In situ and minimally invasive breast cancer: morphologic and kinetic features on contrast-enhanced MR imaging

Ultrasound diagnosis of non-mass MRI-detected lesions

Magnetic resonance imaging (MRI)-detected lesions are often category 2 or 3 lesions on initial ultrasound examination. In addition, in the case of new non-mass lesions detected on MRI, one would expect to find lesions with ductal dilatation with minimal secretory accumulation, single short lesions with ductal dilatation, cyst-like lesions less than 5 mm in size, mammary gland-like lesions less than 8 mm in size, and very indistinct lesions. Detection is expected to be even more difficult. Currently, there are no clear uniform criteria for the indication of second-look ultrasonography (US) for MRI-detected lesions, so it is not possible to make a general comparison, but recent studies have indicated that the ratio of mass to non-mass MRI-detected lesions is 7:3. And it has been pointed out that the percentage of malignancy is about 30% for each. Before about 2012, the US detection rate was about 70%, and MRI-guided biopsies of undetected lesions showed a small percentage of malignant lesions. Therefore, some observers believe that lesions not detected on US should be followed up, while others believe that MRI-guided biopsy should be performed. Recently, however, the use of surrounding anatomical structures as landmarks for second-look US has increased the detection rate to as high as 87-99%, and the percentage of malignancy remains the same. In addition, recent surveillance of high-risk breast cancer requires careful management of MRI-detected lesions. In this review, we will discuss the literature on MRI-detected lesions and describe ultrasound techniques to accurately detect small lesions and reliably reveal pale lesions based on their structural differences from their surroundings.

An Unusual Presentation of Extensive Ductal Carcinoma in Situ Accompanying Invasive Ductal Carcinoma on MRI: A Case Report

The incidence of ductal carcinoma in situ has increased with the rise in screening mammography; currently, ductal carcinoma in situ constitutes 20%-25% of all breast cancers, and up to half of them may become invasive. Its early detection is critical in improving the cure rate. Moreover, MRI has higher sensitivity for its detection than mammography. Herein, we report an unusual case of ductal carcinoma in situ presenting as a continuous, serpentine, linear enhancement with regional distribution on MRI.

Pure Ductal Carcinoma In Situ of the Breast: Analysis of 270 Consecutive Patients Treated in a 9-Year Period

Simple Summary

Ductal carcinoma in situ (DCIS) accounts for 20 to 25% of all breast cancers and its incidence of progression to invasive ductal carcinoma is at least 13 to 50%. The aim of our retrospective observational analysis is to review the issues of this histological type of cancer. We confirmed in a wide population of 270 consecutive patients who underwent surgery in a single institute that the management of DCIS can be difficult and particularly complex. There are many variables to be taken into consideration such as the choice of the diagnostic and bioptical technique. This delicate management must be carried out in specialized centres such as Breast Units involving multiple professional figures to define and guarantee the best possible treatment for each patient.

Abstract

Introduction: Ductal carcinoma in situ (DCIS) is an intraductal neoplastic proliferation of epithelial cells that are confined within the basement membrane of the breast ductal system. This retrospective observational analysis aims at reviewing the issues of this histological type of cancer. Materials and methods: Patients treated for DCIS between 1 January 2009 and 31 December 2018 were identified from a retrospective database. The patients were divided into two groups of 5 years each, the first group including patients treated from 2009 to 2013, and the second group including patients treated from 2014 to 2018. Once the database was completed, we performed a statistical analysis to see if there were significant differences among the 2 periods. Statistical analyses were performed using GraphPad Prism software for Windows, and the level of significance was set at p < 0.05. Results: 3586 female patients were treated for breast cancer over the 9-year study period (1469 patients from 2009 to 2013 and 2117 from 2014 to 2018), of which 270 (7.53%) had pure DCIS in the final pathology. The median age of diagnosis was 59-year-old (range 36–86). In the first period, 81 (5.5%) women out of 1469 had DCIS in the final pathology, in the second, 189 (8.9%) out of 2117 had DCIS in the final pathology with a statistically significant increase (p = 0.0001). From 2009 to 2013, only 38 (46.9%) were in stage 0 (correct DCIS diagnosis) while in the second period, 125 (66.1%) were included in this stage. The number of patients included in clinical stage 0 increased significantly (p = 0.004). In the first period, 48 (59.3%) specimen margins were at a greater or equal distance than 2 mm (negative margins), between 2014 and 2018; 137 (72.5%) had negative margins. Between 2014 and 2018 the number of DCIS patients with positive margins decreased significantly (p = 0.02) compared to the first period examined. The mastectomies number increased significantly (p = 0.008) between the 2 periods, while the sentinel lymph node biopsy (SLNB) numbers had no differences (p = 0.29). For both periods analysed all the 253 patients who underwent the follow up are currently living and free of disease. We have conventionally excluded the 17 patients whose data were lost. Conclusion: The choice of the newest imaging techniques and the most suitable biopsy method allows a better pre-operative diagnosis of the DCIS. Surgical treatment must be targeted to the patient and a multidisciplinary approach discussed in the Breast Unit centres.

The role of MRI and clinicopathologic features in predicting the invasive component of biopsy-confirmed ductal carcinoma in situ

Background

The upgrade rate of biopsy-confirmed ductal carcinoma in situ (DCIS) to invasive carcinoma is up to 50% on final pathology. We investigated MRI and clinicopathologic predictors of the invasive components of DCIS diagnosed by preoperative biopsy and then compared MRI features between patients with DCIS, microinvasive ductal carcinoma (mIDC), and invasive ductal carcinoma (IDC) diagnosed on final pathology.

Methods

Two hundred and one patients with 206 biopsy-confirmed DCIS lesions were enrolled. MRI and clinicopathologic features were used to predict either mIDC or IDC via a cumulative logistic regression analysis. For the lesions detected on MRI, morphologic and kinetic analyses were performed using the Chi-square, Fisher’s exact, and Kruskal-Wallis tests.

Results

Of all the lesions, 112 (54.4%) were diagnosed as DCIS, 50 (24.3%) were upgraded to mIDC, and 44 (21.4%) to IDC. The detection on MRI as mass (Odds ratio (OR) = 8.84, 95% confidence interval (CI) = 1.05–74.04, P = 0.045) or non-mass enhancement (NME; OR = 11.17, 95% CI = 1.35–92.36, P = 0.025), negative progesterone receptor (PR; OR = 2.40, 95% CI = 1.29–4.44, P = 0.006), and high Ki-67 level (OR = 2.42, 95% CI = 1.30–4.50, P = 0.005) were significant independent predictors of histologic upgrade. On MRI, 87 (42.2%) lesions appeared as mass and 107 (51.9%) as NME. Irregularly shaped, not-circumscribed, heterogeneous, or rim-enhancing masses with intratumoral high signal intensity or peritumoral edema, clumped or clustered ring-enhancing NMEs, and high peak enhancement were significantly associated with histologic upgrade (P < 0.001).

