Inconclusive findings at mammography: the value of MR imaging

Summary Purpose: To evaluate the usefulness of magnetic resonance (MR) imaging in the assessment of inconclusive findings at mammography, such as indeterminate focal or diffuse breast abnormalities, post-treatment breasts with extensive scarring, dense breasts, and findings suggesting multifocal or multicentric breast cancer. Material and Methods: 254 patients underwent mammography, sonography, and MRI of the breast. Dynamic MR imaging was done using a thin-section three-dimensional gradient-echo sequence (FLASH, TR = 11.8 ms; TE = 5 ms; flip angle = 25 °) which was applied in a dynamic fashion before and every 90 seconds after injection of gadopentetate dimeglumine. Diagnoses were confirmed at biopsy (n = 165) or by follow-up (n = 89). Results: Among various breast anomalies, the highest proportion of breast cancers was associated with dense breast tissue (27.8 %), architectural distortion (26.9 %), and irregular scars (15.8 %). Sensitivity of dynamic MR imaging was 93.7 %, and specificity was 83.3 %. As compared to mammography and sonography, MR detected 6 occult carcinomas, and showed additional malignant lesions in 19/63 women (30.2 %) with biopsy-proven breast cancer. Conclusion: MR imaging of the breast may provide valuable additional information in indeterminate breast anomalies. However, because of its inherent limitations, it should not replace core needle biopsy in all lesions which are amenable to biopsy. Because of its high sensitivity in the detection of invasive carcinomas in any type of breast tissue, MR imaging is considered the modality of choice in the evaluation of dense breasts in high-risk patients or in patients with clinical suspicion of occult breast cancer, and for preoperative tumor staging.      

乳腺癌MRI诊断的临床应用价值

目的 评价MRI在乳腺癌临床诊断中的应用价值。资料与方法 30例临床或乳腺X线摄影诊断有困难的患者行乳腺和腋窝MRI检查，17例经组织病理证实为乳腺癌，分析MRI显示乳腺癌病灶和胸肌浸润以及淋巴结转移的敏感性，所有结果均与病理对照。结果 17例乳腺癌患者共检出35个病灶，包括6例多中心性乳腺癌、4例多灶性乳腺癌和7例单发病灶(包括2例隐匿性乳腺癌)。6例(35．3％)出现胸肌浸润；腋窝淋巴结转移11例，其中9例病理证实，其敏感性为81．8％。结论乳腺MRI对检出隐匿性乳腺癌，多灶性和多中心性乳腺癌，评估胸肌有无浸润以及腋窝淋巴结有无转移具有重要价值。     

Sensitivity of MRI versus mammography for detecting foci of multifocal, multicentric breast cancer in Fatty and dense breasts using the whole-breast pathologic examination as a gold standard

OBJECTIVE: Our aim was to compare the effectiveness of mammography and MRI in the detection of multifocal, multicentric breast cancer. SUBJECTS AND METHODS: Ninety patients with planned mastectomies (nine bilateral) underwent mammography and dynamic gadolinium-enhanced MRI. Off-site reviewers aware of the entry criterion (planned mastectomy) evaluated both examinations for the presence of malignant foci, recording the density pattern on mammography. The gold standard was pathologic examination of the whole excised breast (slice thickness, 5 mm). RESULTS: Of 99 breasts, pathologic findings revealed 52 unifocal, 29 multifocal, and 18 multicentric cancers for a total of 188 malignant foci (158 invasive and 30 in situ). Overall sensitivity was 66% (124/188) for mammography and 81% (152/188) for MRI (p < 0.001); 72% (113/158) and 89% (140/158) for invasive foci (p < 0.001); and 37% (11/30) and 40% (12/30) for in situ foci (p > 0.05, not significant), respectively. Mammography and MRI missed 64 and 36 malignant foci, respectively, with median diameters of 8 and 5 mm (p = 0.033) and an invasive-noninvasive ratio of 2.4:1 (45:19) and 1.0:1 (18:18) (p = 0.043), respectively. The overall positive predictive value (PPV) was 76% (124/164) for mammography and 68% (152/222) for MRI (not significant). In breasts with an almost entirely fatty pattern, sensitivity was 75% for mammography and 80% for MRI (not significant), and the PPV was 73% and 65% (not significant), respectively. In breasts with fibroglandular or dense pattern, the sensitivity was 60% and 81% (p < 0.001), and the PPV was 78% and 71% (not significant), respectively. CONCLUSION: MRI was more sensitive than mammography for the detection of multiple malignant foci in fibroglandular or dense breasts. Mammography missed larger and more invasive cancer foci than MRI. A relatively low PPV was a problem for both techniques.     

