Rationale and Objectives
We aimed to investigate the utility of problem-solving breast magnetic resonance imaging (MRI) for mammographic Breast Imaging Reporting and Data System (BI-RADS) categories 3 and 4 microcalcifications.
Materials and Methods
Between January 1, 2010 and December 31, 2011, 138 women with 146 areas of categories 3 and 4 microcalcifications without sonographic correlates underwent breast MRI and had a stereotactic core biopsy using an 11-gauge needle or follow-up at least for 24 months. Positive predictive value (PPV), negative predictive value, sensitivity, and specificity were calculated on the basis of BI-RADS category, with categories 1–3 being considered benign and categories 4 and 5 being considered malignant.
Results
Twenty-four cases (16.4%) were malignant (18 ductal carcinoma in situ, 6 invasive). MRI increased PPV and specificity from 43% to 68% and from 80% to 93% ( P = .054 and .005) compared to mammography. Within 102 category 3 microcalcifications, 5 carcinomas were assessed correctly as category 4 by MRI. Within 44 category 4 microcalcifications, a correct diagnosis was made by MRI in 77% (34 of 44) as opposed to 43% (19 of 44) by mammography, and 80% (20 of 25) of unnecessary biopsies could have been avoided. Within the 24 carcinomas, 5 were negative at MRI. MRI-negative carcinomas have a significantly higher possibility of being low grade (ductal carcinoma in situ or invasive) ( P = .0362).
Conclusions
Breast MRI has the potential to improve the diagnosis of category 3 or 4 microcalcifications and could alter indications for biopsy. Breast MRI could help predict the presence or absence of higher-grade carcinoma for category 3 or 4 microcalcifications.
Introduction
Breast magnetic resonance imaging (MRI) has been widely used for patients with newly diagnosed breast carcinoma and for high-risk screening . However, there is no clear consensus on the use of MRI for “problem-solving” purposes in cases of inconclusive mammographic or ultrasound findings. Because positive predictive values (PPVs) of screening mammography and ultrasound have been reported to be only 18.4%–31.0% and 6.7%–13.2% , respectively, it would be desirable to reduce the number of biopsies that yield benign results. Although the performance of problem-solving breast MRI has been reported to be excellent for noncalcified lesions , reported results of those for microcalcifications are inconsistent , and only few studies used a large dataset including Breast Imaging Reporting and Data System (BI-RADS) categories 3 and 4 microcalcifications.
Previous studies evaluating the role of MRI in the diagnosis of microcalcifications suggested that false-negative carcinomas at MRI are low- or intermediate-grade ductal carcinoma in situ (DCIS) , although the characteristics of such cases were not further investigated in these studies. The results suggest that low-grade carcinomas negative at MRI might be biologically unimportant , and MRI could be used for microcalcifications at least to detect high-grade carcinomas.
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Materials and Methods
Inclusion Criteria
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Imaging Technique and Interpretation
Mammography Protocol and Interpretation
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Breast MRI Protocol and Interpretation
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Management
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Statistical Analysis
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Results
Patient Cohort
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Table 1
Demographic Data ( n = 138)
Age (y) Mean 51.7 Median 51 Range 33–74 Menopausal status Premenopausal 53 (38) Postmenopausal 72 (52) Irregular 6 (4) Unknown 7 (5) Indication for mammography Screening 109 (79) Diagnostic 29 (21) Follow-up after benign biopsy 9 Follow-up for a US lesion 5 Follow-up for calcifications 3 Follow-up after breast cancer 3 Other reasons (breast pain, palpable lesion) 9 Family history of breast cancer Yes (not first degree relative) 9 (7) Yes (first degree relative) 6 (4) No 123 (89) Personal history of breast cancer Yes 3 (2) No 135 (98) History of high-risk lesion Yes 4 (3) No 134 (97) Breast density Entirely fatty 6 (4) Scattered areas of fibroglandular density 50 (36) Heterogeneously dense 66 (48) Extremely dense 16 (11)
US, ultrasound.
Data are numbers of patients except for age. Numbers in parentheses are percentages.
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Table 2
Final Diagnoses of Microcalcifications and Incidental MRI Findings
No. of Lesions No. of Incidental MRI Lesions Total Histologic type of breast cancers Total no. of cancers 24 1 25 DCIS 18 (75) 1 (100) 19 (76) DCIS with microinvasion 2 (8) 0 2 (8) IDC + DCIS 4 (17) 0 4 (16) Breast cancer stage pTis 19 (79) 1 (100) 20 (80) pT1a 2 (8) 2 (8) pT1b 0 0 pT1c 3 (13) 3 (12) Nuclear grade of DCIS Low-grade 1 (6) 1 (100) 2 (11) Intermediate-grade 11 (61) 0 11 (58) High-grade 6 (33) 0 6 (31) Nuclear grade of invasive breast cancers Grade 1 2 (33) 1 (100) 3 (43) Grade 2 4 (67) 0 4 (57) Grade 3 0 0 0 High-risk lesions Total no. of high-risk lesions 3 0 3 ADH 2 (67) 0 2 (67) ADH and ALH 1 (33) 0 1 (33) Benign diagnoses Total diagnosis of benign findings 119 8 127 Benign diagnosis confirmed by biopsy 29 (24) 2 (25) 30 (24) Fibrocystic changes 24 (20) 0 24 (19) Fibroadenoma 1 (1) 0 1 (1) Intraductal papilloma without atypia 0 1 (13) 1 (1) Nonspecific benign findings 4 (3) 1 (13) 5 (4) Benign diagnosis confirmed by follow-up 90 (76) 6 (75) 96 (76)
ADH, atypical ductal hyperplasia; ALH, atypical lobular hyperplasia; DCIS, ductal carcinoma in situ; IDC, invasive ductal carcinoma; MRI, magnetic resonance imaging.
