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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 20  |  Issue : 2  |  Page : 32-38

The value of combination of dynamic contrast-enhanced magnetic resonance imaging and diffusion-weighted imaging in the evaluation of breast masses


Department of Radiological, AL-Yarmouk Teaching Hospital, College of Medicine, Al-Mustansiriya University, Baghdad, Iraq

Date of Submission29-Dec-2020
Date of Decision05-May-2021
Date of Acceptance20-Jul-2021
Date of Web Publication15-Dec-2021

Correspondence Address:
Dr. Sahar Basim Ahmed
Department of Radiological, AL-Yarmouk Teaching Hospital, College of Medicine, Al-Mustansiriya University, Baghdad
Iraq
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mj.mj_8_21

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  Abstract 


Aim of the study: The aim was to characterize benign and malignant breast lesions on the basis of their magnetic resonance imaging (MRI) morphology and dynamic contrast enhancement in combination with the diffusion-weighted imaging (DWI) and their apparent diffusion coefficient (ADC) values at 1.5 T MRI, along with histopathological correlation. Patients and Methods: In this prospective study, 56 patients with suspicious breast mass who underwent 1.5 T MRI and proved by histopathology were included. Morphology was studied depending on the MRI signal intensity and dynamic contrast-enhanced imaging plus kinetic curve of enhancement of breast lesions. DWI and ADC values were calculated at b values of 0, 600, and 850 s/mm. The ADC value and histopathology correlation were analyzed. Results: Out of the 56 lesions, 27 lesions were histologically malignant (48.2%) and 29 were histologically benign (51.8%), with age range between 25 and 75 years, with a mean of 54.1 years, and with a standard deviation of ±12.69 years. The MRI results found a sensitivity (SN) of 85.2%, a specificity (SP) of 72.4%, a positive predictive value (PPV) of 74.2%, a negative predictive value (NPV) of 84%, and an accuracy of 78.6%. The DWI findings were as follows: 100% SN, 82.8% SP, 84.4% PPV, 100% NPV, and 85.3% accuracy. The combined MRI interpretation and DWI and ADC findings were as follows: 100% SN, 92.1% SP, 71.1% PPV, 100% NPV, and 86.4% accuracy. All malignant lesions showed restriction at DWI, while only 17.2% of the benign lesions are restricted at DWI. The mean of ADC value was higher in benign cases as compared to the malignant lesions (0.815 vs. 1.287 × 10−3) with statistically significant difference (P = 0.001). Conclusions: The combination of contrast-enhanced breast MRI with DWI and ADC value increases the diagnostic accuracy and SP in the characterization of benign and malignant breast lesions.

Keywords: Apparent diffusion coefficient, breast mass, diffusion-weighted imaging, dynamic contrast-enhanced magnetic resonance imaging


How to cite this article:
Mahmmud NA, Ahmed SB, Othman AM. The value of combination of dynamic contrast-enhanced magnetic resonance imaging and diffusion-weighted imaging in the evaluation of breast masses. Mustansiriya Med J 2021;20:32-8

How to cite this URL:
Mahmmud NA, Ahmed SB, Othman AM. The value of combination of dynamic contrast-enhanced magnetic resonance imaging and diffusion-weighted imaging in the evaluation of breast masses. Mustansiriya Med J [serial online] 2021 [cited 2022 May 23];20:32-8. Available from: https://www.mmjonweb.org/text.asp?2021/20/2/32/332566




  Introduction Top


Magnetic resonance imaging breast

Nowadays, magnetic resonance imaging (MRI) of the breast is frequently applied when other diagnostic modalities fail to find a primary source in the breast. Remarkable advances in MRI technology have allowed sensitive detection and anatomic definition of cancer.[1]

Dynamic contrast-enhanced MRI (DCE-MRI) and diffusion-weighted MRI (DW-MRI) are currently used as an adjunct to mammography and ultrasound (US) in women at high risk, or those with extremely dense breasts, selective “problem-solving” or adjunct diagnosis where standard clinical and imaging evaluation do not provide a clear diagnosis, imaging of breast silicone implants, monitoring response to neoadjuvant (primary), systemic therapy in locally advanced disease, irradiated breasts, and pre- and post-surgical breasts for staging of highly invasive breast cancers.[2]

Although the most frequently used techniques for breast imaging are mammography and US, contrast-enhanced MRI is becoming increasingly significant, mainly because of its high sensitivity (SN) for detecting invasive breast cancer the negative predictive value of breast MRI for invasive breast cancer (99)% may help to avoid further investigation and unnecessary biopsies.[2] There is evidence that MRI does lead to changes in surgical treatment, typically from breast-conserving surgery to mastectomy.