Multifocal,multicentric, and contralateral breast cancers: bilateral whole-breast US in the preoperative evaluation of patients

PURPOSE: To evaluate the efficacy of preoperative bilateral whole-breast ultrasonography (US) in the detection of additional multifocal, multicentric, and contralateral cancers and the effect of US information on therapeutic decisions. MATERIALS AND METHODS: Two hundred one patients who had newly diagnosed breast cancer or who were suspected of having breast cancer underwent US examination of the ipsilateral and contralateral breasts with a 10-, 12-, or 13-MHz transducer. All solid lesions found at US alone were classified according to level of suspicion and were selected for biopsy. The US results were compared with mammographic findings. Sensitivity, specificity, and positive and negative predictive values were calculated. RESULTS: In ipsilateral breasts, US depicted 194 (97%) of 201 foci of invasive cancer and 52 (75%) of 69 foci of ductal carcinoma in situ (DCIS), whereas mammography and physical examination depicted 173 (86%) foci of invasive cancer and 56 (81%) foci of DCIS. In the contralateral breast, US depicted 11 (92%) of 12 foci of invasive cancer and four (57%) of seven foci of DCIS, whereas mammography and physical examination depicted six (50%) foci of invasive cancer and five (71%) foci of DCIS. Overall, US depicted mammographically and clinically unsuspected multifocal or multicentric cancers in 28 patients (14%) and contralateral cancer in eight patients (4%). On the basis of these US findings, therapy was correctly changed in 32 patients (16%). The sensitivity, specificity, and positive and negative predictive values of prospective classification of 77 solid lesions detected at US alone were 100% (36 of 36), 51% (21 of 41), 64% (36 of 56), and 100% (21 of 21), respectively. CONCLUSION: Bilateral whole-breast US complements mammography in the preoperative evaluation of patients with breast cancer.     

Breast carcinoma: effect of preoperative contrast-enhanced MR imaging on the therapeutic approach

PURPOSE: To determine if magnetic resonance (MR) imaging can help determine the therapeutic approach in women with breast cancer. MATERIALS AND METHODS: Preoperative contrast-enhanced MR imaging of the breast was performed in 463 patients with probably benign lesions (n = 63), suspicious lesions (n = 230), or lesions highly suggestive of malignancy (n = 170) per established clinical, mammographic, and/or ultrasonographic (US) criteria. T1-weighted fast low-angle shot MR imaging was performed before and after administration of gadopenetetate dimeglumine. MR imaging findings were correlated with other imaging results and histopathologic findings. Special attention was paid to multifocality and multicentricity. RESULTS: Histopathologic analysis revealed 143 benign and 405 malignant lesions. The sensitivity, specificity, and accuracy were 58%, 76%, and 62% for clinical examination; 86%, 32%, and 72% for conventional mammography; 75%, 80%, and 76% for US; and 93%, 65%, and 85% for contrast-enhanced MR imaging. Multifocality in 30 of 42 patients, multicentricity in 24 of 50 patients, and additional contralateral carcinomas in 15 of 19 patients were depicted with MR imaging alone. Due to the MR imaging findings, therapy was changed correctly in 66 patients (14.3%); unnecessary open biopsy was performed in 16 patients (3.5%). CONCLUSION: Contrast-enhanced MR imaging of the breast is highly sensitive for invasive breast cancer. MR imaging may reveal unsuspected multifocal, multicentric, or contralateral breast carcinoma and result in therapy changes.     

Preoperative breast MRI in patients with invasive lobular breast cancer

To investigate the use of MRI in preoperative characterization of invasive lobular breast cancer (ILC) and in detection of multifocal/multicentric disease. We retrospectively reviewed T1-weighted FLASH 3D precontrast and postcontrast MR images together with subtraction images of 26 women with histopathologically proven invasive lobular cancer. Two experienced radiologists described tumor patterns of ILC independently. MR findings of unifocal, multifocal, single quadrant and multiquadrant disease were correlated with results of other imaging techniques and compared with histopathological findings as gold standard. Most ILC presented on MRI as a single spiculated/irregular, inhomogeneous mass (pattern 1, n=12) or as a dominant lesion surrounded by multiple small enhancing foci (pattern 2, n=8). Multiple small enhancing foci with interconnecting enhancing strands (pattern 3) and an architectural distortion (pattern 4) were both described in three cases. There was one case of a focal area of inhomogeneous enhancement (pattern 5) and one normal MR examination (pattern 6). Unifocal and multifocal lesions were identified on MRI in four patients with normal conventional imaging. In nine women, multiple additional lesions or more extensive multiquadrant disease were correctly identified only on MRI. MRI may play an important role in the evaluation of patients with ILC, which is often difficult to diagnose on clinical examination and conventional imaging and more likely occur in multiple sites and in both breasts. However, false-negative MR findings do occur in a small percentage of ILC.     