Conclusion

MRI detection, negative PR, and high Ki-67 levels are associated with a histologic upgrade in patients with biopsy-confirmed DCIS. Suspicious MRI features are more frequent in such patients.

Magnetic resonance imaging of the breast: role in the evaluation of ductal carcinoma in situ

Ductal carcinoma in situ (DCIS) is a precursor mammary lesion whose malignant cells do not extend beyond the basement membrane and presents a risk of progression to malignant disease. Its early detection increased with screening mammography. The objective of this study was to review the literature on the main presentations of DCIS on magnetic resonance imaging (MRI), through searches of the Medline/PubMed, Latin-American and Caribbean Center on Health Sciences Information (Lilacs), and Scientific Electronic Library Online (SciELO) databases. DCIS can occur in its pure form or in conjunction with invasive disease, in the same lesion, in different foci, or in the contralateral breast. MRI has a high sensitivity for the detection of pure DCIS, being able to identify the non-calcified component, and its accuracy increases with the nuclear grade of the lesion. The most common pattern of presentation is non-nodular enhancement; heterogeneous internal structures; a kinetic curve showing washout or plateau enhancement; segmental distribution; and restricted diffusion. MRI plays an important role in the detection of DCIS, especially in the evaluation of its extent, contributing to more reliable surgical excision and reducing local recurrence.

Predictive values of BI-RADS(®) magnetic resonance imaging (MRI) in the detection of breast ductal carcinoma in situ (DCIS)

PURPOSE

The purpose of this study was to evaluate BI-RADS indicators in the detection of DCIS by MRI.

MATERIALS AND METHODS

Prospective observational study that started in 2014 and lasted 24 months. A total of 110 consecutive patients were evaluated, who presented with suspicious or highly suspicious microcalcifications on screening mammography (BI-RADS categories 4 and 5) and underwent stereotactic-guided breast biopsy, having had an MRI scan performed prior to biopsy.

RESULTS

Altogether, 38 cases were characterized as positive for malignancy, of which 25 were DCIS and 13 were invasive ductal carcinoma cases. MRI had a sensitivity of 96%; specificity of 75.67%; positive predictive value (PPV) for DCIS detection of 57.14%; negative predictive value (NPV) in the detection of DCIS of 98.24%; and an accuracy of 80.80%.

CONCLUSION

BI-RADS as a tool for the detection of DCIS by MRI is a powerful instrument whose sensitivity was higher when compared to that observed for mammography in the literature. Likewise, the PPV obtained by MRI was higher than that observed in the present study for mammography, and the high NPV obtained on MRI scans can provide early evidence to discourage breast biopsy in selected cases.

The role of preoperative breast magnetic resonance (MR) imaging for surgical decision in patients with triple-negative breast cancer

BACKGROUND

Several reliable randomized studies do not recommend routine preoperative breast MR imaging for patients with breast cancer. However, because the principle of MR imaging is based on the dynamics of contrast enhancement, a specific biologic subgroup of tumors should sensitively respond to the imaging process.

METHODS

From 2008 to 2013, 918 eligible patients with breast cancer underwent breast surgery and were divided into two groups based on preoperative breast MR findings: patients in whom the surgical plan was changed and those in whom the surgical plan remained unchanged. We investigated the changing patterns of breast surgery based on routine mammography, ultrasound, and preoperative breast magnetic resonance (MR) findings and analyzed the association between additional suspicious lesions on breast MR imaging and clinicopathologic factors.

RESULTS

Additional suspicious breast lesions were detected on preoperative MR imaging in 104 cases (11.3%), and the surgical strategy was changed as the final decision in 97 cases (10.6%). There was no difference between oncologic results between two groups. However, the triple-negative breast cancer (TNBC) was significantly associated with changing of the surgical strategy based on breast MR findings (P = 0.048).

CONCLUSIONS

Additional preoperative breast MR imaging may be helpful in surgical decision for patients with TNBC.

Breast magnetic resonance imaging performance: safety, techniques, and updates on diffusion-weighted imaging and magnetic resonance spectroscopy

Dynamic contrast-enhanced breast magnetic resonance imaging (MRI) is a well-established, highly sensitive technique for the detection and evaluation of breast cancer. Optimal performance of breast MRI continues to evolve. This article addresses breast MRI applications, covers emerging breast MRI safety concerns; outlines the technical aspects of breast MRI, including equipment and protocols at 3 T and 1.5 T; and describes current promising areas of research including diffusion-weighted imaging and magnetic resonance spectroscopy.

MRI kinetics with volumetric analysis in correlation with hormonal receptor subtypes and histologic grade of invasive breast cancers

OBJECTIVE. The aim of this study was to assess whether computer-assisted detection-processed MRI kinetics data can provide further information on the biologic aggressiveness of breast tumors. MATERIALS AND METHODS. We identified 194 newly diagnosed invasive breast cancers presenting as masses on contrast-enhanced MRI by a HIPAA-compliant pathology database search. Computer-assisted detection-derived data for the mean and median peak signal intensity percentage increase, most suspicious kinetic curve patterns, and volumetric analysis of the different kinetic patterns by mean percentage tumor volume were compared against the different hormonal receptor (estrogen-receptor [ER], progesterone-receptor [PR], ERRB2 (HER2/neu), and triple-receptor expressivity) and histologic grade subgroups, which were used as indicators of tumor aggressiveness. RESULTS. The means and medians of the peak signal intensity percentage increase were higher in ER-negative, PR-negative, and triple-negative (all p ≤ 0.001), and grade 3 tumors (p = 0.011). Volumetric analysis showed higher mean percentage volume of rapid initial enhancement in biologically more aggressive ER-negative, PR-negative, and triple-negative tumors compared with ER-positive (64% vs 53.6%, p = 0.013), PR-positive (65.4% vs 52.5%, p = 0.001), and nontriple-negative tumors (65.3% vs 54.6%, p = 0.028), respectively. A higher mean percentage volume of rapid washout component was seen in ERRB2-positive tumors compared with ERRB2-negative tumors (27.5% vs 17.9%, p = 0.020). CONCLUSION. Peak signal intensity percentage increase and volume analysis of the different kinetic patterns of breast tumors showed correlation with hormonal receptor and histologic grade indicators of cancer aggressiveness. Computer-assisted detection-derived MRI kinetics data have the potential to further characterize the aggressiveness of an invasive cancer.

MR features to suggest microinvasive ductal carcinoma of the breast: can it be differentiated from pure DCIS?

BACKGROUND

Morphologic and kinetic characteristics of breast lesions are regarded as a major criterion for their differential diagnosis in dynamic magnetic resonance imaging (MRI). However, there have not been well-reported MRI findings of microinvasive ductal carcinoma.

