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Breast DCE-MRI

Posted Aug 31, 2014 Updated Apr 10, 2023
By Savannah C. Partridge PhD , Karen M. Stone MD , Roberta M. Strigel MS MD , Wendy B. DeMartini MD , Sue Peacock MSc , Constance D. Lehman MD PhD
11 min read

Rationale and Objectives

Breast dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) scanning protocols vary widely. The purpose of this study was to determine the effects of postcontrast timing on delayed-phase lesion kinetics assessment and ability to discriminate malignant from benign lesions.

Materials and Methods

Following institutional review board approval, we retrospectively reviewed all lesions assessed on magnetic resonance examinations from April 2005 to June 2006. DCE-MRI was performed with 90-second temporal resolution. Delayed-phase kinetic parameters including percentages of persistent, plateau, and washout, and categorizations of predominant and worst curve type were compared between 4.5 and 7.5 minutes postcontrast. Ability to discriminate benign and malignant lesions based on delayed-phase kinetic parameters was compared between postcontrast timings by receiver operating characteristic (ROC) analysis.

Results

Two hundred eighty consecutive breast lesions (206 malignant and 74 benign) were evaluated in 228 women. Comparing kinetics assessments at 7.5 versus 4.5 minutes: volume percentage of washout increased in malignancies by a mean of 9.4% ( P < .0001) and increased slightly in benign lesions (mean 3.2%, P = .007); predominant curve type categorizations changed significantly only for malignancies ( P < .0001); and worst curve categorizations did not change significantly for either benign or malignant lesions ( P > .05). There were no significant differences between timings in area under ROC curves for delayed-phase kinetic parameters.

Conclusions

The choice of delayed postcontrast timing more strongly affects the kinetics assessments for malignancies than benign breast lesions, but our results suggest that a shortened breast DCE-MRI protocol may not significantly impact diagnostic accuracy. Furthermore, worst curve type classifications are least affected by postcontrast timing and may provide reliable assessment of delayed-phase kinetics across protocols.

Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) is an important tool for screening high-risk women, evaluating extent of disease in patients with newly diagnosed breast cancer, and monitoring breast tumors during neoadjuvant treatment . DCE-MRI provides sensitive and moderately specific characterization of breast lesions when used in conjunction with the American College of Radiology (ACR) MRI Breast Imaging Reporting and Data System (BI-RADS) lexicon to assess lesion morphology and initial and delayed enhancement patterns . In addition to established diagnostic morphologic features such as margin and distribution , DCE-MRI enhancement kinetics has been reported to improve delineation between benign and malignant lesions in multiple studies .

The shape of the time–signal intensity curve is an important measure in characterizing enhancing lesions , and computer-aided evaluation of enhancement kinetics improves diagnostic accuracy . For standardized reporting and as recommended by the ACR BI-RADS lexicon, enhancement of breast lesions is defined by initial-phase and delayed-phase enhancement. Initial-phase enhancement is classified as slow, medium, or rapid depending on the slope of the line from time zero (at the time of contrast injection) to the peak enhancement within the first 2 minutes. Delayed enhancement is classified as persistent (increasing), plateau (stable), or washout (decreasing) curve types . In general, a washout curve has been shown to be a strong independent predictor of malignancy in prior studies, with Kuhl et al. reporting cancer in 87% of lesions with any washout and Schnall et al. identifying malignancy in 76% of such lesions .

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Materials and methods

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Patients and Lesions

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Breast MRI Technique

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Figure 1, Schematic showing dynamic contrast-enhanced magnetic resonance imaging series acquisition protocol. Five postcontrast scans were acquired, each requiring 90 seconds. The first postcontrast scan was begun 45 seconds after initiation of contrast injection to center k space at 1.5 minutes postcontrast. Precontrast, initial, and delayed contrast-enhanced scans were incorporated into computer-aided evaluation software with centering of k space 1.5 minutes and either 4.5 or 7.5 minutes after contrast injection. (Color version of figure is available online.)

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Initial Interpretation

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CAE and Kinetic Data

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Figure 2, Process for characterization of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) early- and delayed-phase enhancement patterns. Shown are (a) the enhancement criteria definitions and (b) example of lesion characterization in a 60-year-old female with a new diagnosis of a subareolar infiltrating ductal carcinoma in the right breast. (a) Initial phase: initial peak enhancement, defined as change in signal intensity between the precontrast and initial postcontrast sequence centered at 1.5 minutes postcontrast. Delayed phase: change in signal intensity between initial and delayed postcontrast sequence (4.5 or 7.5 minutes); defined as persistent enhancement (labeled blue ) if signal intensity increases >10% or as washout enhancement (labeled red ) if signal intensity decreases by >10%. A ≤10%change in delayed signal intensity is defined as plateau enhancement (labeled green ). (b) DCE-MRI kinetics color overlay map where tumor voxels demonstrate peak initial enhancement >50%, and the percentage of tumor voxels demonstrating persistent enhancement ( blue ) is 12%, plateau enhancement ( green ) is 43%, and washout enhancement ( red ) is 45%. Predominant curve type is washout; worst curve type is washout. (Color version of figure is available online.)