Retrospective analysis of sentinel node localization in multifocal, multicentric, palpable, or nonpalpable breast cancer.

Multicentric or multifocal breast cancer is considered as one of the limitations for sentinel lymph node (SLN) localization. We did a retrospective analysis to evaluate the success rate, sensitivity, accuracy, and negative predictive values of SLN localization in multicentric or multifocal breast lesions. METHODS: Fifty-nine patients with multifocal or multicentric breast lesions proven by either fine-needle aspiration (19/59), core biopsy (39/59), or lumpectomy (8/59) underwent SLN localization. Of these patients, 46 had SLN localization by both radiocolloid and blue dye, and 13 had SLN localization by radiocolloid alone. Approximately 10 MBq (99m)Tc-labeled unfiltered sulfur colloid in 0.3-0.4 mL were injected intradermally over the 1 or 2 breast tumor locations 2-4 h before surgery. During surgery, vital blue dye was injected intraparenchymally in 4-6 places around the tumor. All lymph nodes with counts of >10 times that of the background counts, whether or not blue dye positive, and all blue dye-positive lymph nodes, whether or not radiocolloid positive, were excised and labeled accordingly. All lymph nodes underwent frozen sectioning and were examined by hematoxylin and eosin and immunohistologic (cytokeratin) staining. RESULTS: Of the 59 patients, 48 had axillary lymph node dissection irrespective of the results of pathologic examination of the SLN. The success rate, sensitivity, negative predictive value, and accuracy were 93%, 100%, 100%, and 100% using the radiocolloid probe, 87%, 100%, 100%, and 100% using blue dye, and 93.5%, 100%, 100%, and 100% using combined methods, respectively. Concordance between blue dye and radiocolloid was 91% (the incidence of the number of sentinel nodes detected was 37.5%, 30.3%, 10.7%, and 21.4% for 1, 2, 3, and 4 or more lymph nodes, respectively). Metastatic lymph node involvement was found in 39.5% of patients. CONCLUSION: The sentinel node localization approach showed a high negative predictive value in breast cancer patients with multifocal or multicentric lesions, contrary to the common belief of significant false-negative results in these patients.     

MR imaging-guided 9-gauge vacuum-assisted core-needle breast biopsy: initial experience

PURPOSE: To perform magnetic resonance (MR) imaging-compatible vacuum-assisted 9-gauge core-needle biopsy of suspicious enhancing breast lesions identified at MR imaging. MATERIALS AND METHODS: The institutional review board granted exempt status for this HIPAA-compliant study and waived the requirement for informed consent. The MR imaging-guided 9-gauge vacuum-assisted core-needle biopsy findings of 85 lesions in 75 patients aged 31-89 years were retrospectively reviewed. The biopsies were performed as part of the patients' clinical care with a Food and Drug Administration-approved biopsy system and not within a research protocol. All included patients had received a diagnosis of malignant, benign, or high-risk (for cancer) breast tissue at core-needle biopsy and had undergone subsequent surgery or follow-up imaging. MR imaging-guided biopsy results were compared with final histopathologic or follow-up imaging findings. RESULTS: At MR imaging-guided core-needle biopsy, malignancy was identified in 52 (61%) lesions: 35 invasive cancers and 17 ductal carcinoma in situ (DCIS) lesions. Four (24%) of the 17 DCIS lesions were upgraded to invasive cancer at excisional biopsy or mastectomy. A high-risk lesion (ie, atypical ductal hyperplasia, atypical lobular hyperplasia, lobular carcinoma in situ, or radial scar) was identified in 18 (21%) cases. Two (25%) of eight atypical ductal hyperplasia lesions were upgraded to DCIS at excision. No malignancy was found in the atypical lobular hyperplasia (n = 2), lobular carcinoma in situ (n = 5), or radial scar (n = 3) lesions. Fifteen (18%) lesions were found to be benign lesions of unknown type at excision or mastectomy. For 13 of these 15 lesions, the benign results were concordant with the imaging findings. Both (two of 86, 2%) discordant cases represented false-negative lesions. The remaining 13 benign lesions were validated at excisional biopsy (n = 9) or follow-up imaging (n = 4). CONCLUSION: Initial experience revealed MR imaging-guided 9-gauge vacuum-assisted core-needle breast biopsy to be a reasonable alternative to MR imaging-guided wire localization of suspicious lesions identified at MR imaging only, on the basis of published information regarding the latter.     