Breast magnetic resonance imaging interpretation

Each lesion should be evaluated regarding its shape, margin, precontrast T1 and T2-weighted images (T1 and T2 WI) signal intensity, enhancement characters, as well as any change from the previous study. In general, bright signal on T1 and T2 WI is suggestive of benign finding with the exception of colloid carcinoma which can demonstrate high signal intensity on T2 WI, while most invasive carcinomas demonstrate low or intermediate signal intensity on T2 WI.[3],[4]

There are certain morphologic and kinetic characteristics of the lesions, such as irregular shape, irregular or spiculated margin, rim enhancement (in the case of mass enhancement), linear or segmental enhancement (in nonmass enhancement), and with awash-out curve, which are considered to be suggestive of malignancy.[4]

The morphological features of breast masses at MRI include shape, margin and pattern of internal enhancement and non enhancing septa (in mass enhancement) and (nonmass enhancement lesions ) presents as a focal, regional in distribution, with persistent pattern of dynamic curve are considered to be suggestive of benign disease.[4] Finally, MRI studies are classified into one of the six Breast Imaging-Reporting and Data System (BI-RADS) categories depending on the combined interpretation of both morphological and kinetic analysis, and appropriate recommendation is made.[4]

The kinetic information is typically expressed as a time intensity curve (TIC). TICs can be divided into three main shapes according to the initial enhancement phase within the 1st 2 min and the delayed enhancement phase after 2 min. The delayed-phase enhancement pattern is usually used to describe the curve shape.[3]

Diffusion weighted imaging

Diffusion weighted imaging (DWI) is considered the way of characterizing tissue properties by providing information about the free movement of water molecules (Brownian) in various tissue of the body. Hence in cysts, blood vessels, bladder, and tissues with big intercellular spaces, water move freely without any restriction and will show signal loss after the application of diffusion gradients.[5] On the contrary, in the case of solid tumors with high cellularity, there will be a significant reduction in the extracellular space, and free water movement will be restricted. Therefore, the signal will be greater after the application of diffusion gradients.[1],[6]

MRI can measure the diffusion of water in vivo. DW-magnetic resonance (MR) pulse sequence measures the apparent diffusion coefficient (ADC) value of water molecules in tissue voxels.

Diffusion-sensitizing gradients are placed along a single axis to alter the signal intensity of the diffusing water.[7]

Analysis of diffusion-weighted imaging

ADC can be calculated during postprocessing by the use of at least two different b values, and the final image with different ADC values measured for each pixel of the image is known as an ADC map.[8]

A low ADC value indicates restricted diffusion, typically seen in malignancies.[8]

The signal intensity seen in the DWI sequence is produced by the movement of water molecule and the T2 relaxation time. The “T2 effect” that can be mistaken with diffusion restriction is known as “shine-through.” Therefore, the ADC map permits quantifying DWI and is helpful to avoid this pitfall, as a region with truly restricted diffusion will show low signal intensity on the ADC map, but lesions with high fluid content will demonstrate high signal intensity on T2-weighted and on diffusion images.[8] This unwanted effect can be decreased by reducing the echo time which is basic pulse sequence parameter[7],[8],[9],[10] and increasing the b-value, but it can never be totally eliminated.[7]

DW breast MRI has been mainly applied to differentiate breast lesions and to add a new parameter for the diagnosis, with the hope of avoiding unnecessary biopsies, especially for lesions that are visible only on MRI that require sampling under MRI guidance, a time-wasting and high-cost procedure.[9]

Previous studies demonstrated an inverse relationship between the cellularity of breast malignancy and ADC value.[10],[11]

Most of these studies have shown a significant difference in ADC value between benign and malignant tumors. Each of them defines the cutoff point for the ADC value that provides a high SN and specificity (SP) for the detection of breast cancer, However, an overlap between benign and malignant diseases was demonstrated.[10],[12],[13]

A lot of studies have revealed the usefulness of breast DWI in the differentiation of benign from malignant lesions of the breast. These studies proved that the SN of breast DWI was in the range of 80%–96% and its SP was in the range of 46%–91%.[13],[14],[15] Partridge et al. concluded that there is 10% improvement in the positive predictive value (PPV) when combining DWI with DCE-MRI in the differentiation of breast masses.[13]

When measuring ADC value, the lesion must be identified on the ADC map and DW images, and then the region of interest (ROI) must be placed carefully over the solid part of the tumor to ensure that cystic or necrotic parts as well as the normal breast parenchyma are not included in this region.[15]

The aim of the study

The aim was to evaluate the role of DWI and DCE MRI in the characterization of breast lesions and comparing the results with the histological finding.