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Data Collection

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Statistical Analysis

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Results

Patients and Lesions

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Table 1

Patient and Lesion Characteristics

Characteristic_N_ (%) Age (N = 228 patients) <40 years 28 (12) 40–49 years 59 (26) 50–59 years 67 (29) 60–69 years 47 (21) >70 years 27 (12) Lesion characteristics ( N = 280 lesions) Lesion size <1 cm 78 (28) 1–2 cm 82 (29) 2.1–5 cm 80 (29) >5 cm 40 (14) Histopathology Benign 74 (26) DCIS 35 (13) Invasive Ductal Carcinoma 151 (54) Invasive Lobular Carcinoma 17 (6) Other malignancies ∗ 3 (1) Lesion type Focus 8 (3) Mass 189 (68) Non–mass enhancement 83 (30) ACR BI-RADS classification BI-RADS 3 33 (12) BI-RADS 4 72 (26) BI-RADS 5 7 (3) BI-RADS 6 168 (60)

ACR, American College of Radiology; BI-RADS, Breast Imaging Reporting and Data System; DCIS, ductal carcinoma in situ.

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Lesion Delayed Enhancement Patterns

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Figure 3, An 85-year-old woman who underwent breast magnetic resonance imaging (MRI) screening because of personal history of breast cancer 6 years prior. A suspicious 16-mm enhancing lobular mass was detected in the central posterior left breast, which was proven to be invasive ductal carcinoma on MRI-guided biopsy. Shown are maximum intensity projections with dynamic contrast-enhanced MRI kinetics color overlay demonstrating regions of persistent ( blue ), plateau ( green ), and washout ( red ) enhancement. (a) At 4.5 minutes postcontrast, the percentages of persistent, plateau, and washout enhancements were 26%, 59%, and 16%, respectively. Predominant curve type is plateau; worst curve type is washout. (b) At 7.5 minutes postcontrast, the percentages of persistent, plateau, and washout enhancements were 23%, 22%, and 55%, respectively. Predominant curve type is washout (changed from 4.5 minutes assessment); worst curve type is washout. (Color version of figure is available online.)

Figure 4, A 49-year-old woman with known invasive ductal carcinoma diagnosed in the left breast who underwent breast magnetic resonance imaging for extent of disease evaluation. Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) demonstrated a 14-mm mass in the right breast that ultimately yielded benign pseudoangiomatous stromal hyperplasia and columnar cell change with atypia on biopsy. Shown are maximum intensity projections of the right breast with DCE-MRI kinetics color overlay demonstrating regions of persistent ( blue ), plateau ( green ), and washout ( red ) enhancement. (a) At 4.5 minutes postcontrast, the percentages of persistent, plateau, and washout enhancements were 34%, 66%, and 0%. Predominant curve type is plateau; worst curve type is plateau. (b) At 7.5 minutes postcontrast, the percentages of persistent, plateau, and washout enhancements were 75%, 25%, and 0%. Predominant curve type is persistent (changed from 4.5-minute assessment); worst curve type is plateau. (Color version of figure is available online.)

Figure 5, Comparison of individual curve type volume percentages measured at 4.5 versus 7.5 minutes postcontrast for benign (a–c) and malignant (d–f) lesions. Bland–Altman plots show the difference versus the mean for percentages of persistent enhancement (a,d) , plateau enhancement (b,e) , and washout (c,f) . Dashed lines indicate 95% confidence intervals and solid line indicates mean difference. Plots represent differences between time points in percentages (a) persistent, (b) plateau, and (c) washout enhancement for benign lesions and percentages (d) persistent, (e) plateau, and (f) washout enhancement for malignancies. A malignant outlier case ( arrows ; d , f ) was a ductal carcinoma in situ (DCIS) lesion that demonstrated a dramatic shift from predominantly persistent enhancement at 4.5 minutes to predominantly washout at 7.5 minutes, which is further illustrated in Figure 6 .

Figure 6, A 67-year-old woman with known ductal carcinoma in situ (DCIS) diagnosed in the right breast who underwent breast magnetic resonance imaging for extent of disease evaluation. Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) demonstrated an 11-mm heterogeneous nonmass enhancement in the lower right breast corresponding to the biopsy proven DCIS. Shown are maximum intensity projections of the right breast with DCE-MRI kinetics color overlay demonstrating regions of persistent ( blue ), plateau ( green ), and washout ( red ) enhancement. (a) At 4.5 minutes postcontrast, the percentages of persistent, plateau, and washout enhancements were 34%, 66%, and 0%, respectively. Predominant curve type is persistent; worst curve type is plateau. (b) At 7.5 minutes postcontrast, the percentages of persistent, plateau, and washout enhancements were 75%, 25%, and 0%, respectively. Predominant curve type is washout (changed from 4.5-minute assessment); worst curve type is washout. (Color version of figure is available online.)