MR imaging-guided 10-gauge vacuum-assisted breast biopsy: histological characterisation

Purpose

The aim of this study was to evaluate a handheld vacuum-assisted device for magnetic resonance imaging (MRI)-guided breast biopsy.

Materials and methods

In 47 patients, a total of 47 suspicious breast lesions (mean maximum diameter 9 mm) seen with MRI (no suspicious changes on breast ultrasound or mammography) were sampled using a 10-gauge vacuum-assisted breast biopsy (VAB) device under MRI guidance. Histology of biopsy specimens was compared with final histology after surgery or with follow-up in benign lesions.

Results

Technical success was achieved in all biopsies. Histological results from VAB revealed malignancy in 15 lesions (32%), atypical ductal hyperplasia in four lesions (8%) and benign findings in 28 lesions (60%). One of four lesions with atypical ductal hyperplasia was upgraded to ductal carcinoma in situ after surgery. One of seven lesions showing ductal carcinoma was upgraded to invasive carcinoma after surgery. Two lesions diagnosed as infiltrating carcinoma by VAB were not validated at excisional biopsy due to complete removal of the lesion during the procedure. During the follow-up (mean 18 months) of histologically benign lesions, we observed no cases of breast cancer development. Because of morphological changes on follow-up MRI scans, two lesions underwent surgical excision, which confirmed their benign nature. Besides minor complications (massive bleeding, n=1) requiring no further therapeutic intervention, no complications occurred.

Conclusions

MRI-guided biopsy of breast lesions using a handheld vacuum-assisted device is a safe and effective method for the workup of suspicious lesions seen on breast MRI alone.     

Can scintimammography with (99m)Tc-MIBI identify multifocal and multicentric primary breast cancer?

Scintimammography with (99m)Tc-MIBI has been shown to be an effective adjunct to imaging of the breast with mammography. Uptake of (99m)Tc-MIBI is particularly high in sites of non-calcified cancer and ductal carcinoma in situ (DCIS), and as a consequence it may be possible to use this method of imaging in identifying multifocal or multicentric disease. The aim of this study was to evaluate the efficacy of preoperative scintimammography in the detection of multifocal and multicentric breast cancer and compare these results with mammography. A retrospective review was performed of 353 women imaged with (99m)Tc-MIBI as part of the clinical assessment of their suspected primary breast cancer. The results of the scintimammography and mammography were then compared with the final pathological diagnosis obtained after mastectomy in all patients. Histopathological assessments of breast tissue from mastectomy confirmed 40 women (12%) had multifocal (34) or multicentric (six) breast cancer. Scintimammography correctly identified 39 of these cancers and the multifocal or multicentric character of the cancer was identified in 22 (52%) of these patients. Anatomical imaging performed in all 40 patients including 25 with mammography alone, mammography and ultrasound in 11 cases and ultrasound alone in four patients. Anatomical imaging identified cancer to be present in 28 patients (70%) and the combination of mammography and ultrasound identified correctly that the cancer was multifocal or multicentric in eight patients (22%). In this study scintimammography was able to identify more cases of multifocal and multicentric cancer than mammography and/or ultrasound. In patients where pre-operative identification of multicentric or multifocal disease can alter treatment scintimammography may be a useful investigative tool.     

Overall breast density in MR mammography: diagnostic and therapeutic implications in breast cancer

The objective of this study was to assess the efficacy of MR mammography (MRM) in evaluating breast cancer extent in women with fatty or dense breasts, and its contribution to the therapeutic approach. The authors reviewed 97 carcinomas detected in 93 women (both symptomatic and from screening) that were classified in two groups according to breast density pattern. Mammography, ultrasound (US), and MRM were performed to evaluate size, extension of the in situ component, presence of multifocal/multicentric disease, and contralateral involvement. Results obtained on mammography plus US were balanced against MRM, considering pathologic analysis as the gold standard. For fatty breasts (n=47), exact measurement was found on mammography plus US and on MRM alone in 70%, underestimation on mammography plus US 23.5% and on MRM 11% (P=0.005). For dense breasts (n=50), exact measurement was found on mammography plus US in 40% and on MRM alone 68%, underestimation on mammography plus US 52% and on MRM 10% (P=0.005). Overall, good correlation (R>0.71) was found between pathologic and clinical size with all imaging methods; nevertheless, when evaluating multifocal/multicentric disease, a poor correlation was observed between histologic assessment and mammography plus US (R=0.52), but it was excellent with regard to MRM (R=0.99). In fatty breasts, the combination of mammography and US allows for a precise assessment of tumoral extension. However, these results show that in dense breasts, MRM is superior to mammography plus US, suggesting that its systematic use in this group of patients is justifiable.     

