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ORIGINAL ARTICLE
Adv Biomed Res 2017,  6:7

Is there any Correlation between Magnetic Resonance Imaging Features of Breast Lesions of BIRADS Category 4 with Histopathologic Results?


Department of Radiology, Isfahan University of Medical Sciences, Isfahan, Iran

Date of Web Publication31-Jan-2017

Correspondence Address:
Dr. Ghazale Jamalipoor Soofi
Department of Radiology, Alzahra Hospital, Soffeh Street, Isfahan 81744
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2277-9175.199258

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  Abstract 

Background: To evaluate the correlation of magnetic resonance imaging (MRI) features of breast lesions of Breast Imaging Reporting and Database System (BI-RADS) category 4 with histopathologic results. Materials and Methods: In a prospective study between December 2013 and April 2015, patients with suspicious mammographic and/or ultrasound findings referred for Breast MRI were evaluated. Patients with lesions of BI-RADS category 4 were enrolled with a written informed consent. In each patient, mass lesion (ML) or nonmass lesion (NML) was determined, and different characteristics of the lesions were recorded. A follow-up program was taken with mean 3–12 months. Patients who underwent core needle biopsy or open biopsy were summoned. Results: Seventy-eight females aged 24–67 years (mean 43.1 ± 8.8) met the inclusion criteria and had adequate samples for histopathologic study. Twenty-nine (37.2%) patients had ML and 49 (62.8%) patients had NML. Tissue sampling in 63 (80.7%) patients was through core needle biopsy and in 15 (19.2%) patients through surgery. A wide spectrum of benign and malignant pathologic diagnoses was seen. In statistical analysis, none of the MRI features has a significant correlation with any specific histopathologic diagnosis (P = 0.185). However, the relation between the MRI category (ML or NML) and pathology results was significant at level of 0.1 (P = 0.06). Conclusion: This study showed that a wide spectrum of histopathologic results is seen in BI-RADS category 4. However, in this sample volume, none of the MRI features in this BI-RADS category has a significant correlation with any specific histopathologic diagnosis.

Keywords: Breast, core needle biopsy, magnetic resonance imaging


How to cite this article:
Farghadani M, Soofi GJ, Sarrami AH. Is there any Correlation between Magnetic Resonance Imaging Features of Breast Lesions of BIRADS Category 4 with Histopathologic Results?. Adv Biomed Res 2017;6:7

How to cite this URL:
Farghadani M, Soofi GJ, Sarrami AH. Is there any Correlation between Magnetic Resonance Imaging Features of Breast Lesions of BIRADS Category 4 with Histopathologic Results?. Adv Biomed Res [serial online] 2017 [cited 2019 Sep 21];6:7. Available from: http://www.advbiores.net/text.asp?2017/6/1/7/199258


  Introduction Top


Nowadays, dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) is a well-established modality in screening for breast cancer in high-risk patients.[1],[2],[3],[4],[5] During the recent years, many studies have been done to determine the most significant features on DCE-MRI which may be correlated with the diagnosis of specific breast pathologies. Differences in enhancement characteristics and in the signal intensity–time curves have been introduced as the basis for distinguishing between benign and malignant lesions. These differences are due to differences in vascularity, vessel permeability, and extracellular diffusion space between these lesions.[6],[7],[8],[9] Lesions of Breast Imaging Reporting and Database System (BI-RADS) category 4 are among the most challenging entities in DCE-MRI, which have suspicious features and need further evaluation. The spectrum of lesions in this category is wide and previous studies have reported a risk of 2%–95% for malignancy in this category. Historically, BI-RADS category 4 is divided into three subcategories: 4a, 4b, and 4c with low, intermediate, and moderate probability of malignancy, respectively.[1],[2] However, many of the lesions of BI-RADS category 4 underwent tissue sampling, and therefore use of this subcategories neither significantly affect the clinicians' decision nor the patients' emotional burden. One of the indications of DCE-MRI is an additional evaluation of suspicious lesions to reduce the rate of invasive procedures and subsequently to remove patient's stress in interval of determining pathologic result of tissue sampling. Despite all the advances in identifying the behavior of breast pathologies in DCE-MRI, the data about specific characteristics which could predict various breast pathologies are still insufficient.

Our study was designed to find the probable correlation of DCE-MRI characteristics with histopathologic results in BI-RADS category 4.