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Table 2

Lesion Volume Percentages of Persistent, Plateau, and Washout Curve Types Compared at 4.5 and 7.5 minutes Postcontrast

Curve Types_N_ 4.5 Minutes, Median (Range) 7.5 Minutes, Median (Range) Wilcoxon Signed Rank Test P Value Benign lesions 74 Persistent 70.5 (0–100) 69.0 (0–100) .48 Plateau 19.5 (0–72) 17.5 (0–71) .002 Washout 0.4 (0–99) 0.3 (0–96) .007 Malignant lesions 206 Persistent 45.5 (0–100) 45.0 (0–100) .12 Plateau 32.5 (0–85) 23.0 (0–66) <.0001 Washout 12.0 (0–80) 22.5 (0–98) <.0001 Invasive carcinoma 171 Persistent 40.0 (0–100) 36.0 (0–100) .10 Plateau 35.0 (0–85) 23.0 (0–66) <.0001 Washout 15.0 (0–80) 27.0 (0–94) <.0001 Ductal carcinoma in situ 35 Persistent 73.0 (6–99) 64.0 (1–98) .75 Plateau 23.0 (1–70) 24.0 (1–52) .03 Washout 2.0 (0–52) 8.0 (0–98) .003

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Predominant Curve Type

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Table 3

Predominant Curve Type Classifications Compared at 4.5 and 7.5 minutes Postcontrast

Predominant Curve Types_N_ 4.5 Minutes, N (%) 7.5 Minutes, N (%) Chi-squared P Value Benign lesions 74 .35 Persistent 54 (73.0) 55 (74.3) Plateau 12 (16.2) 7 (9.5) Washout 8 (10.8) 12 (16.2) Malignant lesions 206 <.0001 Persistent 109 (52.9) 111 (53.9) Plateau 64 (31.1) 27 (13.1) Washout 33 (16.0) 68 (33.0) Invasive lesions 171 <.0001 Persistent 83 (48.5) 83 (48.5) Plateau 56 (32.8) 24 (14.0) Washout 32 (18.7) 64 (37.4) Ductal carcinoma in situ lesions 35 .14 ∗ Persistent 26 (74.3) 28 (80.0) Plateau 8 (22.9) 3 (8.6) Washout 1 (2.9) 4 (11.4)

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Worst Curve Type

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Table 4

Worst Curve Type Classifications Compared at 4.5 and 7.5 minutes Postcontrast

Worst Curve Types_N_ 4.5 Minutes, N (%) 7.5 Minutes, N (%) Chi-squared P -value Benign lesions 74 .97 Persistent 12 (16.2) 13 (17.6) Plateau 20 (27.0) 20 (27.0) Washout 42 (56.8) 41 (55.4) Malignant lesions 206 .23 ∗ Persistent 2 (1.0) 3 (1.5) Plateau 21 (10.2) 12 (5.8) Washout 183 (88.8) 191 (92.7) Invasive lesions 171 .51 ∗ Persistent 2 (1.2) 3 (1.8) Plateau 16 (9.4) 10 (5.9) Washout 153 (89.5) 158 (92.4) Ductal carcinoma in situ 35 † Persistent 0 (0) 0 (0) Plateau 5 (14.3) 2 (5.7) Washout 30 (85.7) 33 (94.3)

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Diagnostic Accuracy

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Table 5

Receiver Operating Characteristic (ROC) Curve Analysis

ROC Curve Comparison 4.5-Minute Protocol 7.5-Minute Protocol_P_ Value AUC 95% CI AUC 95% CI All lesions ( N = 280) ∗ Percentage washout 0.70 0.64–0.75 0.72 0.66–0.77 .27 Predominant curve 0.60 0.54–0.65 0.61 0.55–0.67 .65 Worst curve 0.67 0.61–0.72 0.69 0.63–0.74 .42 MRI-detected lesions ( N = 112) † Percentage washout 0.64 0.54–0.73 0.70 0.60–0.78 .08 Predominant curve 0.56 0.46–066 0.59 0.50–.068 .31 Worst curve 0.63 0.53–0.72 0.68 0.58–0.76 .13

AUC, area under the curve; BI-RADS, Breast Imaging Reporting and Data System.

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Figure 7, Receiver operating characteristic analysis for discriminating 280 breast lesions (206 malignant and 74 benign) based on delayed-phase kinetics. Percentage washout curve type produced area under the curve (AUC) of 0.70 (95% confidence interval [CI]: 0.64–0.75) and 0.72 (95% CI: 0.66–0.77) at 4.5 and 7.5 minutes, respectively (a) . Predominant curve type produced AUC of 0.60 (95% CI: 0.54–0.65) and 0.61 (95% CI: 0.55–0.67) at 4.5 and 7.5 minutes, respectively (b) . Worst curve type produced AUC of 0.67 (95% CI: 0.61–0.72) and 0.69 (95% CI: 0.63–0.74) at 4.5 and 7.5 minutes, respectively (c) . Differences in AUC between the 4.5 and 7.5 minutes assessments were not significant for any of the delayed-phase characteristics ( P > .05).

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Discussion

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Academic Radiology, Volume 21, Issue 9
Journals General Radiology
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