Data are numbers of lesions. Numbers in parentheses are percentages.
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Overall Performances of Mammography Only and Mammography Plus MRI
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Table 3
Overall Performances of Mammography and MRI
Parameter Mammography Mammography + MRI_P_ Value True-positive 19 19 NA True-negative 97 113 False-positive 25 9 False-negative 5 5 Sensitivity 79.2% (22/27) 79.2% (22/27) NS Specificity 79.5% (97/122) 92.6% (113/122) .005 PPV 43.2% (22/47) 67.9% (22/31) .054 NPV 95.1% (97/102) 95.8% (113/118) NS
MRI, magnetic resonance imaging; NA, not available; NPV, negative predictive value; NS, not significant; PPV, positive predictive value.
Data are numbers of lesions for test characteristics, and percentages for sensitivity, specificity, PPV, and NPV.
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Frequency of Malignancy According to Mammography Findings
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Mammographic Category 3 Microcalcifications
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Mammographic Category 4 Microcalcifications
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False-Negative Malignancy at Mammography and MRI
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Table 4
Nuclear Grades of Carcinomas ( n = 24)
Modality Test Characteristics Low Grade or Grade 1 Higher Grade_P_ Value MRI True-positive 0 19 .0362 False-negative 2 3 Mammography True-positive 3 16 1 False-negative 0 5
MRI, magnetic resonance imaging.
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Incidental Lesions Found at MRI
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Discussion
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Acknowledgments
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Supplementary Data
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Appendix S1
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References
1. Kuhl C.K., Schrading S., Leutner C.C., et. al.: Mammography, breast ultrasound, and magnetic resonance imaging for surveillance of women at high familial risk for breast cancer. J Clin Oncol 2005; 23: pp. 8469-8476.
2. Halladay J.R., Yankaskas B.C., Bowling J.M., et. al.: Positive predictive value of mammography: comparison of interpretations of screening and diagnostic images by the same radiologist and by different radiologists. AJR Am J Roentgenol 2010; 195: pp. 782-785.
3. van Luijt P.A., Fracheboud J., Heijnsdijk E.A., et. al.: Nation-wide data on screening performance during the transition to digital mammography: observations in 6 million screens. Eur J Cancer 2013; 49: pp. 3517-3525.
4. Lehman C.D., Lee C.I., Loving V.A., et. al.: Accuracy and value of breast ultrasound for primary imaging evaluation of symptomatic women 30–39 years of age. AJR Am J Roentgenol 2012; 199: pp. 1169-1177.
5. Weigert J., Steenbergen S.: The Connecticut Experiment: the role of ultrasound in the screening of women with dense breasts. Breast J 2012; 18: pp. 517-522.
6. Pediconi F., Catalano C., Roselli A., et. al.: The challenge of imaging dense breast parenchyma: is magnetic resonance mammography the technique of choice? A comparative study with x-ray mammography and whole-breast ultrasound. Invest Radiol 2009; 44: pp. 412-421.
7. El-Barhoun E.N., Pitman A.G.: Impact of breast MR in non-screening Australian clinical practice: audit data from a single-reader single-centre site. J Med Imaging Radiat Oncol 2011; 55: pp. 461-473.
8. Bick U., Engelken F., Diederichs G., et. al.: MRI of the breast as part of the assessment in population-based mammography screening. Rofo 2013; 185: pp. 849-856.
9. Benndorf M., Baltzer P.A., Vag T., et. al.: Breast MRI as an adjunct to mammography: does it really suffer from low specificity? A retrospective analysis stratified by mammographic BI-RADS classes. Acta Radiol 2010; 51: pp. 715-721.
10. Bennani-Baiti B., Bennani-Baiti N., Baltzer P.A.: Diagnostic performance of breast magnetic resonance imaging in non-calcified equivocal breast findings: results from a systematic review and meta-analysis. PLoS ONE 2016; 11: e0160346
11. Zhu J., Kurihara Y., Kanemaki Y., et. al.: Diagnostic accuracy of high-resolution MRI using a microscopy coil for patients with presumed DCIS following mammography screening. J Magn Reson Imaging 2007; 25: pp. 96-103.
12. Strobel K., Schrading S., Hansen N.L., et. al.: Assessment of BI-RADS category 4 lesions detected with screening mammography and screening US: utility of MR imaging. Radiology 2015; 274: pp. 343-351.