Should We Screen Oncotype DX Eligible Patients With Breast MRI?

PurposeOncotype DX is a genomic test used to predict chemotherapy benefit and recurrence risk in early stage breast cancer patients. A previous study has shown that in patients with multiple tumors sent for Oncotype DX analysis, differing results between the tumors were yielded that ultimately changed chemotherapy management in 27% of cases. The purpose of this study is to determine the utility of preoperative MRI in Oncotype DX eligible patients.MethodsA retrospective, Institutional review board approved study identified 888 consecutive new breast cancer patients from 2012 to 2016 at a single institution and identified 541 patients who potentially would be eligible for Oncotype DX. Frequency of additional disease in this population group was recorded. The method of imaging used, either conventional imaging (mammography and ultrasound) or additional MRI, was evaluated.ResultsOf 541 patients, 360 patients had conventional imaging performed only and 181 patients had an additional breast MRI. Of 541 patients, 73 patients (13.5%) had additional biopsy proven multifocal, multicentric, or contralateral tumors identified. The total number of additional disease within the conventional imaging group was 39 of 360 patients (10.8%), vs 34 of 181 patients (18.8%) in the MRI group, which was statistically significant (P = 0.02). Total 34 of 73 patients (46.6%) had additional disease only detected by MRI.ConclusionsIn patients who may be eligible for Oncotype DX evaluation, 13.5% of patients were found to have additional disease. Nearly half of the patients had additional disease only detected by MRI, indicating the potentially utility of preoperative MRI in this patient population.     

Diagnostic imaging of lobular carcinoma of the breast: mammographic, ultrasonographic and MR findings

PURPOSE: To evaluate the most frequent mammographic, US and MR findings of invasive lobular carcinoma and the role of MRI in defining multifocality and/or multicentricity of this tumor histotype. MATERIAL AND METHODS: We studied 45 lobular carcinomas (39 patients) were selected from 421 breast cancers. Core biopsy with a 14 G needle was performed in 39 cases, under US guidance in 36/39 and under mammographic guidance in 3/39 cases. Surgical biopsy was performed in 2 cases and the diagnosis could be made only after mastectomy in 5 cases. All patients were examined with mammography and US and (10-13 MHz) and 8 also with MRI. RESULTS: 28/46 palpable lesions (60.9%). Core biopsy correctly diagnosed 38/39 lesions (97.4%). The most frequent mammographic findings was that of a nodular opacity without microcalcifications (34.8%), followed by a mass with spiculated borders (30.4%). Microcalcifications were seen in one case only (2.2%). Mammography detected no abnormalities in 15.2% of cases, but US showed a lesion in 2 of these cases. The most frequent US pattern was that of a hypoechoic lesion (43.5%), followed by posterior US beam attenuation. No US signs of abnormality were seen 15.2%. MRI correctly detected 13 lesions. Contrast enhancement was greater than 70% at one minute in 10 cases and greater than 40% in one case; two lesions exhibited atypical slow contrast enhancement, peaking at 5 minutes. MRI detected 5 lesions missed at both mammography and US and showed multifocal (3 and 2) lesions where the other techniques had detected one lesion only. DISCUSSION: At mammography and US invasive lobular carcinoma exhibits no different features than ductal carcinoma but is difficult to identify especially in its early stages. US is a useful tool especially to characterize mammography-detected lesions but in our experience it also demonstrated 2 lesions missed at mammography. MRI is a precious examination to define the multifocal, multicentric or bilateral character of invasive lobular carcinoma. CONCLUSIONS: Invasive lobular carcinoma of the breast is often very difficult to diagnose. Thus, we suggest the use of integrated diagnostic imaging with mammography, US and, in some cases, MRI for earlier diagnosis and to identify further tumor localizations.     