PURPOSE

To evaluate MRI characteristics of microinvasive ductal carcinoma of the breast and to compare MRI findings in patients with microinvasive ductal carcinoma and pure ductal carcinoma in situ (DCIS).

MATERIAL AND METHODS

Eighty-one patients with pathologically confirmed microinvasive ductal carcinomas (n = 37) or pure DCIS (n = 44) were included in this study. The MRI findings were analyzed without knowledge of the pathologic and conventional imaging findings. For all the lesions detected on MRI, morphologic and kinetic analyses were performed according to the Breast Imaging Reporting and Data System. For the non-mass lesions, the presence of clustered ring enhancement was also analyzed. Statistical analyses were performed using Student's t test, χ(2) test, and Fisher's exact test.

RESULTS

In total 35 cases of microinvasive ductal carcinoma and 39 cases of DCIS were detected on MRI. The most common and dominant MRI findings of microinvasive ductal carcinoma and DCIS were non-mass lesions with heterogeneous enhancement. However, the spiculated margin of the mass-type lesion (P = 0.022), the segmental distribution (P = 0.023), and clustered ring enhancement (P = 0.006) of the non-mass-type lesion, and the enhancement kinetics showing strong initial enhancement (P = 0.004) with subsequent wash-out (P = 0.001) were significantly more frequent in microinvasive ductal carcinoma than in DCIS.

CONCLUSION

Non-mass lesions with segmental distribution, heterogeneous enhancement, and strong initial enhancement with a wash-out curve were the dominant MRI findings of microinvasive ductal carcinoma. Compared with DCIS, microinvasive ductal carcinoma showed more suspicious imaging characteristics. For the non-mass lesions, clustered ring enhancement was also a characteristic finding of microinvasion on MRI.

Dynamic contrast-enhanced MRI reveals the extent and the microvascular pattern of breast ductal carcinoma in situ

To report the role of magnetic resonance imaging (MRI) in assessing the extent of breast ductal carcinoma in situ (DCIS). To assess whether the microvascularity pattern in DCIS correlates with magnetic resonance enhancement. Eighty-five histologically proven DCIS (77 pure DCIS, eight microinvasive DCIS) were prospectively studied with MRI. The morphology of magnetic resonance enhancement and the kinetic curve was recorded. Histopathologically, intraductal lesions were classified according to Van Nuys score. Tumor microvascularity was immunohistochemically assessed in a subset of 24 DCIS evaluating the number of microvessels, microvascularity area, and microvascularity pattern (diffuse or periductal). On the mammogram, 74% of DCIS appeared as microcalcifications. On MRI, 70% of DCIS showed enhancement. Non-mass-like uptake was observed in 78% of cases. The mean size of nonenhancing carcinomas was significantly lower than that of enhancing carcinomas (p = 0.033). The diffuse pattern was more frequent than the periductal pattern. A significant relationship between the morphology of MR enhancement and the microvascularity pattern was observed (p = 0.036); thus, 90% of DCIS showing segmental enhancement on MRI displayed a diffuse pattern while all DCIS with ductal enhancement showed a periductal pattern. There was a significant relationship between the maximum area of microvascularity and the vascular pattern (p = 0.015); periductal patterns showed larger areas than diffuse patterns. The lesion size was significantly larger as the Van Nuys score increased (p < 0.001) and was also related to the number of microvessels (p = 0.012). The mean area of microvascularity of DCIS was significantly larger as the Van Nuys score increased (p = 0.02). Breast MRI helps depict the extent of DCIS and reveals its microvascular pattern.

MRI findings of cancers preoperatively diagnosed as pure DCIS at core needle biopsy

BACKGROUND

Under-estimation of invasion components occur occasionally at core needle diagnosed ductal carcinoma in situ (DCIS) that may change the prognosis or treatment planning.

PURPOSE

To determine whether enhanced magnetic resonance imaging (MRI) features of biopsy-proven ductal cancers in situ help predict the under-estimation of invasive breast cancers.

MATERIAL AND METHODS

After a retrospective review of the enhanced MRI features on preoperative proven breast ductal cancers in situ by biopsy, tumor morphology (mass and non-mass), enhancing curve patterns, and non-mass enhanced appearances were compared between pure ductal cancers in situ and invasive ductal cancers (IDCs) after surgery. A statistical analysis was performed, and P values <0.05 were deemed significant.

RESULTS

Twenty-five breast cancers from 24 women were analyzed. Eleven DCIS remained as DCISs, and 14 were upgraded to IDC after surgery. Eight of 14 IDCs (57%) and one of 11 DCISs (9%) presented as mass lesions; otherwise six (43%) IDCs and 10 (91%) DCISs were non-mass lesions (P = 0.013). Among the non-mass cancers, six of 10 DCISs (60%) were focally enhanced and six of 6 IDCs (100%) were segmentally enhanced. The overall cancer sizes measured on enhanced MRI were moderately correlated with histopathology, with a Spearman's rank correlation coefficient of 0.656 (P = 0.001). The mean diameter of the IDCs was larger than that of the pure DCISs on enhanced MRI (2.69 ± 1.42 cm for IDC and 1.62 ± 1.03 cm for DCIS; P = 0.048). The cut-off size was optimally selected at 1.95 cm with a 64% sensitivity and a 77% specificity, using a receiver-operating characteristic curve. The enhancement curves, with washout or persistent rising, were statistically insignificant (P = 0.085 and 0.93, respectively).

CONCLUSION

Enhanced MRI provided informative morphology and size features that might help to predict the underestimation of invasiveness in preoperative biopsy-proven DCIS.

The diverse pathology and kinetics of mass, nonmass, and focus enhancement on MR imaging of the breast

PURPOSE

To compare the pathology and kinetic characteristics of breast lesions with focus-, mass-, and nonmass-like enhancement.

MATERIALS AND METHODS

A total of 852 MRI detected breast lesions in 697 patients were selected for an IRB approved review. Patients underwent dynamic contrast enhanced MRI using one pre- and three to six postcontrast T(1)-weighted images. The "type" of enhancement was classified as mass, nonmass, or focus, and kinetic curves quantified by the initial enhancement percentage (E(1)), time to peak enhancement (T(peak)), and signal enhancement ratio (SER). These kinetic parameters were compared between malignant and benign lesions within each morphologic type.

RESULTS

A total of 552 lesions were classified as mass (396 malignant, 156 benign), 261 as nonmass (212 malignant, 49 benign), and 39 as focus (9 malignant, 30 benign). The most common pathology of malignant/benign lesions by morphology: for mass, invasive ductal carcinoma/fibroadenoma; for nonmass, ductal carcinoma in situ (DCIS)/fibrocystic change(FCC); for focus, DCIS/FCC. Benign mass lesions exhibited significantly lower E(1), longer T(peak), and lower SER compared with malignant mass lesions (P < 0.0001). Benign nonmass lesions exhibited only a lower SER compared with malignant nonmass lesions (P < 0.01).

