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Preliminary Results of a Simplified Breast MRI Protocol to Characterize Breast Lesions

Posted Oct 31, 2017 Updated Apr 10, 2023
By Valeria Romeo MD , Renato Cuocolo MD , Raffaele Liuzzi PhD , Albina Riccardi MD , Antonello Accurso MD , Alessra Acquaviva MD , Roberta Buonocore MD , Massimo Imbriaco MD
11 min read

Rationale and Objectives

This study aimed to investigate whether a simplified breast magnetic resonance imaging (MRI) protocol consisting of a localizer, one precontrast sequence, and three time-point postcontrast sequences (at 28 seconds, 84 seconds and 252 seconds after the contrast agent administration) is suitable for the characterization of breast lesions as compared to a full diagnostic protocol (FDP). This study also aimed to review the current literature concerning abbreviated breast MRI protocols and offer an alternative protocol.

Materials and Methods

Breast magnetic resonance (MR) examinations with detected breast lesions of 98 patients were retrospectively evaluated. Two expert radiologists in consensus reviewed the simplified breast protocol (SBP) first and only thereafter the regular FDP, recording a diagnosis for each detected lesion for both protocols. Receiver operating characteristic curve analysis was performed to determine the diagnostic performance of the SBP compared to the standard FDP. A revision of the previously reported abbreviated breast magnetic resonance protocols was also carried out.

Results

A total of 180 lesions were identified; of these, 110 (61%) were malignant and 70 (39%) were benign. Of the 110 malignant lesions, 86 (78%) were invasive ductal carcinoma, 18 (16%) were invasive lobular carcinoma, and 6 (6%) were ductal carcinoma in situ. Areas under the curve for the receiver operating characteristic curves for the SBP vs the FDP were equivalent (0.98 vs 0.99, respectively; P = 0.76). The SBP could be performed in approximately 6 minutes and 58 seconds, compared to 14 minutes and 48 seconds for the FDP.

Conclusions

An SBP protocol including a late postcontrast time point is accurate for the characterization of breast lesions and was comparable to the standard FDP protocol, allowing a potential reduction of the total acquisition and interpretation times.

Introduction

MMagnetic resonance imaging (MRI) is widely recognized as a useful imaging modality for the screening of high-risk women because of its higher sensitivity, for preoperative and post-treatment evaluation, for the investigation of carcinoma of unknown primary tumor or syndrome, and for patients without conclusive mammographic or sonographic imaging findings . Recently, there is increasing evidence on the use of abbreviated protocols (APs) for diagnostic purposes; many different abbreviated breast MRI protocols have been proposed as possible alternatives to the standard full breast MRI protocol to reduce acquisition time for breast cancer screening and for lesion characterization . In particular, Kuhl et al. have recently shown the accuracy of an AP for screening purpose, consisting of only one precontrast and one postcontrast acquisition and their derived images (first postcontrast subtracted and maximum intensity projection images). We have noticed that almost all the APs reported in the literature include a combination of morphologic T2-weighted sequence or early dynamic postcontrast time points; none of the above-mentioned APs include the later postcontrast time point, which is, according to our experience, as important as the first postcontrast time point to detect essential morphologic and dynamic breast lesions details. Therefore, the aim of this study was to investigate whether a breast MRI protocol consisting of a localizer, a precontrast acquisition, and three time-point postcontrast sequences (at 28, 84, and 252 seconds after the contrast agent administration), which we defined as a “simplified breast protocol” (SBP), is accurate for the characterization of breast lesions and faster as well, compared to a full diagnostic breast MRI protocol; we also aimed to revise the current literature concerning abbreviated breast MRI protocols.

Materials and Methods

Study Population

This retrospective study was approved by our local institutional review board.

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Standard Full Diagnostic MRI Protocol

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Simplified Breast MRI Protocol (SBP)

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Table 1

Comparison of the Full Diagnostic MRI Protocol vs the Simplified Breast MRI Protocol

Full Diagnostic MRI Protocol (14 min and 48 s) Simplified Breast MRI Protocol (6 min and 58 s) Scout view or localizer ( ~ 1 min) Scout view or localizer ( ~ 1 min) Axial T2-weighted sequence (5 min) Dynamic contrast-enhanced axial T1-weighted 3D sequence (5 min and 58 s) Dynamic contrast-enhanced axial T1-weighted 3D sequence (5 min and 58 s) \* Axial T1-weighted high-resolution THRIVE sequence (2 min and 50 s)

3D, three-dimensional; MRI, magnetic resonance imaging; THRIVE, T1-weighted high-resolution isovolumetric examination.