Malignancy rates of stereotactic biopsies of two or more distinct sites of suspicious calcifications in women without known breast cancer

ObjectiveTo determine the malignancy rate in women without a concurrent breast cancer diagnosis at presentation who underwent stereotactic biopsies of distinct sites of suspicious calcifications.MethodsThis retrospective study included 280 women without a concurrent breast cancer diagnosis who underwent 587 stereotactic biopsies of two or more distinct sites of suspicious calcifications in one or both breasts at our institution from 2010 to 2015.ResultsThe overall malignancy rate was 27.9% (78/280, 95% CI, 22.7%–33.5%) at the patient level and 18.7% (110/587, 95% CI, 15.7%–22.1%) at the lesion level. Eighteen had invasive cancers (mean [range] diameter, 0.5 cm [0.1–1.7]; six grade I, ten grade II, two grade III), one of whom had multifocal and another bilateral malignancy. Sixty had ductal carcinoma in situ. Of the 171 with all calcifications of the same morphology, 139 (81.3%) had all calcifications in the same pathology category (benign, high-risk, or malignant).ConclusionThe malignancy rate is substantial in women who undergo stereotactic biopsies of two or more distinct calcification sites. Given the nearly 20% rate of dissimilar histopathology between calcification sites with similar morphology, if only one site is biopsied and results in a malignant pathology, biopsy of the additional calcifications is warranted. Even if the pathology result of the one site biopsy is benign, biopsy of additional sites may perhaps still be necessary.     

Malignancy rates of stereotactic biopsies of two or more distinct sites of suspicious calcifications in women without known breast cancer

ObjectiveTo determine the malignancy rate in women without a concurrent breast cancer diagnosis at presentation who underwent stereotactic biopsies of distinct sites of suspicious calcifications.MethodsThis retrospective study included 280 women without a concurrent breast cancer diagnosis who underwent 587 stereotactic biopsies of two or more distinct sites of suspicious calcifications in one or both breasts at our institution from 2010 to 2015.ResultsThe overall malignancy rate was 27.9% (78/280, 95% CI, 22.7%–33.5%) at the patient level and 18.7% (110/587, 95% CI, 15.7%–22.1%) at the lesion level. Eighteen had invasive cancers (mean [range] diameter, 0.5 cm [0.1–1.7]; six grade I, ten grade II, two grade III), one of whom had multifocal and another bilateral malignancy. Sixty had ductal carcinoma in situ. Of the 171 with all calcifications of the same morphology, 139 (81.3%) had all calcifications in the same pathology category (benign, high-risk, or malignant).ConclusionThe malignancy rate is substantial in women who undergo stereotactic biopsies of two or more distinct calcification sites. Given the nearly 20% rate of dissimilar histopathology between calcification sites with similar morphology, if only one site is biopsied and results in a malignant pathology, biopsy of the additional calcifications is warranted. Even if the pathology result of the one site biopsy is benign, biopsy of additional sites may perhaps still be necessary.     

Classification of hypervascularized lesions in CE MR imaging of the breast

The purpose of this paper is to define and evaluate a classification category for contrast-enhanced (CE) MR imaging of the breast based on the BI-RADS mammographic categories of the American College of Radiology. Using five evaluation criteria for MR findings (initial signal increase, post-initial signal behavior, shape, border, and contrast material distribution within enhancing tumors) 522 patients (1031 breasts) were analyzed. Scores were given from 0 to 8 points and classified into five categories (group I: 0 points, negative; group II: 1-2 points, benign; group III: 3 points, probably benign; group IV: 4-5 points, suspicious abnormality; group V: 6-8 points, highly suspicious for malignancy) to 265 focal hypervascularized breast lesions in 244 breasts (patient group A). These findings were correlated with histology or follow-up. Additionally, this classification was correlated to the contrast medium uptake within the parenchyma of the remaining 787 breasts without any focal lesion (patient group B). Two hundred sixty-five hypervascularized lesions in 238 patients (244 breasts, patient group A) were classified into group I: 0%; group II: 27.3%; group III: 22.3%; group IV: 18.6%; and group V: 31.8%. Histology revealed 115 benign and 134 malignant tumors in these groups. Sixteen benign lesions were controlled by follow-up. Sensitivity for the detection of malignancy using the presented multifactorial MRM classification was 92%, and specificity was 92%. Excluding cases of ductal carcinoma in situ specificity increased to 95%. Seven hundred eighty-seven breasts without any focal hypervascularized lesion (patient group B) were classified into groups I or II. Follow-up ( n=771) or histology ( n=14) confirmed the diagnosis in 785 of these breasts. Histopathology revealed, however, malignant tumors in the remaining two cases. The classification of lesions based on a multifactorial analysis is very helpful in the interpretation of CE MRI of the breast. The evaluation of all diagnostic imaging modalities, however, is essential in determining the correct diagnosis and/or in deciding on the appropriate therapeutic procedure.     