CONCLUSION

By considering the diverse pathology and kinetic characteristics of different lesion morphologies, diagnostic accuracy may be improved.

3-5 BI-RADs Microcalcifications: Correlation between MRI and Histological Findings

Purpose. To evaluate the correlation between MRI and histopathological findings in patients with mammographically detected 3–5 BI-RAD (Breast Imaging Reporting And Data Systems) microcalcifications and to allow a better surgical planning. Materials and Method. 62 female Patients (age 50 ± 12) with screening detected 3–5 BI-RAD microcalcifications underwent dynamic 3 T contrast-enhanced breast MRI. After 30-day (range 24–36 days) period, 55 Patients underwent biopsy using stereotactic vacuum-assisted biopsy (VAB), 5 Patients underwent stereotactic mammographically guided biopsy, and 2 Patients underwent MRI-guided VAB. Results. Microhistology examination demonstrated 36 malignant lesions and 26 benign lesions. The analysis of MRI findings identified 8 cases of MRI BI-RADS 5, 23 cases of MRI BI-RADS 4, 11 cases of MRI BI-RADS 3, 4 cases type A and 7 cases type B, and 20 cases of MRI BI-RADS 1-2. MRI sensitivity, specificity, positive predictive value, and negative predictive value were 88.8%, 76.9%, 84.2%, and 83.3%, respectively.

Can breast magnetic resonance imaging demonstrate characteristic findings of preoperative ductal carcinoma in situ in Taiwanese women?

OBJECTIVE

Magnetic resonance imaging (MRI) is more sensitive than mammography and sonography for breast cancer detection, but its diagnostic specificity is still being debated, and standardised criteria are lacking.

METHODS

This study used a dedicated breast MRI system with a Spiral RODEO pulse sequence, and applied postprocessing techniques including multiplanar reformation (MPR) with ductal orientation, early subtracted phase (ESP) and a postcontrast kinetic curve. We discuss the possible MRI/pathology correlations based on pathogenetic concepts. We retrospectively collected data from 13 cases of benign intraductal and early-stage malignant lesions to observe the capability of MPR, ESP and kinetic curve techniques to diagnose early lesions differentially. MRI features and pathological findings for these cases were collected.

RESULTS

Thirteen cases of ductal carcinoma in situ with MRI characteristics and pathological findings were identified. We analysed early ductal lesions, such as intraductal epithelial hyperplasia, intraductal papilloma, ductal carcinoma in situ and small focal invasive ductal carcinoma. Using MRI with MPR to demonstrate ductal orientation, we found 12 cases with a ductogram appearance and 6 with crossing-over glandular tissue. The tumour size estimated by MRI was accurate in 6 cases, but overestimated in seven.

CONCLUSION

Dedicated breast MRI with MPR, ESP and kinetic curve analyses might be helpful in defining some characteristics of early-stage malignant lesions.

Characterization of Pure Ductal Carcinoma In Situ on Dynamic Contrast-Enhanced MR Imaging: Do Nonhigh Grade and High Grade Show Different Imaging Features?

To characterize imaging features of pure DCIS on dynamic contrast-enhanced MR imaging (DCE-MRI), 31 consecutive patients (37-81 years old, mean 56), including 2 Grade I, 16 Grade II, and 13 Grade III, were studied. MR images were reviewed retrospectively and the morphological appearances and kinetic features of breast lesions were categorized according to the ACR BI-RADS breast MRI lexicon. DCE-MRI was a sensitive imaging modality in detecting pure DCIS. MR imaging showed enhancing lesions in 29/31 (94%) cases. Pure DCIS appeared as mass type or non-mass lesions on MRI with nearly equal frequency. The 29 MR detected lesions include 15 mass lesions (52%), and 14 lesions showing non-mass-like lesions (48%). For the mass lesions, the most frequent presentations were irregular shape (50%), irregular margin (50%) and heterogeneous enhancement (67%). For the non-mass-like lesions, the clumped internal enhancement pattern was the dominate feature, seen in 9/14 cases (64%). Regarding enhancement kinetic curve, 21/29 (78%) lesions showed suspicious malignant type kinetics. No significant difference was found in morphology (P > .05), tumor size (P = 0.21), and kinetic characteristics (P = .38) between non-high grade (I+II) and high-grade (III) pure DCIS.

Characterizing early contrast uptake of ductal carcinoma in situ with high temporal resolution dynamic contrast-enhanced MRI of the breast: a pilot study

Improvements in the reliable diagnosis of preinvasive ductal carcinoma in situ (DCIS) by dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) are needed. In this study, we present a new characterization of early contrast kinetics of DCIS using high temporal resolution (HiT) DCE-MRI and compare it with other breast lesions and normal parenchyma. Forty patients with mammographic calcifications suspicious for DCIS were selected for HiT imaging using T(1)-weighted DCE-MRI with ∼7 s temporal resolution for 90 s post-contrast injection. Pixel-based and whole-lesion kinetic curves were fit to an empirical mathematical model (EMM) and several secondary kinetic parameters derived. Using the EMM parameterized and fitted concentration time curve for subsequent analysis allowed for calculation of kinetic parameters that were less susceptible to fluctuations due to noise. The parameters' initial area under the curve (iAUC) and contrast concentration at 1 min (C(1 min)) provided the highest diagnostic accuracy in the task of distinguishing pathologically proven DCIS from normal tissue. There was a trend for DCIS lesions with solid architectural pattern to exhibit a negative slope at 1 min (i.e. increased washout rate) compared to those with a cribriform pattern (p < 0.04). This pilot study demonstrates the feasibility of quantitative analysis of early contrast kinetics at high temporal resolution and points to the potential for such an analysis to improve the characterization of DCIS.

Magnetic resonance imaging of the breast: recommendations from the EUSOMA working group

The use of breast magnetic resonance imaging (MRI) is rapidly increasing. EUSOMA organised a workshop in Milan on 20-21st October 2008 to evaluate the evidence currently available on clinical value and indications for breast MRI. Twenty-three experts from the disciplines involved in breast disease management - including epidemiologists, geneticists, oncologists, radiologists, radiation oncologists, and surgeons - discussed the evidence for the use of this technology in plenary and focused sessions. This paper presents the consensus reached by this working group. General recommendations, technical requirements, methodology, and interpretation were firstly considered. For the following ten indications, an overview of the evidence, a list of recommendations, and a number of research issues were defined: staging before treatment planning; screening of high-risk women; evaluation of response to neoadjuvant chemotherapy; patients with breast augmentation or reconstruction; occult primary breast cancer; breast cancer recurrence; nipple discharge; characterisation of equivocal findings at conventional imaging; inflammatory breast cancer; and male breast. The working group strongly suggests that all breast cancer specialists cooperate for an optimal clinical use of this emerging technology and for future research, focusing on patient outcome as primary end-point.

