Rationale and Objectives
A variety of morphologic and kinetic signs of benign or malignant breast lesions contribute to a final diagnosis and differential diagnosis in magnetic resonance (MR) mammography (MRM). As a new sign, prepectoral edema (PE) in patients without any history of previous biopsy, operation, radiation, or chemotherapy was detected during routine breast MR examinations. The purpose of this study was to retrospectively evaluate the role of this morphologic sign in the differential diagnosis of breast lesions.
Materials and Methods
Between January 2005 and October 2006, a total of 1109 consecutive MRM examinations have been performed in our institution. In this study, only patients who would later be biopsied or operated in our own hospital were included. They had no previous operation, biopsy, intervention, chemotherapy, hormone replacement therapy, or previous mastitis. In total, 162 patients with 180 lesions were included, histologically correlated later-on by open biopsy (124 patients and 136 lesions) or core biopsy (38 patients and 44 lesions). The evaluations were performed by four experienced radiologists in consensus.
Results
One hundred eighty evaluated lesions included 104 malignant lesions (93 invasive and 11 noninvasive cancers) and 76 benign lesions. PE was detected in 2.6% of benign lesions (2 of 76), in none of the Ductal cacinoma in situ (DCIS) cases (0 of 11), and in 25.8% of malignant lesions (24 of 93; P < .000). PE was found significantly more frequently in presence of malignant tumors >2 cm in diameter (48.5%, 17 of 35 vs. 13.8%, 8 of 58; P < .001). PE was not statistically associated to malignant tumor type, presence or absence of additional DCIS, and number of lesions. This resulted in the following diagnostic parameters for PE as an indicator for malignancy: sensitivity of 19.3%, specificity of 97.3%, positive predictive value (PPV) of 92.3%, negative predictive value of 48%, and accuracy of 57.7%.
Conclusions
In case of occurrence, the “PE sign” seems to be a specific indicator for malignant tumors with a high PPV, independent from its entity.
The role of magnetic resonance (MR) imaging (MRI) as an imaging modality of the breast (MR mammography [MRM]) has evolved to be increasingly important over the last 30 years. So far, current guidelines of the American College of Radiology (ACR) list among the specific indications for breast MR mainly the following :
1) Patients after operation or radiation
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Figure 1
Top left : T1 native; top right : 1 minute subtraction; low left : 7 minutes subtraction; low right : T2-weighted TSE-Turbo Soin Echo G3 ductal invasive carcinoma, showing as enhancing lesions in the left breast in S1. The multiple cancers reveal type 3 kinetic curves as well and appear dark in T2. Accompanying prepectoral edema are clearly visible in T2, displaying as hyperintense fluid spatters.
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Figure 2
T2-weighted TSE-Turbo Soin Echo image. CA- Cancer Ductal invasive carcinoma, G3 ( orange circle ). Mild amounts of prepectoral edema in the right breast ( blue arrows ). (Color version of figure is available online.)
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Figure 3
T2-weighted TSE-Turbo Soin Echo image. Ductal invasive carcinoma, G3 ( orange circle ). Extensive amounts of prepectoral edema in the left breast ( blue arrows ). (Color version of figure is available online.)
