiliation: Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, A27, Edward Ford Building, Sydney, NSW, 2006, Australia. luke.marinovich@sydney.edu.au.
authors.forename: Michael L
authors.initials: ML
authors.lastname: Marinovich
authors.affiliation: Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, A27, Edward Ford Building, Sydney, NSW, 2006, Australia. petra.macaskill@sydney.edu.au.
authors.forename: Petra
authors.initials: P
authors.lastname: Macaskill
authors.affiliation: Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, A27, Edward Ford Building, Sydney, NSW, 2006, Australia. les.irwig@sydney.edu.au.
authors.forename: Les
authors.initials: L
authors.lastname: Irwig
authors.affiliation: Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Unità di Radiologia, IRCCS Policlinico San Donato, Piazza E. Malan 2, San Donato Milanese, Milano, Italy. francesco.sardanelli@unimi.it.
authors.forename: Francesco
authors.initials: F
authors.lastname: Sardanelli
authors.affiliation: MD Anderson Cancer Center Orlando, 1400 South Orange Avenue, MP 700, Orlando, FL, 32806, USA. Terry.Mamounas@orlandohealth.com.
authors.forename: Eleftherios
authors.initials: E
authors.lastname: Mamounas
authors.affiliation: German Breast Group & Universitäts-Frauenklinik Frankfurt, Martin-Behaim-Str. 12, 63263, Neu-Isenburg, Germany. Gunter.vonMinckwitz@germanbreastgroup.de.
authors.forename: Gunter
authors.initials: G
authors.lastname: von Minckwitz
authors.affiliation: University of Padova, Division of Medical Oncology 2, Istituto Oncologico Veneto IRCCS, Padova, Italy. valentina.guarneri@unipd.it.
authors.forename: Valentina
authors.initials: V
authors.lastname: Guarneri
authors.affiliation: Department of Radiology, University of Washington, 825 Eastlake Ave E, G3-200, Seattle, WA, 98109-1023, USA. spartrid@seattlecca.org.
authors.forename: Savannah C
authors.initials: SC
authors.lastname: Partridge
authors.affiliation: Division of General Surgery, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4C 5T2, Canada. Frances.Wright@sunnybrook.ca.
authors.forename: Frances C
authors.initials: FC
authors.lastname: Wright
authors.affiliation: School of Medicine, Jeju National University Hospital, Aran 13gil 15(ara-1 dong), Jeju-si, Jeju-do, South Korea. basson@hanmail.net.
authors.forename: Jae Hyuck
authors.initials: JH
authors.lastname: Choi
authors.affiliation: Berkshire Cancer Centre, Royal Berkshire NHS Foundation Trust, London Road, Reading, RG1 5AN, UK. mbhattacharyya@doctors.org.uk.
authors.forename: Madhumita
authors.initials: M
authors.lastname: Bhattacharyya
authors.affiliation: Direzione Radiodiagnostica, Fondazione del Piemonte per l'Oncologia-IRCCS, Str. Prov.142, Candiolo, Torino, Italy. laura.martincich@ircc.it.
authors.forename: Laura
authors.initials: L
authors.lastname: Martincich
authors.affiliation: Department of Radiology, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA. eyeh@partners.org.
authors.forename: Eren
authors.initials: E
authors.lastname: Yeh
authors.affiliation: Institute of Radiology, University of Udine, p.le S.M. della Misericordia, 15, 33100, Udine, Italy. londero.viviana@aoud.sanita.fvg.it.
authors.forename: Viviana
authors.initials: V
authors.lastname: Londero
authors.affiliation: Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, A27, Edward Ford Building, Sydney, NSW, 2006, Australia. nehmat.houssami@sydney.edu.au.
authors.forename: Nehmat
authors.initials: N
authors.lastname: Houssami
mesh_terms: D000328:Adult; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D014408:Biomarkers, Tumor; D001943:Breast Neoplasms / Q000175:diagnosis* / Q000188:drug therapy / Q000473:pathology; D017024:Chemotherapy, Adjuvant; D005260:Female; D006801:Humans; D008207:Lymphatic Metastasis; D008279:Magnetic Resonance Imaging; D008327:Mammography; D008875:Middle Aged; D009367:Neoplasm Staging; D015203:Reproducibility of Results; D047368:Tumor Burden; D016217:Ultrasonography, Mammary
chemical_list: D014408:Biomarkers, Tumor