Relationship of temporal resolution to diagnostic performance for dynamic contrast enhanced MRI of the breast

PURPOSE

To investigate the relationship between temporal resolution of dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) and classification of breast lesions as benign versus malignant.

MATERIALS AND METHODS

Patients underwent T(1)-weighted DCE MRI with 15 s/acquisition temporal resolution using 1.5 Tesla (n = 48) and 3.0T (n = 33) MRI scanners. Seventy-nine patients had pathologically proven diagnosis and 2 had 2 years follow-up showing no change in lesion size. The temporal resolution of DCE MRI was systematically reduced as a postprocessing step from 15 to 30, 45, and 60 s/acquisition by eliminating intermediate time points. Average wash-in and wash-out slopes, wash-out percentage changes, and kinetic curve shape (persistently enhancing, plateau, or wash-out) were compared for each temporal resolution. Logistic regression and receiver operating characteristic (ROC) curve analysis were used to compare kinetic parameters and diagnostic accuracy.

RESULTS

Sixty patients (74%) had malignant lesions and 21 patients (26%) had benign lesions. All temporal-resolution parameters significantly predicted benign versus malignant diagnosis (P < 0.05). However, 45 s/acquisition and higher temporal-resolution datasets showed higher accuracy than the 60 s/acquisition dataset by ROC curve analysis (0.72 versus 0.69 for average wash-in slope; 0.85 versus 0.82, for average wash-out slope; and 0.88 versus 0.80 for kinetic curve shape assessment, for 45 s/acquisition versus 60 s/acquisition temporal-resolution datasets, respectively (P = 0.027).

CONCLUSION

DCE MRI data with at least 45-s temporal resolution maximized the agreement between the kinetic parameters and correct classification of benign versus malignant diagnosis.

Ductal carcinoma in situ of the breast: a systematic review of incidence, treatment, and outcomes

BACKGROUND

The National Institutes of Health Office of Medical Applications of Research commissioned a structured literature review on the incidence, treatment, and outcomes of ductal carcinoma in situ (DCIS) as a background article for the State of the Science Conference on Diagnosis and Management of DCIS.

METHODS

Published studies were identified and abstracted from MEDLINE and other sources. We include articles published between 1965 and January 31, 2009; 374 publications were identified that addressed DCIS incidence, staging, treatment, and outcomes in adult women.

RESULTS

In the United States, DCIS incidence rose from 1.87 per 100 000 in 1973-1975 to 32.5 in 2004. Incidence increased in all ages but more so in women older than 50 years. Increased use of mammography explains some but not all of the increased incidence. Risk factors for incident DCIS include older age and family history. Although tamoxifen treatment prevented both invasive breast cancer and DCIS, raloxifene treatment decreased incidence of invasive breast cancer but not DCIS. Among patients with DCIS, magnetic resonance imaging was more sensitive than mammography for detecting multicentric disease and estimating tumor size. Because about 15% of patients with DCIS identified on core needle biopsy are diagnosed with invasive breast cancer after excision or mastectomy, the accuracy of sentinel lymph node biopsy after excision is relevant to surgical management of DCIS. Most studies demonstrated that sentinel lymph node biopsy is feasible after breast-conserving surgery (BCS). Younger age, positive surgical margins, tumor size and grade, and comedo necrosis were consistently related to DCIS recurrence. DCIS outcomes after either mastectomy or BCS plus radiation therapy were superior to BCS alone. Tamoxifen treatment after DCIS diagnosis reduced risk of recurrent disease.

CONCLUSIONS

Scientific questions deserving further investigation include the relationship between mammography use and DCIS incidence and whether imaging technologies and treatment guidelines can be modified to focus on lesions that are most likely to become clinically problematic.

Kinetic curves of malignant lesions are not consistent across MRI systems: need for improved standardization of breast dynamic contrast-enhanced MRI acquisition

OBJECTIVE

The purpose of this study was to compare MRI kinetic curve data acquired with three systems in the evaluation of malignant lesions of the breast.

MATERIALS AND METHODS

The cases of 601 patients with 682 breast lesions (185 benign, 497 malignant) were selected for review. The malignant lesions were classified as ductal carcinoma in situ (DCIS), invasive ductal carcinoma (IDC), and other. The dynamic MRI protocol consisted of one unenhanced and three to seven contrast-enhanced images acquired with one of three imaging protocols and systems. An experienced radiologist analyzed the shapes of the kinetic curves according to the BI-RADS lexicon. Several quantitative kinetic parameters were calculated, and the kinetic parameters of malignant lesions were compared across the three systems.

RESULTS

Imaging protocol and system 1 were used to image 304 malignant lesions (185 IDC, 62 DCIS); imaging protocol and system 2, 107 lesions (72 IDC, 21 DCIS); and imaging protocol and system 3, 86 lesions (64 IDC, 17 DCIS). Compared with those visualized with imaging protocols and systems 1 and 2, IDC lesions visualized with imaging protocol and system 3 had significantly less initial enhancement, longer time to peak enhancement, and a slower washout rate (p < 0.004). Only 47% of IDC lesions imaged with imaging protocol and system 3 exhibited washout type curves, compared with 75% and 74% of those imaged with imaging protocols and systems 2 and 1, respectively. The diagnostic accuracy of kinetic analysis was lowest for imaging protocol and system 3, but the difference was not statistically significant.

CONCLUSION

The kinetic curve data on malignant lesions acquired with one system showed significantly lower initial contrast uptake and a different curve shape in comparison with data acquired with the other two systems. Differences in k-space sampling, T1 weighting, and magnetization transfer effects may be explanations for the difference.

Accuracy of MRI for estimating residual tumor size after neoadjuvant chemotherapy in locally advanced breast cancer: relation to response patterns on MRI

BACKGROUND

This study evaluated the accuracy of magnetic resonance imaging (MRI) for estimating residual tumor size after neoadjuvant chemotherapy in patients with locally advanced breast cancer and assessed whether the tumor pattern on MRI after chemotherapy influenced the accuracy of the MRI measurement of the residual tumor size.

PATIENTS AND METHODS

Fifty patients who received neoadjuvant chemotherapy with doxorubicin and docetaxel for locally advanced breast cancer were evaluated with MRI before and after chemotherapy. We compared the residual tumor size measured by MRI with the pathologically determined size and investigated the influence of the residual tumor pattern on MRI (shrinkage, nest or rim, and mixed) and pathologic characteristics on the accuracy of the MRI measurement.