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Image Analysis

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Statistical Analysis

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Results

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Table 2

Final Diagnosis of Malignant and Benign Breast Lesions

Malignant Lesion_n_ = 110 61% Standard of Reference IDC 86 78% Histology ILC 18 16% Histology DCIS 6 6% Histology

Benign Lesion_n_ = 70 39% Standard of Reference Fibroadenoma 44 63% Follow-up ( n = 23) Histology ( n = 21) BI-RADS 3 lesions 18 26% Follow-up BI-RADS 2 lesions 8 11% Follow-up

BI-RADS, Breast Imaging Reporting and Data System; DCIS, ductal carcinoma in situ; IDC, invasive ductal carcinoma; ILC, invasive lobular carcinoma.

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Table 3

Sensitivity, Specificity, PPV, NPV, Diagnostic Accuracy and 95% Confidence Intervals (in Brackets) for the FDP vs the SBP for the Characterization of Breast Lesions in the Patient Population ( n = 98)

Sensitivity (%) Specificity (%) PPV (%) NPV (%) Accuracy \* FDP 97 (92–99) 95 (88–99) 97 (92–99) 95 (88–99) 0.990 (0.96–0.99) SBP 99 (95–99) 93 (84–97) 95 (90–98) 98 (91–99) 0.989 (0.96–0.99)P Value 0.62 0.72 0.72 0.62 0.76

FDP, full diagnostic protocol; NPV, negative predictive value; PPV, positive predictive value; SBP, simplified breast protocol.

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Figure 1, Example of a simplified breast magnetic resonance imaging protocol in a 50-year-old woman with a 14-mm invasive ductal carcinoma of the left breast, in the upper retroareolar region ( arrows ). Dynamic postcontrast subtracted images show that (a) at time point 1 (28 seconds), the mass has irregular margins with fast and heterogeneous enhancement; (b) at time point 2 (84 seconds), the margins of the mass become well depicted and spiculated; (c) at time point 5 (252 seconds), a focal area of intralesional hypointensity is detectable ( arrowhead ).

Figure 2, Example of simplified breast magnetic resonance imaging protocol in a 48-year-old woman with an 8-mm benign lesion in the left breast. Dynamic postcontrast subtracted images show a rounded mass with circumscribed margins and a slow, persistent, and homogeneous enhancement at 28 seconds (a) , 84 seconds (b) , 252 seconds (c) ( arrows ). The lesion was diagnosed as a fibroadenoma.

Figure 3, Example of a simplified breast magnetic resonance imaging protocol in a 37-year-old woman with a bilobed fibroadenoma in the upper inner quadrant of the right breast ( arrows ). Dynamic postcontrast subtracted images show a mass with a fast but homogeneous and progressive enhancement at 28 seconds (a) , 84 seconds (b) and 252 seconds (c) , with regular margins that are better defined in (b) and (c) compared to (a) .

Figure 4, Example of a simplified breast magnetic resonance imaging protocol in a 59-year-old woman with a 9-mm invasive ductal carcinoma in the retroareolar region of the right breast ( arrows ). Dynamic postcontrast subtracted images show the following: (a) at time point 1 (28 seconds), an irregular mass has a fast and heterogeneous enhancement; (b) at time point 2 (84 seconds), the mass has a more intense enhancement compared to the first time point, with progressive enlargement; (c) at time point 5 (252 seconds), the mass has a poor definition of lesion margins.

Figure 5, Receiver operating characteristic curve for the simplified breast protocol ( dotted line ) vs the full diagnostic protocol ( continuous line ) in the total number of lesions ( n = 180, in 98 patients). The value of the area under the curve is 0.989 for the simplified breast protocol vs 0.990 for the full diagnostic protocol ( P = 0.76).

Table 4

Summary of the Previous Published Articles Concerning Abbreviated Breast Magnetic Resonance Imaging Protocols

Author Purpose Abbreviated Protocol Duration Kuhl et al. 2014 Screening

3 minutes Mango et al. 2015 Screening

15 minutes Grimm et al. 2015 Screening Abbreviated 1

11 minutes Abbreviated 2

13 minutes Harvey et al. 2016 High-risk screening

4.4 minutes Moschetta et al. 2016 Characterization of breast lesions

10 minutes Machida et al. 2016 Screening

Not specified Chen et al. 2016 Screening in dense breast tissue

3 minutes Heacock et al. 2016 Evaluation of known breast cancer

12 minutes

MIP, maximum intensity projection; VIBE, volumetric interpolated breath-hold examination.

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Discussion

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Academic Radiology, Volume 24, Issue 11
Journals General Radiology
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