PREOPERATIVE BREAST MRI:

should BIRADS-3 be considered ?

Páramo M, Zalazar R, Pina-Insausti LJ, Martínez-Regueira F, Elizalde A, Olartecoechea B, Spiteri N

Pamplona, Spain

• The authors have nothing to disclose

• This study was approved by the ethic committee at

our institution

PREOPERATIVE BREAST MRI

- It can detect multifocal and/or multicentric and/or bilateral

cancers not seen on conventional techniques (SE: 95-98%) ,

changing the treatment in up to 20 %

- However, it can increase the false positive

rate (SP: 40-95%) and the number of

biopsies. Even some chosen treatments can

be too agressive for the tumour burden

INTRODUCTION

Houssami N et al. Ann Surg. 2013 Patani N, Mokbel K. Int J Clin Pract. 2008

Houssami N, Hayes DF. CA Cancer J Clin. 2009

- BI-RADS 3 category comprises probably benign lesions with a

positive predictive value less than 2 %

INTRODUCTION

- The management of BI-RADS 3

lesions is controversial, because

both follow-up or percutaneous

biopsy can be performed

BI-RADS 3 CATEGORY

Linda A et al. Radiol Med. 2013 Baum JK et al. Radiology. 2011

Dorrius MD et al. Cancer Imaging. 2010

To compare the sensitivity (SE) and specificity (SP) of

preoperative breast MRI including BI-RADS 3 category

lesions as positive for malignancy or not

OBJECTIVE

51 consecutive women with:

(1.5T AERA, Siemens,

Erlangen, Germany)

MATERIALS AND METHOD

Inclusion criteria

Histologically proven

breast cancer

Preoperative

MRI

+

(Biopsy: IDC)

(1.5T AERA, Siemens, Erlangen, Germany)

CE-MRI (1.5T Aera, Siemens, Erlangen, Germany)

- STIR (TR=5000 ms, TE=57.0 ms, TI=170 MS Flip angle=141°, Voxel=1.1x1.1x4 mm)

- FLASH 3D (TR=4.82 ms, TE=1.85 ms, Flip angle=10°, Fat-Sat, Voxel=0.8x0.8x1.5 mm)

- Injection of 0.1 mmol/kg of paramagnetic contrast (Gadovist, Bayer)

- Dynamic T1w post-contrast study ( 5 acquisitions at a time resolution of 60s)

- Subtraction images are obtained

MATERIALS AND METHOD

GROUP 1 BI-RADS 3 = MALIGNANT

GROUP 2

BI-RADS 3 = BENIGN

134 breast lesions Retrospective

analysis

51 women Mean age of 53 years old (range 38-76)

MATERIALS AND METHOD

Lecture

− Preoperative MRI images were interpreted

RETROSPECTIVELY by consensus of two expert breast

radiologists, blinded to the final diagnosis

Analysis

− All lesions were compared to the gold standard (histology

and/or follow-up)

− The results were collected using an excel table to calculate

the SE and SP, and the statistical significance was studied

using PEPI software (4.04 JH Abramson & PM Gahlinger)

MATERIALS AND METHOD

77 Malignant

(histologically proven)

57 Benign

(biopsy and/or follow-up)

A.- Descriptive

RESULTS

Table 1.- Histology of malignant lesions

Number

IDC 59

ILC 9

DCIS 4

Coloid carcinoma 2

Tubular carcinoma 1

Papillary carcinoma 1

Phylodes tumour 1

TOTAL 77

Table 2.- Histology of benign lesions

Number

Fibroadenoma 10

Adenosis 4

Columnar cell changes 3

Fat necrosis 3

TOTAL 20

37

follow-up

20

biopsy

134 breast lesions

134 breast lesions

77 Malignant

(histologically proven)

57 Benign

(biopsy and/or follow-up)

Number of cases

BI-RADS 1 0

BI-RADS 2 3

BI-RADS 3 49

BI-RADS 4 5

BI-RADS 5 0

Number of cases

BI-RADS 1 1

BI-RADS 2 0

BI-RADS 3 5

BI-RADS 4 15

BI-RADS 5 56

RESULTS A.- Descriptive

77 Malignant

(histologically proven)

57 Benign

(biopsy and/or follow-up)