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Material and methods
Study Design
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Image Acquisition and Interpretation
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Statistical Evaluation
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Sensitivity:TP(TP+FN) Sensitivity
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TP
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TP
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FN
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Specificity:TN(TN+FP) Specificity
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TN
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Positivepredictivevalue(PPV):TP(TP+FP) Positive
predictive
value
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PPV
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TP
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Negativepredictivevalue(NPV):TN(TN+FN) Negative
predictive
value
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NPV
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TN
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TN
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Accuracy:(TP+TN)(TP+TN+FP+FN) Accuracy
:
(
TP
+
TN
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(
TP
+
TN
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FP
+
FN
)
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MR Scanner
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Table 1
Examination Protocol
Sequences Native Dynamic ∗ Post-CM T2w-TSE Weighting T1 T1 T1 T2 Pulse sequence FLASH FLASH † FLASH TSE Orientation Coronal Transversal Coronal Transversal Time of repetition (ms) 113 113 113 8900 Echo time (ms) 4.6 4.6 4.6 207 Flip angle (°) 80 80 80 90 Slice thickness (mm) 3 3 3 3 Gap (mm) 0.3 0.3 0.3 0.3 Field of view (mm) 350 350 350 350 Number of slices 33 33 33 33 Matrix (pixel) 384 × 384 384 × 384 384 × 384 512 × 512
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Institutional Review Board Approval Statement
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Results
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Table 2
Malignant Lesions in the Patient Collective
Invasive carcinoma % ( n ) Invasive ductal carcinoma 78.5 (73/93) Invasive lobular carcinoma 12.9 (12/93) Invasive medullary carcinoma 2.2 (2/93) Invasive mucinous carcinoma 1.1 (1/93) Invasive tubular carcinoma 1.1 (1/93) Invasive tubulolobular carcinoma 1.1 (1/93) Invasive ductal and lobular carcinoma 3.2 (3/93) Total 100 (93) Noninvasive carcinoma DCIS 90.9 (10/11) LCIS 9.1 (1/11) Total 100 (11) Total malignant lesions 57.8 (104/180)
DCIS, Ductal carcinoma in situ; LCIS, Lobular carcinoma in situ.
Table 3
Benign Lesions in the Patient Collective
% ( n ) Neoplasia Papilloma 30.3 (23/76) Fibroadenoma 17.1 (13/76) Phyllodes tumor/hamartoma 2.6 (2/76) Hemangioma 1.3 (1/76) Total 51.3 (39/76) Mastopathic changes Fibrocystic changes 38.2 (29/76) Atypical ductal hyperplasia 10.5 (8/76) Total 48.7 (37/76) Total benign lesions 42.2 (76/180)
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Table 4
PE in Malignant versus Benign Tumors ( P < .000)
No PE, % ( n ) PE, % ( n ) Total Benign lesions 97 (74/76) 2.6 (2/76) 76 Noninvasive cancers 100 (11/11) 0 (0/11) 11 Invasive cancers 74 (69/93) 25.8 (24/93) 93 Total 154 26 180
PE, prepectoral edema.
Table 5
Statistical Results for Prepectoral Edema as an Indicator for Malignancy
% Sensitivity 19.3 Specificity 97.3 Positive predictive value 92.3 Negative predictive value 48 Accuracy 58
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Table 6
PE in Correlation to the Type of Carcinoma ( P = 1.000)
No PE, % ( n ) PE, % ( n ) Total IDC 74.0 (54/73) 26.0 (19/73) 73 Other CA types 75.0 (15/20) 25.0 (5/20) 20 Total 74.2 (69) 25.8 (24) 93
PE, prepectoral edema; CA, Cancer; IDC, Invasive ductal cancer.
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Table 7
PE in Correlation to Tumor Size ( P < .001)
No PE, % ( n ) PE, % ( n ) Total Tumor ≤ 2 cm 86.2 (50/58) 13.8 (8/58) 58 Tumor > 2 cm 51.4 (18/35) 48.5 (17/35) 35 Total 73.1 (68) 26.8 (25) 93
PE, prepectoral edema.
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Table 8
PE in Correlation to the Number of Foci
No PE, % ( n ) PE, % ( n ) Total 1 focus 79.6 (39/49) 20.4 (10/49) 49 2 foci 71.4 (10/14) 28.6 (4/14) 14 3–4 foci 76.9 (10/13) 23.1 (3/13) 13 5–7 foci 75.0 (6/8) 25.0 (2/8) 8 >7 foci 37.5 (3/8) 62.5 (5/8) 8 Total 73.9 (68) 26.1 (24) 92
PE, prepectoral edema.
Table 9
PE in Correlation to Accompanying DCIS/LCIS ( P = .811)
No PE PE Total DCIS not present 75.9 (41/54) 24.1 (13/54) 54 DCIS present 71.8 (28/39) 28.2 (11/39) 39 Total 74.2 (69) 25.8 (24) 93
PE, prepectoral edema; DCIS, Ductal carcinoma in situ; LCIS, Lobular carcinoma in situ.
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Discussion
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Study Limitations
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Conclusions
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