  Patients and Methods Top


This prospective study was performed at Al-Yarmouk Teaching Hospital in Baghdad from January 2018 to 2019.

From a total of 56 female patients, with the age range between 25 and 75 years and with a mean of 54.1 years, 56 lesions classified by physician and ± US and/or mammography were included.

Inclusion criteria

Patients with suspicious breast lesions at mammography or breast US or with suspicious clinical findings.

Exclusion criteria

  1. Patients with contraindication to MRI examination or its contrast media
  2. Patients who refused MRI examination
  3. Patients who refused biopsy or surgery
  4. Patients with inconclusive MRI study.


Data collection

All the patients underwent full history taking and general and local examination. All patients underwent DW MRI and DCE MRI examination, and the results of breast MRI were compared with the histopathological results that were used as the standard diagnostic method.

Magnetic resonance imaging protocol

All patients were subjected to MRI examination in prone position on 1.5 tesla Acheiva philips medical system in Eindhoven -Best /Netherlands, setup in Baghdad /Iraq, at AL-Yarmouk teaching hospital with a dedicated breast coil. MRI was done within 7–14 days of menstrual cycle in premenopausal women. Examination included image acquisition followed by image postprocessing.

The following sequences were done:

  • Axial T1 WI: Slice thickness = 3 mm
  • Axial T2 fat suppression WI: Slice thickness = 3 mm
  • DW image: It was done before contrast administration in the axial plane at spin-echo sequence using breast surface coil at the following b values: 0, 600, 850 s/mm2, slice thickness = 3 mm
  • ADC map was derived automatically in the MR system
  • Dynamic T1 postcontrast fat suppressed image: Dynamic study with intravenous contrast; dimeglumine Gadopentetate (each mL = 469 mg); the dose given to the patient about 1 mmol/kg by manual injection, slice thickness = 3 mm.


Image analysis

All the images were evaluated on the workstation by two specialized radiologists.

Each lesion was identified on the dynamic subtracted image, and T1, T2, and T2 fat suppression WIs.

The size, signal intensity, enhancement pattern, as well as the morphologic features of each lesion were analyzed. The time–signal intensity curves were obtained on dynamic MR images by placing the ROI at the most enhancing area of the lesion.

The morphologic features were assessed. The shape, margin, enhancement characteristics, and signal intensity on both T1- and T2-WIs were analyzed.

The enhancement kinetics of each lesion were evaluated, and the types of curves were determined according to delayed-phase enhancement as type I = persistent, II = plateau, and III = washout curves.

DWI was then evaluated regarding the signal intensity, and the mean ADC of each lesion was measured by placing the ROI manually within the solid portion of the lesion.

Histopathological diagnosis was done in all patients, considering it as a gold standard for the study.


  Results Top


The total number of patients recruited in this study was 56. All of them had palpable breast lesion and investigated by MRI.

Histopathological types and results

Of all the 56 participants, 29 females (51.8%) were complaining of benign lesion, while the remaining 27 females (48.2%) complained of malignant lesion.

The histopathological results of malignant lesions were as follows: invasive ductal carcinoma (88.9%), one lesion (3.7%) was each of ductal carcinoma in situ, atypical ductal hyperplasia, and malignant phylloid tumor. Regarding the 29 benign lesions, 41.4% of lesions were fibroadenoma, 10.4% were abscess, 24.3% were fibrocystic changes, 6.9% were fat necrosis, while one lesion (3.4%) was each of intraductal papilloma, hematoma, lipoma, duct ectasia, and galactocele [Table 1].
Table 1: Distribution of study patients by histopathological results (n=56)

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Magnetic resonance imaging findings

On the right side, there were 48.3% benign lesions and 37% malignant lesions, whereas 51.7% of benign lesions and 63% of malignant lesions were on the left side.