13. Stehouwer B.L., Merckel L.G., Verkooijen H.M., et. al.: 3-T breast magnetic resonance imaging in patients with suspicious microcalcifications on mammography. Eur Radiol 2014; 24: pp. 603-609.
14. Li E., Li J., Song Y., et. al.: A comparative study of the diagnostic value of contrast-enhanced breast MR imaging and mammography on patients with BI-RADS 3–5 microcalcifications. PLoS ONE 2014; 9: e111217
15. Kneeshaw P.J., Lowry M., Manton D., et. al.: Differentiation of benign from malignant breast disease associated with screening detected microcalcifications using dynamic contrast enhanced magnetic resonance imaging. Breast 2006; 15: pp. 29-38.
16. Jiang Y., Lou J., Wang S., et. al.: Evaluation of the role of dynamic contrast-enhanced MR imaging for patients with BI-RADS 3–4 microcalcifications. PLoS ONE 2014; 9: e99669
17. Fiaschetti V., Pistolese C.A., Perretta T., et. al.: 3–5 BI-RADS microcalcifications: correlation between MRI and histological findings. ISRN Oncol 2011; 2011: pp. 643890.
18. Brnic D., Brnic D., Simundic I., et. al.: MRI and comparison mammography: a worthy diagnostic alliance for breast microcalcifications?. Acta Radiol 2016; 57: pp. 413-421.
19. Bluemke D.A., Gatsonis C.A., Chen M.H., et. al.: Magnetic resonance imaging of the breast prior to biopsy. JAMA 2004; 292: pp. 2735-2742.
20. Uematsu T., Yuen S., Kasami M., et. al.: Dynamic contrast-enhanced MR imaging in screening detected microcalcification lesions of the breast: is there any value?. Breast Cancer Res Treat 2007; 103: pp. 269-281.
21. Kikuchi M., Tanino H., Kosaka Y., et. al.: Usefulness of MRI of microcalcification lesions to determine the indication for stereotactic mammotome biopsy. Anticancer Res 2014; 34: pp. 6749-6753.
22. Houserkova D., Prasad S.N., Svach I., et. al.: The value of dynamic contrast enhanced breast MRI in mammographically detected BI-RADS 5 microcalcifications. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2008; 152: pp. 107-115.
23. Akita A., Tanimoto A., Jinno H., et. al.: The clinical value of bilateral breast MR imaging: is it worth performing on patients showing suspicious microcalcifications on mammography?. Eur Radiol 2009; 19: pp. 2089-2096.
24. Bazzocchi M., Zuiani C., Panizza P., et. al.: Contrast-enhanced breast MRI in patients with suspicious microcalcifications on mammography: results of a multicenter trial. AJR Am J Roentgenol 2006; 186: pp. 1723-1732.
25. Sanders M.E., Schuyler P.A., Dupont W.D., et. al.: The natural history of low-grade ductal carcinoma in situ of the breast in women treated by biopsy only revealed over 30 years of long-term follow-up. Cancer 2005; 103: pp. 2481-2484.
26. Sagara Y., Mallory M.A., Wong S., et. al.: Survival benefit of breast surgery for low-grade ductal carcinoma in situ: a population-based cohort study. JAMA Surg 2015; 150: pp. 739-745.
27. Morimoto T., Okazaki M., Endo T.: Current status and goals of mammographic screening for breast cancer in Japan. Breast Cancer 2004; 11: pp. 73-81.
28. Tozaki M., Fukuda K.: High-spatial-resolution MRI of non-masslike breast lesions: interpretation model based on BI-RADS MRI descriptors. AJR Am J Roentgenol 2006; 187: pp. 330-337.
29. Tozaki M., Igarashi T., Fukuda K.: Positive and negative predictive values of BI-RADS-MRI descriptors for focal breast masses. Magn Reson Med Sci 2006; 5: pp. 7-15.
30. Tozaki M., Fukuma E.: 1H MR spectroscopy and diffusion-weighted imaging of the breast: are they useful tools for characterizing breast lesions before biopsy?. AJR Am J Roentgenol 2009; 193: pp. 840-849.
31. Uematsu T., Kasami M., Watanabe J.: Does the degree of background enhancement in breast MRI affect the detection and staging of breast cancer?. Eur Radiol 2011; 21: pp. 2261-2267.
32. Bennani-Baiti B., Baltzer P.A.: MR imaging for diagnosis of malignancy in mammographic microcalcifications: a systematic review and meta-analysis. Radiology 2017; 283: pp. 692-701.
33. Kuhl C.K., Schrading S., Bieling H.B., et. al.: MRI for diagnosis of pure ductal carcinoma in situ: a prospective observational study. Lancet 2007; 370: pp. 485-492.
34. Sanders M.E., Schuyler P.A., Simpson J.F., et. al.: Continued observation of the natural history of low-grade ductal carcinoma in situ reaffirms proclivity for local recurrence even after more than 30 years of follow-up. Mod Pathol 2015; 28: pp. 662-669.
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