RESULTS

The correlation coefficient between the residual tumor sizes determined by MRI and by pathology was 0.645. The MRI measurement agreed with the pathologically determined size in 36 patients (72%) and disagreed in 14 patients 928%), overestimating the size in 13 (26%) and underestimating the size in one (2%). disagreement appeared to be more frequent in the cases showing a nest or rim pattern than in those exhibiting a shrinkage pattern, although this was not statistically significant (p = 0.119).

CONCLUSIONS

MRI is an accurate method for predicting the extent of residual tumor after neoadjuvant chemotherapy; however, it may overestimate the residual disease, especially in cases showing a nest or rim tumor pattern and in those having combined lesions with ductal carcinoma in situ or multiple scattered nodules after neoadjuvant chemotherapy.

Magnetic resonance imaging of ductal carcinoma in situ: what is its clinical application? A review

BACKGROUND

After breast-conserving surgery of ductal carcinoma in situ (DCIS) of the breast or invasive breast carcinoma with an extensive intraductal component, tumor-positive surgical margins are frequently found. Therefore, the extent of the intraductal disease needs to be accurately determined preoperatively.

METHODS

Data for this review were identified by search of PubMed. Reference lists of selected articles were cross-searched for additional literature.

RESULTS

DCIS is accurately detected with magnetic resonance imaging (MRI), but the typical malignant features are inconsistently seen and most often in high-grade DCIS or in DCIS with a small invasive component. The histopathologic extent of DCIS is more accurately demonstrated with MRI. However, overestimation due to benign proliferative lesions does frequently occur. An improved depiction of DCIS could lead to improved preoperative staging. Conversely, the identification of more extensive disease on MRI could give rise to unnecessary interventions. Therefore, MRI should be used carefully and preferable in specialized and experienced centers.

CONCLUSION

[corrected] To date, there is no evidence that the use of MRI improves outcomes (ie, decreases recurrence rates) in patients with DCIS.

The effect of margins on the clinical management of ductal carcinoma in situ of the breast

Complete excision is key to successful breast-conserving treatment for patients diagnosed with ductal carcinoma in situ (DCIS). Patients with extensive DCIS should be considered the choice of mastectomy (followed by reconstruction), while for smaller DCIS breast-conserving treatment should be performed by complete excision. This review reports on the effect of margins on the clinical management of patients with a diagnosis of DCIS. The role of preoperative imaging including MRI, surgical procedures, and pathology are described.

DCEMRI of breast lesions: is kinetic analysis equally effective for both mass and nonmass-like enhancement?

To perform a pilot study investigating whether the sensitivity and specificity of kinetic parameters can be improved by considering mass and nonmass breast lesions separately. The contrast media uptake and washout kinetics in benign and malignant breast lesions were analyzed using an empirical mathematical model (EMM), and model parameters were compared in lesions with mass-like and nonmass-like enhancement characteristics. 34 benign and 78 malignant breast lesions were selected for review. Dynamic MR protocol: 1 pre and 5 postcontrast images acquired in the coronal plane using a 3D T1-weighted SPGR with 68 s timing resolution. An experienced radiologist classified the type of enhancement as mass, nonmass, or focus, according to the BI-RADS lexicon. The kinetic curve obtained from a radiologist-drawn region within the lesion was analyzed quantitatively using a three parameter EMM. Several kinetic parameters were then derived from the EMM parameters: the initial slope (Slope(ini)), curvature at the peak (kappa(peak)), time to peak (T(peak)), initial area under the curve at 30 s (iAUC30), and the signal enhancement ratio (SER). The BI-RADS classification of the lesions yielded: 70 mass lesions, 38 nonmass, 4 focus. For mass lesions, the contrast uptake rate (alpha), contrast washout rate (beta), iAUC30, SER, Slope(ini), T(peak) and kappa(peak) differed substantially between benign and malignant lesions, and after correcting for multiple tests of significance SER and T(peak) demonstrated significance (p < 0.007). For nonmass lesions, we did not find statistically significant differences in any of the parameters for benign vs. malignant lesions (p > 0.5). Kinetic parameters could distinguish benign and malignant mass lesions effectively, but were not quite as useful in discriminating benign from malignant nonmass lesions. If the results of this pilot study are validated in a larger trial, we expect that to maximize diagnostic utility, it will be better to classify lesion morphology as mass or nonmass-like enhancement prior to kinetic analysis.

Imaging studies for the early detection of breast cancer

INTRODUCTION

The effectiveness of mammographic screening has been proven at evidence level 1A. Mammography offers the best ratio of benefits to side effects of any screening method tested to date. In this literature review, we ask whether early detection might be improved still further by combining mammography with other imaging modalities.

METHODS

The authors performed a selective literature search for combined key words in the Medline and Cochrane Library databases from 1/2000 to 11/2007, screened all titles, and evaluated the full text of all original articles. We selected articles for further analysis according to systematic criteria (minimum numbers, avoidance of overlap) and also considered published guidelines.

RESULTS

No screening studies of comparable size to those for mammography are available for ultrasound or MRI. Smaller studies have indicated that the use of these two modalities might lead to the detection of additional cancers in selected subgroups. For mass screening an increase in the detection rate of 10% to 15% might become possible. This increase would probably be associated with a tripling of the breast biopsy rate, compared to mammography alone. The number of indeterminate cases in which short-term follow-up (i.e., at 6 months) would be recommended would increase roughly tenfold with MRI, and to an unknown extent with ultrasound. The related quality-assurance issues remain to be addressed.

DISCUSSION

Randomized controlled studies are needed for a realistic assessment of the achievable benefits and unavoidable side effects of combined screening. For women whose risk of breast cancer is not elevated, mammography remains the standard screening method.

Recent advances and current controversies in the management of DCIS of the breast

Ductal carcinoma in situ (DCIS) is commonly diagnosed today, mainly due to widespread use of screening mammography. Despite a better understanding of its biological behavior, many issues regarding its optimal management remain controversial. The biological behavior of DCIS has been associated with distinct molecular and histological features (such as expression of COX2, Ki67, c-erbB2, p53 mutation, presence or absence of comedonecrosis, nuclear grade, hormone receptor status, etc.). Recent advances in the diagnosis of DCIS include using magnetic resonance imaging, and the use of stereotactic-guided directional vacuum-assisted biopsy (DVAB). Ductoscopy and ductal lavage have a limited role in the management of DCIS. Surgical treatment of DCIS includes simple local excision to various forms of wider excision (segmental resection or quadrantectomy), or even mastectomy (either simple or skin-sparing). Radiotherapy following breast-conserving surgery significantly reduces local recurrence rates. Axillary lymph node dissection is not required for the management of DCIS; however, during the last decade, sentinel lymph node biopsy is increasingly used to exclude the presence of axillary metastases (when invasive disease is present within the DCIS). This approach has many advantages (including the avoidance of a second surgery if invasive disease is diagnosed within the DCIS) and should be considered when there is an increased probability for the presence of invasive breast cancer within the DCIS. The role of other minimally invasive methods (such as the "therapeutic" application of the DVAB technique, radiofrequency ablation, laser therapy, cryotherapy and brachytherapy) in the management of small DCIS remains unproven. Tamoxifen should be considered in the management of selected patients with DCIS, such as patients with hormone receptor positive DCIS, young patients, and patients without risk factors for potential side effects. Additionally, and controversial, there is evidence that aromatase inhibitors may be better than tamoxifen in the management of DCIS.

