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PPV3 of Suspicious Breast MRI Findings

Posted Nov 30, 2014 Updated Apr 10, 2023
By Haydan Smith , Alison L. Chetlen DO , Susann Schetter DO , Julie Mack MD , Meredith Watts MD , Junjia (Jay) Zhu PhD
16 min read

Rationale and Objectives

Magnetic resonance imaging (MRI) characteristics of Breast Imaging Reporting and Data System (BI-RADS) 4 and 5 lesions were evaluated to identify characteristics that may improve the positive predictive value (PPV) of a biopsy.

Materials and Methods

MRI BI-RADS 4 or 5 breast findings in 101 women who underwent biopsy leading to a diagnosis of cancer within 1 year (PPV 3 ; n = 115 cases) were reviewed. Patient history, lesion morphology, enhancement pattern and kinetics, and T 2 characteristics were examined.

Results

The PPV 3 of all BI-RADS 4 and 5 breast lesions seen on MRI was 22.6% (26 of 115). Excluding lesions with second-look imaging correlates decreased the PPV 3 to 11.8% (6/51). Of the MRI-guided biopsies, 20.9% (24 of 115) yielded a high-risk lesion, altering surgical management. MRI lesion type did not significantly affect the PPV 3 : the PPV 3 was 26.3% (15 of 57) for masses, 21.4% (9 of 42) for non mass enhancement (NME) and 12.5% (2 of 16) for suspicious foci. The PPV 3 for lesions found on diagnostic MRI in women with newly diagnosed cancer was 30.8% (20 of 65) which was statistically significantly greater compared to a PPV 3 of 11.9% (5 of 42) for lesions identified on high-risk screening MRI.

Conclusions

Suspicious MRI findings identified on a second-look examination are more likely malignant than those seen only on MRI. Suspicious MRI findings discovered in patients with concurrent malignancy have a greater PPV 3 than those detected on high-risk screening MRIs. However, the type of MRI finding (mass vs. NME vs. foci) does not significantly affect the PPV 3 and should not be used as a discriminator for determining biopsy threshold.

Breast magnetic resonance imaging (MRI) is a highly sensitive imaging tool in the detection and characterization of breast cancer . MRI is useful in the evaluation of women with a new diagnosis of breast cancer to determine the extent of disease and screen the contralateral breast when there is a new diagnosis . There is also evidence that supplemental screening with MRI when women have a lifetime chance of malignancy of 20% is beneficial . Breast MRI is highly sensitive but less specific than ultrasound (US) or mammography . As a result, the recommendation for biopsy of a suspicious lesion may yield cancer in a lesser percentage of patients than when mammograms or US are used to diagnose cancer. Therefore, suspicious MRI findings would be expected to have a decreased positive predictive value (PPV 3 ) when compared to the PPV for suspicious findings identified on mammography and US.

There are a number of MRI characteristics that are considered predictive of malignancy, such as Breast Imaging Reporting and Data System (BI-RADS) assessment , lesion size , enhancement pattern , and enhancement kinetics . However, there is considerable overlap between suspicious and benign MRI characteristics.

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Materials and methods

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Results

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Method of Biopsy of Suspicious MRI Findings

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Figure 1, Method of biopsy of suspicious MRI findings: MRI BI-RADS 4 and 5 findings and subsequent method of biopsy and histologic results. High risk refers to the histologic classification of the lesion (ie, lobular neoplasia, atypical ductal hyperplasia, radial scar, papillary lesion). BI-RADS, Breast Imaging Reporting and Data System; MRI, magnetic resonance imaging.

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Histologic Outcome of Suspicious MRI Findings

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Figure 2, Histologic outcome of suspicious MRI findings: Malignancies detected on breast MRI and subsequent histology according to MRI morphology. High risk refers to the histologic classification of the lesion (ie, lobular neoplasia, atypical ductal hyperplasia (ADH), radial scar, papillary lesion). DCIS, ductal carcinoma in situ; MRI, magnetic resonance imaging; NME, non mass enhancement.

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Imaging Characteristics of Suspicious MRI Findings

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Table 1

Characteristics of Biopsy-Proven Malignancies

Characteristic Number of Carcinomas Invasive or In Situ Invasive In Situ Lesion type Mass 15 11 4 NME 9 5 4 Foci 2 2 0 Pattern of enhancement Homogeneous 15 11 4 Heterogeneous 10 6 4 Peripheral 1 1 0 Early enhancement kinetics Rapid 13 9 4 Medium 11 8 3 Slow 2 1 1 Late enhancement kinetics Persistent 5 3 2 Plateau 10 7 3 Washout 11 8 3 T 1 Hyperintense 0 0 0 Hypointense 13 10 3 Isointense 13 8 5 T 2 Hyperintense 16 11 5 Hypointense 1 1 0 Isointense 7 5 2 Slightly hyperintense 2 1 1 Total 26 18 8

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Morphology

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Figure 3, Imaging characteristics of suspicious MRI findings: Suspicious MRI findings according to MRI morphologic type (mass, NME, or focus) with subsequent method of biopsy and pathologic results. High risk refers to the histologic classification of the lesion (ie, lobular neoplasia, atypical ductal hyperplasia [ADH], radial scar, papillary lesion). BI-RADS, Breast Imaging Reporting and Data System; MRI, magnetic resonance imaging.

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Masses

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Non Mass Enhancement

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Foci

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Pattern of Enhancement

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Enhancement Kinetics

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T 2 Characteristics

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Indication for Breast MRIs

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Suspicious MRI Findings That Did Not Enhance on Day of Biopsy

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Discussion

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Method of Biopsy of Suspicious MRI Findings

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Imaging Characteristics of Suspicious MRI Findings

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Figure 4, Two different patients with newly diagnosed breast cancer with contralateral suspicious areas of NME, with similar appearing axial T 1 fat-saturated postcontrast subtraction images. Both areas underwent MRI-guided biopsy. (a) Axial T 1 fat-saturated postcontrast subtraction image of a 75-year-old female with newly diagnosed left breast invasive lobular carcinoma (ILC) demonstrates an additional suspicious finding in her contralateral breast. A focal area of clumped NME was seen in the right breast 9 o′ clock radian at middle depth ( arrow ). This NME was T 2 hyperintense and demonstrated moderate initial enhancement kinetics with plateau. There was no mammographic correlate. Histology from MRI-guided biopsy was malignant, demonstrating ILC and lobular carcinoma in situ (LCIS). (b) Axial T 1 fat-saturated postcontrast subtraction image of a 46-year-old woman with newly diagnosed invasive ductal carcinoma and lobular carcinoma in situ (LCIS) in the right breast. An additional lesion was found in the left breast ( arrow ) described as clumped heterogeneous NME. This finding was also hyperintense on T 2 and demonstrated rapid initial uptake of contrast with plateau enhancement kinetics. There was no mammographic correlate. Histology from MRI-guided biopsy was benign, demonstrating fibrocystic change and usual ductal hyperplasia. MRI, magnetic resonance imaging; NME, non mass enhancement.

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Morphology

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Pattern of Enhancement

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Enhancement Kinetics

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T 2 Characteristics

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Indication for Breast MRIs

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Strengths of the Study

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Limitations of the Study

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Conclusions

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Acknowledgments

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Academic Radiology, Volume 21, Issue 12
Journals General Radiology
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