乳腺MRI在X线检查乳腺阴性腋淋巴结转移癌阳性患者中的应用价值

目的 探讨乳腺MR检查对临床乳腺触诊和X线检查均为阴性的腋淋巴结转移癌患者寻找其乳腺内原发病灶的应用价值.方法 分析33例以腋淋巴结转移癌为首诊表现(临床乳腺触诊和X线检查均为阴性)患者的乳腺MR影像资料,依据美国放射学会的乳腺影像报告和数据系统MRI标准对所有病变进行分析,并将MRI诊断结果与病理进行对照.结果 33例腋淋巴结转移癌患者中,30例临床行乳腺根治术,其中17例经病理证实为乳腺癌,乳腺MRI检出其中的16例,包括10例肿块性病变和6例非肿块性病变,肿块性病变直径0.5～2.6 cm(平均1.5 cm),直径≤1.5 cm者6例;非肿块性病变包括4例导管性强化和2例段性强化;另1例病理切片发现乳腺癌但乳腺MRI为阴性.其余13例行乳腺根治术患者病理检查未发现乳腺癌灶,其中9例乳腺MRI亦呈阴性表现,另4例MRI提示可疑癌灶.余3例临床未行手术治疗的患者,乳腺MRI亦为阴性.以病理诊断为金标准,MR检出乳腺原发癌灶的敏感度、特异度和准确度分别为94.1%、69.2%和83.3%.结论 相对于一般乳腺癌而言,隐匿性乳腺癌MRI表现更以小灶性的肿块性病变和导管或段性强化的非肿块性病变为常见表现类型.乳腺MR检查对隐匿性乳腺癌的检出具有较高的敏感度和准确度,应作为这类患者的常规检查手段.

Abstract：

Objective To evaluate the role of breast MRI in detecting the primary malignancy in patients presenting solely with axillary lymph node metastases. Methods Thirty-three patients with axillary lynph node metastases but negative findings on either physical examination or mammography underwent breast MRI to identify occult breast carcinoma. MRI of the breast was assessed according to BI-RADS criteria. The pathologic diagnosis was made according to the standard criteria by the WHO Classification of Tumor. Results Among 33 patients presenting solely with axillary metastases, 30 patients underwent modified radical mastectomy. Primary breast carcinoma was proven in 17 patients. MRI detected lesions in 16 patients, including 10 masses and 6 non-mass lesions. Size of the masses ranged from 0. 5 to 2. 6 cm (mean 1.5 cm). Six lesions were smaller than 1.5 cm in size. Non-mass lesions showed ductal enhancement in 4 cases and segmental enhancement in 2 cases. One patient with tumor detected by histopathology showed no abnormal enhancement on MRI. No tumor was found at mastectomy in the other 13 womeu, and negative MR findings were revealed in 9. Four cases with suspicious enhancement on MRI had no corresponding primary foci on pathology. Three patients didn't undergo surgical procedure. The sensitivity, specificity, and accuracy of MRI in the diagnosis of the primary malignancy were 94. 1%,69. 2%, and 83.3%, respectively. Conclusions Small size of mass and ductal or segmental enhancement of non-mass lesion were common MR features of occult malignancy. MRI showed high sensitivity and accuracy in diagnosing occult breast carcinoma. Breast MRI should be taken in search of occult malignancy in patients with axillary metastases.     

乳腺MRI在X线检查乳腺阴性腋淋巴结转移癌阳性患者中的应用价值

目的 探讨乳腺MR检查对临床乳腺触诊和X线检查均为阴性的腋淋巴结转移癌患者寻找其乳腺内原发病灶的应用价值.方法 分析33例以腋淋巴结转移癌为首诊表现(临床乳腺触诊和X线检查均为阴性)患者的乳腺MR影像资料,依据美国放射学会的乳腺影像报告和数据系统MRI标准对所有病变进行分析,并将MRI诊断结果与病理进行对照.结果 33例腋淋巴结转移癌患者中,30例临床行乳腺根治术,其中17例经病理证实为乳腺癌,乳腺MRI检出其中的16例,包括10例肿块性病变和6例非肿块性病变,肿块性病变直径0.5～2.6 cm(平均1.5 cm),直径≤1.5 cm者6例;非肿块性病变包括4例导管性强化和2例段性强化;另1例病理切片发现乳腺癌但乳腺MRI为阴性.其余13例行乳腺根治术患者病理检查未发现乳腺癌灶,其中9例乳腺MRI亦呈阴性表现,另4例MRI提示可疑癌灶.余3例临床未行手术治疗的患者,乳腺MRI亦为阴性.以病理诊断为金标准,MR检出乳腺原发癌灶的敏感度、特异度和准确度分别为94.1%、69.2%和83.3%.结论 相对于一般乳腺癌而言,隐匿性乳腺癌MRI表现更以小灶性的肿块性病变和导管或段性强化的非肿块性病变为常见表现类型.乳腺MR检查对隐匿性乳腺癌的检出具有较高的敏感度和准确度,应作为这类患者的常规检查手段.     