Diagnosis of the intraductal component of invasive breast cancer: assessment with mammography and sonography

OBJECTIVE

The aim of this study was to investigate mammographic and sonographic features and their sensitivities for depiction of the intraductal component associated with invasive ductal carcinoma (IDC).

METHODS

During a 1-year period, 132 patients with IDC underwent surgical treatment. All patients underwent mammography and high-resolution sonography, and the findings were reported according to the American College of Radiology's Breast Imaging Reporting and Data System lexicon. Tumors were classified as "pure IDC" and "IDC with an intraductal component" by histopathologic evaluation. We compared mammographic and sonographic features between the above 2 groups and attempted to correlate them with histopathologic findings. We also investigated separate and combined sensitivities, specificities, and accuracies of both mammography and breast sonography for showing intraductal components. Finally, imaging measurements were compared with pathologic measurements.

RESULTS

One hundred four (79%) of the 132 IDCs contained an intraductal component. Patients with IDC with an intraductal component showed calcifications on mammography and showed an echogenic halo, duct dilatation, calcifications, and increased vascularity in surrounding tissue on sonography more frequently than patients with pure IDC. The sensitivities of mammography, sonography, and their combined assessment for detection of an intraductal component were 55%, 80%, and 86%, respectively. The combined assessment (r = 0.90) measured the extent of the tumor more accurately than mammography (r = 0.71) or sonography (r = 0.79) separately.

CONCLUSIONS

Combined assessment with mammography and sonography offers more accurate information for the presence of an intraductal component and the extent of a tumor than each separate assessment.

Role of ultrasound and sonographically guided core biopsy in the diagnostic evaluation of ductal carcinoma in situ (DCIS) of the breast

PURPOSE

The aim of this study was to evaluate the role of ultrasound (US)-guided core biopsy in the diagnosis of ductal carcinoma in situ (DCIS) and to correlate the histological results on percutaneous biopsy and surgical excision.

MATERIALS AND METHODS

Out of 2,423 consecutive core biopsies performed under US guidance, we evaluated 65 lesions with a histological diagnosis of DCIS. All patients underwent mammography, high-frequency broadband US and percutaneous breast biopsy with a 14-gauge needle and a mean number of five samples (range 4-7 passes). Surgical excision was performed in all cases, and the histological results on the surgical specimen were correlated with those on core biopsy samples. The sonographic features of DCIS lesions were described, comparing pure DCIS (those confirmed by definitive histology) and DCIS with invasive component at surgical excision.

RESULTS

Twenty-seven out of 65 DCIS at core biopsy were found to have an invasive or microinvasive component at surgical excision, leading to rate of histological underestimation of core biopsy of 41.5%. The most frequent sonographic appearances were: (a) mass without microcalcifications (47.4% of pure DCIS, 63% of DCIS with invasive component); (b) mass with microcalcifications (23.7% of pure DCIS, 22% of DCIS with invasive component); (c) isolated microcalcifications (10.5% of pure DCIS); (d) ductal abnormalities (18.4% of pure DCIS, 15% of DCIS with invasive component).

CONCLUSIONS

Due to the high underestimation rate of core biopsy, caution is mandatory in the case of DCIS diagnosis on core biopsy. Although some histological features (such as stromal fibrosis, periductal inflammatory infiltrate, high nuclear grade) can suggest the presence of an invasive component, the sonographic appearance of DCIS cannot be used to predict the cases that are underestimated on US-guided core biopsy. Nevertheless, a sonographically detectable solid component, either inside dilatated ducts or associated with microcalcifications, and a size greater than 20 mm are frequently associated with the presence of an invasive component.

Imaging breast cancer

Imaging has a significant role in diagnosing, treating, and monitoring breast cancer. Advances in this field are having a great impact in the clinical management of this disease. Breast cancer has now become an "outpatient cancer". This article describes the role and advances of imaging in breast cancer.

The value of magnetic resonance imaging in diagnosis and size assessment of in situ and small invasive breast carcinoma

BACKGROUND

The value of magnetic resonance imaging (MRI) in diagnosis and size assessment of ductal carcinoma-in-situ (DCIS) and DCIS with small (<10 mm) invasive carcinoma was evaluated.

METHODS

Fifty-four patients with DCIS and 12 patients with DCIS and small invasive carcinoma were included. Mammographic (N = 64) and MRI (N = 22) images were retrospectively reviewed. Correlation coefficients were calculated to assess differences in size between imaging and histopathologic examination.

RESULTS

Mammographic rate of detection for DCIS was 48/52 (92%) and for DCIS with small invasive carcinoma, 10/12 (83%). MRI revealed 1 false negative case and the rate of detection for DCIS was 16/17 (94%). Correlation of mammographic size with histopathologic size was r = .44 (P < .01) and r = 0.49 (P = .03) for MRI. Mammography underestimated lesion size by 5 mm or more in 47%, whereas with MRI size was adequately assessed in 43% and overestimated in 38%.

CONCLUSIONS

DCIS can be visualised on MRI with high sensitivity, although tumor size can be overestimated.

Comparison of MDCT and MRI for Evaluating the Intraductal Component of Breast Cancer

OBJECTIVE

The purpose of our study was to compare the accuracy of MDCT and MRI for evaluating the intraductal component of breast cancer.

MATERIALS AND METHODS

Sixty-nine patients with histologically proven invasive carcinoma underwent MDCT and MRI. Retrospectively, two radiologists performed a blinded review of the MDCT and MRI. Cases with intraductal component enhancement were classified into two morphologic types: ductal extension and segmental distribution. The lengths of the main tumor and of the intraductal component were measured in cases with ductal extension. For cases with segmental distribution, only the maximum length of the tumor was measured.

RESULTS

The sensitivity, specificity, and accuracy in detecting the intraductal component were 61%, 88%, and 71%, respectively, using MDCT; and 75%, 88%, and 80%, respectively, using MRI. MRI revealed the presence of the intraductal component with significantly higher sensitivity than did MDCT (p = 0.031). In the analysis of the length of the intraductal component in cases with ductal extension, which had relatively small intraductal components, underestimation by 15 mm or more was significantly less frequent with MRI than with MDCT (p = 0.008). There was no significant difference between MDCT and MRI in the evaluation of the maximum length of tumors in cases with segmental distribution, which had relatively large intraductal components.