Type of enhancement

Concerning type of enhancement, the highest proportion of both benign and malignant lesions was with mass enhancement (88.9% and 65.5%, respectively). Nonmass enhancement was seen in 11.1% of benign lesions and 34.5% of malignant lesions. [Table 2] shows the distribution of breast lesions by type of enhancement.
Table 2: Distribution of study patients by histopathology and magnetic resonance imaging findings

Click here to view


Shape of lesion

According to MRI findings, 65.5% of benign masses were of regular shape or margin, whereas majority of the malignant masses (96.3%) were of irregular shape and margin.

Type of curve

Regarding the type of curve, plateau curve (Type II) was seen in the highest proportion of benign and malignant lesions (69% and 74.1%, respectively). Nine benign lesions (31%) and two malignant lesions (7.4%) were with persistent curve (Type I). While washout curve (Type III) was seen in 18.5% of malignant lesions, no benign lesions were with this curve type.

Enhancement pattern of lesion

A homogeneous internal enhancement pattern occurred in 44.8% of benign lesions, whereas 44.4% of malignant lesions were with heterogeneous internal enhancement pattern.

Diffusion-weighted imaging findings

Regarding DWI findings, most of the benign cases (82.8%) showed no restriction, whereas all of the patients with malignant lesions showed restricted DWI findings.

Depending on MRI findings' interpretation, 31 patients who represented 55.4% of the study patients were with malignant lesion, whereas the remaining 25 patients (44.6%) suffered from benign lesion of breast.

Comparison in apparent diffusion coefficient value between benign and malignant lesions

On comparison in the means of ADC value between both types of breast lesions, it was found that ADC value was higher in benign cases compared to that in malignant cases (0.815 vs. 1.287 × 103) with a statistically significant difference (P = 0.001) [Figure 1].
Figure 1: A 77-year-old female presented with rapidly growing right breast mass, (a) T1 weighted image and postcontrast T1 hypointense signal on T1-weighted image, diffusion-weighted imaging and apparent diffusion coefficient map restricted on diffusion-weighted imaging apparent diffusion coefficient value = 0.749 × 10−3, 0.863 × 10−3 mm2/s on 600 and 850 b value. (b) Dynamic magnetic resonance imaging revealing rim-enhancing mass with irregular outline, the mass shows washout curve, histopathological result was invasive ductal carcinoma

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Sensitivity, specificity, and accuracy of diffusion-weighted imaging and apparent diffusion coefficient study

The DWI study was of 100% SN, 82.8% SP, 84.4% PPV, 100% NPV, and 85.3% accuracy.

Sensitivity, specificity, and accuracy of routine magnetic resonance imaging interpretation

The MRI findings were as follows: SN of 85.2%, SP of 72.4%, PPV of 74.2%, NPV of 84%, and accuracy of 78.6%.

SN, SP, and accuracy of combined findings (routine MRI Interpretation and DWI) were as follows: 100% SN, 92.1% SP, 71.1% PPV, 100% NPV, and 86.4% accuracy.


  Discussion Top


The MRI BI-RADS lexicon recommends that a breast MRI protocol should contain T2-weighted and DCE MRI sequences. The addition of diffusion-DWI significantly improves diagnostic accuracy.

In this study, the two most common benign lesions were fibroadenoma and fibrocystic changes, which represented 41.4% and 24.3% of benign lesions, respectively, whereas the most common malignant lesion was invasive ductal carcinoma which represented 88.9% of malignant lesions.

These results were consistent with those of Ali et al.,[15] who mentioned that most of the benign lesions were fibroadenoma and fibrocystic changes, which represented 36.8% and 15.8% of benign lesions, respectively, whereas the two most common malignant lesions were invasive ductal carcinoma and invasive lobular carcinoma, which represented 55.6% and 16.7% of malignant lesions, respectively.

In this study, the most common shape of benign lesions was regular, which represented 56.5% of benign lesions, whereas the shape of all malignant lesions was irregular with high incidence for irregular-shaped lesions (96.3%) of all malignant lesions included in this study.

These results were consistent with those of Tozaki and Fukuma,[12] who showed that most benign lesions were of ovoid or round shape, while malignant lesions were of irregular shape.

In this study, according to enhancement pattern, homogenous enhancement was seen in 44.8% of benign lesions and 37% of malignant lesions, heterogeneous enhancement was seen in 6.9% of benign lesions and 44.4% of malignant lesions, rim enhancement was seen in 10.3% of benign lesions and 11.1% of malignant lesions, and nonmass enhancement was seen in 34.5% of malignant lesions and 11.1% of benign lesions, comparable with other studies.