  Materials and Methods Top


Subjects

In a prospective study between December 2013 and April 2015, we studied patients with suspicious mammographic and/or ultrasound findings referred for breast MRI. Based on MRI study, patients with benign or probably benign lesions as well as those with the lesions strongly suggestive for malignancy were not enrolled in the study. Patients with lesions of BI-RADS category 4, who participated in follow-up, and had pathology proven results were included in the study consecutively. Among these patients, those with history of previous excisional biopsy or surgery, chemotherapy, or unwilling to continue follow-up were excluded from the study. According to inclusion criteria, 95 patients were enrolled for the study. However, 17 patients had exclusion criteria, and therefore, 78 patients were finally studied.

Magnetic resonance imaging data acquisition

MR images were acquired using a 1.5T Philips Achieva imager (Philips Medical Systems, Best, The Netherlands), applying a bilateral phased-array 4-channel breast coil. All patients were examined in prone position. For women in reproductive ages, MR study was performed during the 2nd week of their menstrual cycle. The imaging protocol included axial T1-weighted (TR/TE: 400/10, bandwidth: 31.25 Hz/pixel; field of view [FOV]: 32 mm; slice thickness: 5.0 mm; matrix size: 384 × 256; number of excitations [NEX]: 1), axial short inversion time inversion-recovery (TR/TE: 4500/63; bandwidth: 62.50; FOV: 32 mm; slice thickness: 5.0 mm; matrix size: 320 × 256; NEX: 1), and six series axial dynamic T1-weighted three-dimensional [3D], fat-suppressed spoiled gradient-echo images (TR/TE: 9/4; bandwidth: 31.25; FOV: 32; slice thickness: 4.0 mm with no intersection gap; matrix size: 352 × 288; NEX: 1; flip angle: 300). During dynamic series, bolus injection of 0.2 mmol/kg of gadolinium-DTPA (Dotarem, Guerbet) followed by 15 mL normal saline was done. These series were acquired every 60–90 s (one series before and five series after injection).

Imaging analysis

All breast MRIs were interpreted by a trained breast radiologist. Image analysis was prospective, and none of the patients has previous histopathologic result. Our imaging interpretation was according to the American College of Radiology BI-RADS-MRI lexicon edition 5.[10] Based on the morphologic characteristics and dynamic enhancement profile, the lesions with BI-RADS category 4 were analyzed in more detail. Mass lesion (ML) was defined as an enhancing space-occupying lesion which is larger than 5 mm in diameter. Nonmass lesion (NML) was defined as an area of enhancement that neither has a 3D mass nor has typical mass characteristics.

We used CAD-STREAM ® for processing and assessment of dynamic 3D series. The dynamic enhancement profile was assessed showing rapid washout, plateau, or persistent patterns. The most suspicious curve pattern of each lesion was considered for interpretation if it was more than 2% enhancement.

In patients with ML, shape (irregular or microlobulated), border (ill-defined or spiculated), contrast media distribution (inhomogeneous or ring enhancement), and initial and postinitial contrast enhancement (strong enhancement, rapid, plateau, or continuous washout) were determined. In patients with NML, pattern of enhancement (focal, linear, ductal, segmental, or heterogeneous regional) was focused [Figure 1] and [Figure 2].
Figure 1: Breast dynamic contrast-enhanced-magnetic resonance imaging of a 39-year-old female with a positive family history of breast cancer who had found a mass in her self-examination; in the ultrasound study, a round hypoechoic lesion without posterior shadow in left breast was reported (Breast Imaging Reporting and Database System 4a). (a) T1-weighted, (b) Short Tau Inversion Recovery (STIR), (c and d) Contrast-enhanced T1-weighted (second and fifth series) show a round mass with smooth border which shows ring enhancement

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Figure 2: Using CAD-STREAM® for processing and assessment of dynamic three-dimensional series of the lesion of Figure 1. The dynamic enhancement profile was assessed as showing rapid washout. The lesion underwent core needle biopsy. Histopathologic study revealed invasive ductal carcinoma

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Follow-up

A follow-up program was taken for each patient. In this program, the patient was called by telephone, after 1st month, 3rd month, and every 3 months, overall for 12 months. In each phase, while it was revealed that the patient underwent a core needle biopsy or open biopsy, the follow-up was stopped and the patient was requested to bring or send her histopathologic result. In our study population, all the biopsy samples were studied by one of the two trained pathologists for breast tissues.