CONCLUSION

Compared with MDCT, MRI revealed the presence of the intraductal component with higher sensitivity and equivalent specificity. In cases with ductal extension, MRI is more precise than MDCT for determination of the margin for surgical removal, with less underestimation of the extent of the intraductal component.

High-Spatial-Resolution MRI of Non-Masslike Breast Lesions: Interpretation Model Based on BI-RADS MRI Descriptors

OBJECTIVE

The purpose of this study was to assess an interpretation model based on BI-RADS MRI descriptors and high-spatial-resolution MR images in lesions showing non-masslike enhancement.

MATERIALS AND METHODS

Retrospective review was performed of 30 consecutive lesions showing non-masslike enhancement. MRI was performed on a 1.5-T scanner using the volumetric interpolated breath-hold examination sequence. The distribution patterns were classified into three categories: single quadrant/solitary lesion (linear), single quadrant/grouped lesion (focal, regional, segmental), and multiquadrant lesion (multiple regions, diffuse). The presence of a ductal pattern was assessed in the enhancing lesions after the tumor distribution had been decided. In addition to the BI-RADS MRI descriptors, the presence of clustered ring enhancement was also assessed in heterogeneous enhancing lesions.

RESULTS

The most frequent morphologic finding among the benign lesions was a linear pattern (50%) followed by homogeneous internal enhancement (42%), whereas a segmental pattern (56%) (p = 0.003), heterogeneous internal enhancement (44%), and clustered ring enhancement (44%) (p = 0.01) were the most frequent findings in malignant lesions. The features with the highest positive predictive value for carcinoma were a segmental distribution (100%), a clustered ring enhancement (100%), and a clumped internal architecture (88%). Using this interpretation model, the positive predictive value for carcinoma was 94%.

CONCLUSION

A combination of BI-RADS MRI descriptors and clustered ring enhancement criteria is useful for the differential diagnosis of lesions showing non-masslike enhancement.

Advances in breast imaging: magnetic resonance imaging

Magnetic resonance imaging (MRI) of the breast is rapidly becoming incorporated into clinical practice. Indications for breast MRI include staging of known breast cancer, monitoring response to chemotherapy, assessing recurrence, problem solving, and high-risk screening. Magnetic resonance spectroscopy is a promising technique that may decrease the number of benign biopsies generated by breast MRI in the clinical setting.

Contrast-Enhanced Breast MRI in Patients with Suspicious Microcalcifications on Mammography: Results of a Multicenter Trial

OBJECTIVE

The objective of our study was to test dynamic MRI in evaluating mammographically detected suspicious microcalcifications.

MATERIALS AND METHODS

One hundred twelve patients with mammographically detected microcalcifications with BI-RADS category 5 (n = 78) or 4 (n = 34) lesions were studied at 17 centers a using 3D gradient-echo dynamic coronal technique (< or = 3 mm thickness) and 0.1 mmol/kg of gadoteridol. A pathologic sample was obtained in all cases. Agreement between the major diameter measured on mammography, MRI, or both and the major diameter measured at pathologic examination was calculated in 62 cases.

RESULTS

Of the 112 lesions, pathologic examination revealed 37 benign lesions, 33 ductal carcinoma in situ (DCIS), and 42 invasive carcinomas. The specificity of MRI for benign lesions was 68%. Considering the subgroups of calcifications alone and calcifications associated with masses, the specificity values became 79% and 33%, respectively. The sensitivity of MRI for DCIS was 79%. Analysis of the two subgroups showed sensitivity values of 68% for calcifications alone and of 1% for calcifications associated with masses. The sensitivity for invasive carcinomas was 93%. Analysis of the two subgroups showed sensitivity values to be 92% for calcifications alone and 94% for calcifications associated with masses. Considering the overall results, the sensitivity of MRI was 87%; specificity, 68%; positive predictive value, 84%; negative predictive value, 71%; and accuracy, 80%. Considering the subgroups of calcifications alone and calcifications associated with masses, the sensitivity values became 80% and 97%; the positive predictive values, 86% and 82%; the negative predictive values, 71% and 75% (95% confidence interval [CI], 0.19-0.99); and the accuracy values, 80% and 82% (95% CI, 0.66-0.92), respectively. An odds ratio (OR) of 13.54 (95% CI, 5.20-35.28) showed a raised risk of malignant breast tumor in subjects with positive MR examination of mammographically detected suspicious clusters of microcalcifications. The statistical analysis on each subgroup showed an OR of 15.07 (95% CI, 4.73-48.08) for calcifications alone and an OR of 14.00 (95% CI, 1.23-158.84) for calcifications associated with masses. Any significant improvement in the predictive ability of dynamic MRI depending on the extent of calcifications on mammography was not proved. Considering the 62 cases of proved malignancy with measured maximal diameter at pathologic examination, both mammography and MR examination seem to overestimate tumor extent.

CONCLUSION

The not-perfect sensitivity of MRI (87%), when applying our interpretation criteria and imaging sequences, is a crucial point that prevents us from clinical use of MRI in the diagnosis of mammographically detected microcalcifications.

Contrast-enhanced MRI of ductal carcinoma in situ: Characteristics of a new intensity-modulated parametric mapping technique correlated with histopathologic findings

PURPOSE

To identify morphologic and dynamic enhancement magnetic resonance imaging (MRI) features of pure ductal carcinoma in situ (DCIS) by using a new intensity-modulated parametric mapping technique, and to correlate the MRI features with histopathologic findings.

MATERIALS AND METHODS

Fourteen patients with pure DCIS on pathology underwent conventional mammography and contrast-enhanced (CE) MRI using the intensity-modulated parametric mapping technique. The MR images were reviewed and the lesions were categorized according to morphologic and kinetic criteria from the ACR BI-RADS-MRI Lexicon, with BI-RADS 4 and 5 lesions classified as suspicious.

RESULTS

With the use of a kinetic curve shape analysis, MRI classified seven of 14 lesions (50%) as suspicious, including four with initial-rapid/late-washout and three with initial-rapid/late-plateau. Using morphologic criteria, MRI classified 10/14 (71%) as suspicious, with the most prominent morphologic feature being a regional enhancement pattern. Using the intensity modulated parametric mapping technique, MRI classified 12/14 cases (86%) as suspicious. Parametric mapping identified all intermediate- and high-grade DCIS lesions.

CONCLUSION

The intensity-modulated parametric mapping technique for breast MRI resulted in the highest detection rate for the DCIS cases. Furthermore, the parametric mapping technique identified all intermediate- and high-grade DCIS lesions, suggesting that a negative MRI using the parametric mapping technique may exclude intermediate- and high-grade DCIS. This finding has potential clinical implications.