Morris concluded that homogeneous enhancement is suggestive of a benign process; however, in small lesions, one must be careful as spatial resolution may limit evaluation. In addition, he concluded that the most frequent enhancement pattern among the malignant lesions was heterogeneous enhancement (96%).[16]

In this study, according to the shape of time/signal intensity curve, Type I persistent curve was seen in 31% of benign lesions and 7.4% of malignant lesions, Type II plateau curve was seen in 69% of benign lesions and 74.1% of malignant lesions, and Type III washout curve was seen in none of the benign lesions and 18.5% of malignant lesions.

These results were consistent with those of Kul et al.,[17] who showed that Type I persistent curve was seen in 81.1% of benign lesions and 12.8% of malignant lesions, Type II plateau curve was seen in 10.8% of benign lesions and 40.4% of malignant lesions, and Type III washout curve was seen in 8.1% of benign lesions and 44.7% of malignant lesions.

The conventional contrast-enhanced breast MRI interpretation mainly relies on the integrated analysis of lesion morphology as well as the enhancement kinetics of the lesion. Hence, we obtain information regarding tumor vascularity and vascular permeability in addition to tumor physics. This method demonstrated high SN for breast malignancy (85.2%) but with moderate SP (72.4%). An overlap is noted between the morphological characteristics and the enhancement kinetics of some malignant and benign lesions, leading to misclassification of these lesions.[3],[5],[17],[18]

In this study, we obtained 85.2% of SN and 72.4% of SP for contrast-enhanced breast MRI and in order to increase the diagnostic accuracy of breast MRI, we evaluated the complementary role of DWI (100 SN and 82.8 SP).

The combined analysis of CE-MRI and the DWI increased the SN of CE breast MRI by 14.8% and the SP by 19.7% with the resultant SN and SP of 100% and 92.1%, respectively, which is comparable to the study by Kul et al.,[19] who mentioned that the combination of DCE-MRI with DWI provided 95.7% SN and 89.2% SP. The SP of breast MRI improved by 13.5%; in addition, the results of Ali et al.[15] show results higher than that by Kul et al. who provided 95.7% SN and 89.2% SP for combined DCE-MRI and DWI protocols [Table 3].
Table 3: Sensitivity, specificity, and accuracy of combined findings of dynamic contrast-enhanced magnetic resonance imaging I and diffusion- weighted imaging and apparent diffusion coefficient study in 27 malignant and 29 benign breast lesions

Click here to view


DW image is a functional noninvasive MRI technique. It directly reflects the Brownian motion of water molecules in the body tissues, and it can obtain the physiological feature of the body tissue by quantitative analysis of water molecules (ADC).[20]

Malignant tumors tend to demonstrate ADC value lower than benign tumors, which is because malignant tumors show restricted diffusion. This is related to increased cellular density, larger nuclei, and less extracellular space in malignant tumors.[21]

In this study, according to the lesion signal in DW image, free diffusion showed 82.8% of benign lesions and no malignant lesions, while restricted diffusion showed 17.2% of benign lesions and 100% of malignant lesions, which is comparable with the results of Kul et al's. study.[19]

Previous studies over the last decade demonstrated that the mean ADC for malignant tumor is lower than those of benign tumor with variable results of SN and SP, and DWI had a promising role in the differentiation between benign and malignant breast lesions.[2]

In this study, the mean ADC value of malignant lesions was 0.815 ± 0.258 × 10−3 mm2/s, whereas the mean ADC of benign lesion was 1.287 ± 0.404 × 10−3 mm2/s, demonstrating significant difference (P = 0.001).[22] In this study, breast lesions differentiated with high SN (100%) and high SP (82.8%) as benign or malignant with the aid of ADC readings. Our result were relatively in agreement with those of Ibrahim et al.,[22] who found that in agreement with Ibrahim et al(22).who found that the median ADC value was 0.93 × 10−3 mm2/s. for malignant lesions, where as the median ADC value for benign breast lesions was 1.51 × 10−3 mm2/s.


  Conclusions Top


The diagnostic accuracy of DCE MRI can be increased if it is combined with DWI, thus reducing unnecessary breast biopsies.

The DWI and ADC value had high SN and SP in the characterization of benign and malignant breast lesions.

Recommendations

Incorporating the DWI parameter to the standard of breast MRI protocol to increase the SN and SP for diagnosis of breast lesions is recommended.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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