Number of cases

BI-RADS 1 0

BI-RADS 2 3

BI-RADS 3 49

BI-RADS 4 5

BI-RADS 5 0

Number of cases

BI-RADS 1 1

BI-RADS 2 0

BI-RADS 3 5

BI-RADS 4 15

BI-RADS 5 56

RESULTS A.- Descriptive

TOTAL BI-RADS 3

LESIONS

54

PPV 9.23 %

NPV 90.77 %

134 breast lesions

SE (%) SP (%)

GROUP 1 98.7 5.3

SE (%) SP (%)

GROUP 2 92.2 91.2

Table 3. Evaluation of SE and SP of preoperative MRI in GROUP 1

Table 4. Evaluation of SE and SP of preoperative MRI in GROUP 2

BI-RADS 3

MALIGNANT

BI-RADS 3

BENIGN

B.- Analytical

RESULTS

GROUP 1 GROUP 2

SE (%) 98.7 92.2 ns

SP (%) 5.3 91.2 p< 0.05

Table 5. Comparison of SE and SP of preoperative MRI

between GROUP 1 and GROUP 2

RESULTS B.- Analytical

BI-RADS 3

MALIGNANT

BI-RADS 3

BENIGN

- If BI-RADS 3 lesions had been considered BENIGN, 5

cancers would have been misdiagnosed:

- Tumour histology: 3 invasive ductal carcinomas

and 2 lobular carcinomas

- Mean size: 0.21 mm (0.1-0.6 mm)

RESULTS

- All of them were located very close to the main

tumour (< 15 mm) so likely they would have been

excised on conventional surgery

CASES

(1.5T AERA, Siemens, Erlangen, Germany)

A 55 YEAR-OLD WOMAN WITH BREAST CANCER IN THE LEFT BREAST

Preoperative CE-MRI

A mass enhancement was seen in the left breast highly suspicious of breast cancer (white arrow)

CASE 1

Other three foci (BI-RADS 3 lesions) were also seen in the same breast (red circles).

Preoperative CE-MRI

3

2

1 1. Biopsy: Fibroadenoma

CASE 1 cont.

A 55 YEAR-OLD WOMAN WITH BREAST CANCER IN THE LEFT BREAST

2. Biopsy: Fibroadenoma

3. Biopsy of BI-RADS 3 lesion:

0.6mm invasive ductal carcinoma

(< 15mm distance from breast cancer)

A 48 YEAR-OLD WOMAN WITH BREAST CANCER IN THE LEFT BREAST

Preoperative CE-MRI

A nodular enhancement was seen in the left breast highly suspicious of malignancy (white arrow)

CASE 2

Another focus (BI-RADS 3 lesions) was also seen in the same breast (red circle).

1. Biopsy of BI-RADS 3 lesion:

0.2 mm invasive ductal carcinoma

(< 15mm distance from breast cancer)

1

Preoperative CE-MRI

CASE 2 cont.

A 48 YEAR-OLD WOMAN WITH BREAST CANCER IN THE LEFT BREAST

Preoperative CE-MRI

A 53 YEAR-OLD WOMAN WITH BREAST CANCER IN THE LEFT BREAST

A nodular enhancement was seen in the left breast highly suspicious of breast cancer (white arrow)

CASE 3

Another focus (BI-RADS 3 lesion) was also seen in the same breast, very close to the main tumour (red arrow).

Preoperative CE-MRI

1. Biopsy of BI-RADS 3 lesion:

0.2 mm invasive lobular carcinoma

(< 15mm distance from breast cancer)

1

CASE 3 cont.

A 53 YEAR-OLD WOMAN WITH BREAST CANCER IN THE LEFT BREAST

Preoperative CE-MRI

In this particular case another BI-RADS 3 lesion was seen in the contralateral breast (white arrow) Biopsy: Fibroadenoma

CASE 3 cont.

A 53 YEAR-OLD WOMAN WITH BREAST CANCER IN THE LEFT BREAST

• Retrospective • Small number of cases • This study was not designed to determine the concordance between the two readers

LIMITATIONS

Considering BI-RADS-3 category as benign in preoperative

breast MRI increases the SPECIFICITY significantly (SP: 5.3% vs

91.2%, p<0.05) without a significant decreased of the sensitivity

(SE: 98.7% vs 92.2%, p>0.05)

CONCLUSIONS

All of the malignant BI-RADS 3 lesions were close to the main

tumour (<15mm) and they would have been completely excised

on conventional surgery

MARÍA PÁRAMO ALFARO mparamo@unav.es