Statistical analysis

All analyses were performed in IBM SPSS Statistics (version 22, IBM, Somers, NY, USA) software. P < 0.05 was considered statistically significant. Chi-square test was used to assess the relation of MRI features with pathology results.


  Results Top


Seventy-eight females aged 24–67 years (mean 43.1 ± 8.8) met the inclusion criteria, participated in follow-up, and had adequate samples for histopathologic study. Twenty-six (33.3%) patients had positive family history for breast cancer. Only four patients had previous breast MRI. In 42 (53.8%) cases, breast lesion was in the right breast and in 36 (46.1%) cases in the left breast. Twenty-nine (37.2%) patients had ML and 49 (62.8%) patients had NML. Based on probability of malignancy, 64 (82%) patients were 4a, 10 (12.8%) were 4b, and 4 (5.1%) were 4c. Tissue sampling in 63 (80.7%) patients was through core needle biopsy and in 15 (19.2%) through surgery.

[Table 1] shows the frequency of suspicious features of MRI (BI-RADS category 4) in different pathologies. Using Chi-square test, P values in category of MLs and NMLs were 0.175 and 0.185, respectively. [Table 2] shows mean ages of patients in different breast pathologies. The relation between the MRI category (ML or NML) and pathology results [sorted as [Table 1]] was significant at level of 0.1 (P = 0.06).
Table 1: Frequency of suspicious features of magnetic resonance imaging (Breast Imaging Reporting and Database System Category 4) in different pathologies

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Table 2: Mean age in different pathologies

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[Table 3] describes washout patterns of enhancible MLs with different pathology diagnoses.
Table 3: Washout patterns of enhancible mass lesions with different pathology diagnosis

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[Table 4] shows spectrum of benign and malignant pathologies in our study.
Table 4: Spectrum of pathological results

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  Discussion Top


Breast cancer is an important issue in women health worldwide. Imaging modalities have substantial role in screening, diagnosis, surgical plan, and also postintervention follow-up.[11],[12],[13]

The demand for breast MRI is increasing in practice as our knowledge develops continuously.[14] In the recent three decades, several studies have been introduced various indications of breast MRI and as the latest recommendation of the American Cancer Society breast MRI is useful in screening of each woman with BRCA1 or BRCA2 gene mutation whether in herself or in a first-degree relative, a lifetime risk of breast cancer of 20 or greater, a history of radiation therapy to the chest under the age of 30, a history of genetic syndrome (such as Li–Fraumeni syndrome, Cowden syndrome, or Bannayan–Riley–Ruvalcaba syndrome) in herself or in her first-degree relatives, a personal history of breast cancer, ductal carcinoma in situ (DCIS), lobular carcinoma in situ, or atypical hyperplasia, an extremely dense breasts or unevenly dense breasts when viewed by mammograms.[15]

In this study, we enrolled the lesions of BI-RADs category 4 according to the fifth edition of the ACR BI-RADS MRI lexicon,[10] and therefore, we studied the lesions in two groups as ML and NML. As our results show, the spectrum of histopathologic diagnoses in this category is wide and includes both benign and malignant entities. This study was looking for any relationship between MRI features of both ML and NML with a specific diagnosis which failed to achieve. Likewise, in the study of Sakamoto et al. on the NML, no statistically significant association between distribution patterns and histopathology was found.[16]

The relation between the MRI category (ML or NML) and pathology results [sorted as [Table 1]] was significant at level of 0.1 (P = 0.06). This is mostly due to higher frequency of focal enhancement in NML category that causes some degrees of relation with benign pathologies.

In a study by Liberman et al., segmental enhancement was the most frequent feature of malignancy and also DCIS on MRI.[17] Similarly, Morakkabati-Spitz et al. showed the value of segmental enhancement in malignant lesions.[18] Tozaki et al. and Gity et al. in two different studies on NML showed that among MRI features, segmental distribution has the highest positive predictive value for malignancy.[9],[19] In these two studies, also, washout pattern was the most powerful indicator for malignant pathology. However, in Liberman et al.'s study and Gutierrez et al.'s study, the visually assessed kinetic features were not significant predictors of malignancy.[8],[17]

The main reason for differences between study results is not well known; however, different sample size of studies and also various MRI protocols may describe them.