乳腺MRI在X线检查乳腺阴性腋淋巴结转移癌阳性患者中的应用价值

目的 探讨乳腺MR检查对临床乳腺触诊和X线检查均为阴性的腋淋巴结转移癌患者寻找其乳腺内原发病灶的应用价值.方法 分析33例以腋淋巴结转移癌为首诊表现(临床乳腺触诊和X线检查均为阴性)患者的乳腺MR影像资料,依据美国放射学会的乳腺影像报告和数据系统MRI标准对所有病变进行分析,并将MRI诊断结果与病理进行对照.结果 33例腋淋巴结转移癌患者中,30例临床行乳腺根治术,其中17例经病理证实为乳腺癌,乳腺MRI检出其中的16例,包括10例肿块性病变和6例非肿块性病变,肿块性病变直径0.5～2.6 cm(平均1.5 cm),直径≤1.5 cm者6例;非肿块性病变包括4例导管性强化和2例段性强化;另1例病理切片发现乳腺癌但乳腺MRI为阴性.其余13例行乳腺根治术患者病理检查未发现乳腺癌灶,其中9例乳腺MRI亦呈阴性表现,另4例MRI提示可疑癌灶.余3例临床未行手术治疗的患者,乳腺MRI亦为阴性.以病理诊断为金标准,MR检出乳腺原发癌灶的敏感度、特异度和准确度分别为94.1%、69.2%和83.3%.结论 相对于一般乳腺癌而言,隐匿性乳腺癌MRI表现更以小灶性的肿块性病变和导管或段性强化的非肿块性病变为常见表现类型.乳腺MR检查对隐匿性乳腺癌的检出具有较高的敏感度和准确度,应作为这类患者的常规检查手段.     

Assessment of suspected breast cancer by MRI: a prospective clinical trial using a combined kinetic and morphologic analysis

OBJECTIVE: The objective of our study was to assess the incremental value of contrast-enhanced MRI in the diagnosis and treatment planning using both a three-time point kinetic and morphologic analysis in addition to mammography and sonography in patients thought to have early-stage breast cancer. SUBJECTS AND METHODS: Contrast-enhanced bilateral breast MRI was performed prospectively on 65 patients with highly suspicious imaging findings (BI-RADS category 4 or 5). All enrolled patients were believed to be candidates for breast conservation on the basis of clinical examination, mammography, and sonography. The primary index lesion's characteristics, size, and extent were assessed. Also, additional lesions detected by MRI that could represent potential malignancies in both the ipsilateral and contralateral breast were evaluated. Morphologic assessment and kinetic analysis were performed on each lesion using dedicated postprocessing and display software. The patients were reevaluated as to whether they were still candidates for breast-conservation therapy after the MRI examination and subsequent biopsies. RESULTS: There were 46 patients (71%) whose primary breast lesion (detected by mammography, sonography, or both) was found to be malignant (39 invasive breast cancers, five intraductal cancers, and two lymphomas). For the primary index lesions, the sensitivity for MRI was 100% (44/44) for predicting a breast malignancy and the specificity was 73.7% (14/19) for predicting benign lesions. MRI detected an additional 37 lesions, of which 23 were cancerous, beyond those suspected on mammography or sonography. One or more additional ipsilateral breast cancers were detected in 32% (14/44) of breast cancer patients and contralateral breast cancers in 9% (4/44) of the breast cancer patients. MRI also resulted in an incremental recommendation of mastectomy in 18% (8/44) of the pathologically confirmed breast cancer patients. MRI resulted in additional biopsy of only 14 benign lesions, six of which were shown to be atypical ductal hyperplasia. CONCLUSION: When added to the standard evaluation of clinical examination, mammography, and sonography in patients thought to have early-stage breast cancer, contrast-enhanced MRI using both a kinetic and morphologic analysis will often result in changes in recommended patient management and better treatment planning and will result in no significant increase in biopsies of benign lesions. In addition, there is a significant detection rate of occult contralateral breast cancers.