A major shortcoming in our study is the small sample size despite multiple variables. This is mainly because of low incidence of the lesions with BI-RADS category 4 as well as low interest of the clinicians in our province for using MRI in workup of the breast lesions. Lack of interobserver evaluation is another limitation of this study. Despite most of previous studies which have compared BI-RADS score with final diagnosis, we assessed the relationship of each MRI feature (morphologic items and enhancement pattern) with the final diagnosis.


  Conclusion Top


This study showed that a wide spectrum of histopathologic results is seen in BI-RADs category 4. However, in this sample volume, none of the MRI features in this BI-RADs category has a significant correlation with any specific histopathologic diagnosis.

Financial support and sponsorship

This article is derived from proposal no 394755, Isfahan University of Medical Sciences.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Dang CM, Zaghiyan K, Karlan SR, Phillips EH. Increased use of MRI for breast cancer surveillance and staging is not associated with increased rate of mastectomy. Am Surg 2009;75:937-40.  Back to cited text no. 3
    
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Nouri-Neuville M, de Rocquancourt A, Cohen-Zarade S, Chapellier-Canaud M, Albiter M, Hamy AS, et al. Correlation between MRI and biopsies under second look ultrasound. Diagn Interv Imaging 2014;95:197-211.  Back to cited text no. 4
    
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Abramovici G, Mainiero MB. Screening breast MR imaging: Comparison of interpretation of baseline and annual follow-up studies. Radiology 2011;259:85-91.  Back to cited text no. 5
    
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Lehman CD, Smith RA. The role of MRI in breast cancer screening. J Natl Compr Canc Netw 2009;7:1109-15.  Back to cited text no. 7
    
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Gutierrez RL, DeMartini WB, Eby PR, Kurland BF, Peacock S, Lehman CD. BI-RADS lesion characteristics predict likelihood of malignancy in breast MRI for masses but not for nonmasslike enhancement. AJR Am J Roentgenol 2009;193:994-1000.  Back to cited text no. 8
    
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Gity M, Ghazi Moghadam K, Jalali AH, Shakiba M. Association of different MRI BIRADS descriptors with malignancy in non mass-like breast lesions. Iran Red Crescent Med J 2014;16:e26040.  Back to cited text no. 9
    
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American College of Radiology. Breast Imaging Reporting, Data System (BI-RADS). 5th ed. Available on www.acr.org  Back to cited text no. 10
    
11.
Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. Global cancer statistics. CA Cancer J Clin 2011;61:69-90.  Back to cited text no. 11
    
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Siegel R, Naishadham D, Jemal A. Cancer statistics, 2013. CA Cancer J Clin 2013;63:11-30.  Back to cited text no. 12
    
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Sirous M, Sirous R, Nejad FK, Rabeie E, Mansouri M. Evaluation of different aspects of power Doppler sonography in differentiating and prognostication of breast masses. J Res Med Sci 2015;20:133-9.  Back to cited text no. 13
    
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Warner E, Messersmith H, Causer P, Eisen A, Shumak R, Plewes D. Systematic review: Using magnetic resonance imaging to screen women at high risk for breast cancer. Ann Intern Med 2008;148:671-9.  Back to cited text no. 14
    
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Saslow D, Boetes C, Burke W, Harms S, Leach MO, Lehman CD, et al. American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin 2007;57:75-89.  Back to cited text no. 15
    
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Sakamoto N, Tozaki M, Higa K, Tsunoda Y, Ogawa T, Abe S, et al. Categorization of non-mass-like breast lesions detected by MRI. Breast Cancer 2008;15:241-6.  Back to cited text no. 16
    
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Liberman L, Morris EA, Lee MJ, Kaplan JB, LaTrenta LR, Menell JH, et al. Breast lesions detected on MR imaging: features and positive predictive value. AJR Am J Roentgenol 2002;179:171-8.  Back to cited text no. 17
    
18.
Morakkabati-Spitz N, Leutner C, Schild H, Traeber F, Kuhl C. Diagnostic usefulness of segmental and linear enhancement in dynamic breast MRI. Eur Radiol 2005;15:2010-7.  Back to cited text no. 18
    
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Tozaki M, Igarashi T, Fukuda K. Breast MRI using the VIBE sequence: Clustered ring enhancement in the differential diagnosis of lesions showing non-masslike enhancement. AJR Am J Roentgenol 2006;187:313-21.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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