Evaluation of Contrast-Enhanced Mammography and Development of Flowchart for BI-RADS Classification of Breast Lesions

Kristina Klarić, Andrej Šribar, Anuška Budisavljević, Loredana Labinac, Petra Valković Zujić, Kristina Klarić, Andrej Šribar, Anuška Budisavljević, Loredana Labinac, Petra Valković Zujić

Abstract

This study aimed to evaluate contrast-enhanced mammography (CEM) and to compare breast lesions on CEM and breast magnetic resonance imaging (MRI) using 5 features. We propose a flowchart for BI-RADS classification of breast lesions on CEM based on the Kaiser score (KS) flowchart for breast MRI. Sixty-eight subjects (women and men; median age 61.4 ± 11.6 years) who were suspected of having a malignant process in the breast based on digital mammography (MG) findings were included in the study. The patients underwent breast ultrasound (US), CEM, MRI and biopsy of the suspicious lesion. There were 47 patients with malignant lesions confirmed by biopsy and 21 patients with benign lesions, for each of which a KS was calculated. In the patients with malignant lesions, the MRI-derived KS was 9 (IQR 8-9); its CEM equivalent was 9 (IQR 8-9); and BI-RADS was 5 (IQR 4-5). In patients with benign lesions, MRI-derived KS was 3 (IQR 2-3); its CEM equivalent was 3 (IQR 1.7-5); and BI-RADS was 3 (IQR 0-4). There was no significant difference between the ROC-AUC of CEM and MRI (p = 0.749). In conclusion, there were no significant differences in KS results between CEM and breast MRI. The KS flowchart is useful for evaluating breast lesions on CEM.

Keywords: breast cancer; contrast-enhanced mammography; magnetic resonance imaging.

Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
The Kaiser score flowchart. The diagnostic score ranging from 1 to 12, is associated with an increased risk of malignancy. If the score exceeds 4, a biopsy is recommended. https://doi.org/10.1007/s13244-018-0611-8, accessed on 3 April 2018.
Figure 2
Figure 2
Breast MRI—dynamic contrast-enhanced image: An irregular lesion (arrow) in the right breast with inhomogeneous, predominantly peripheral enhancement and no oedema (a). Breast MRI—time intensity kinetic curve: This is a type III curve, i.e., washout pattern of the lesion that has a rapid uptake with a reduction in enhancement towards the latter part of the study. It is considered strongly suggestive of malignancy (b). CEM—early recombined CC image of the right breast: An irregular lesion (arrow) with inhomogeneous, predominantly peripheral enhancement, no oedema and a mean density value of 2180 (c). CEM—the late recombined image of the right breast: the mean density value of the lesion (arrow) is 2157, which is a decrease of density of more than 10 units, which indicates washout. It is considered strongly suggestive of malignancy (d). Histopathological analysis—72-year-old patient underwent a needle biopsy, because the radiologically visualized mass, located in the right breast at the border of the lower quadrants, near the nipple, measuring 3 × 2.3 cm, radiologically scored as BI-RADS 5. 2 thin cylinders with a total length of 2 cm were obtained by biopsy. Histological analysis revealed tumor tissue made up of streaks of invasive carcinoma, which was categorized as the 5b category, (HE, ×100) (e).
Figure 3
Figure 3
Breast MRI—dynamic contrast-enhanced image: An irregular lesion (arrow) in the right breast with spiculae, inhomogeneous enhancement and no oedema (a). Breast MRI—time intensity kinetic curve: This is a type III curve, i.e., washout pattern of the lesion that has a rapid uptake with a reduction in enhancement towards the latter part of the study. It is considered strongly suggestive of malignancy (b). CEM—early recombined CC image of the right breast: An irregular lesion (arrow) with spiculae, inhomogeneous enhancement, no oedema and a mean density value of 2148 (c). CEM—late recombined CC image of the right breast: The lesion (arrow) shows a mean density value of 2113, a decrease of more than 10 units, which indicates washout. It is considered strongly suggestive of malignancy (d). Histopathological analysis—In a 60-year-old patient, a needle biopsy was performed because of a formation, located in the upper lateral quadrant of the right breast, measuring 3.3 × 1.7 cm, that was radiologically scored as BI-RADS 5. Four cylinders, with a total length of 6 cm were obtained by biopsy. Histologically invasive breast carcinoma was proven, composed of canaliculi and strings, with solid clusters of atypical epithelial cells, showing moderate cell atypia and a moderate number of mitoses. Such a histological finding was categorized as invasive carcinoma, B5b category of B-diagnostic categories (HE, ×100) (e).
Figure 3
Figure 3
Breast MRI—dynamic contrast-enhanced image: An irregular lesion (arrow) in the right breast with spiculae, inhomogeneous enhancement and no oedema (a). Breast MRI—time intensity kinetic curve: This is a type III curve, i.e., washout pattern of the lesion that has a rapid uptake with a reduction in enhancement towards the latter part of the study. It is considered strongly suggestive of malignancy (b). CEM—early recombined CC image of the right breast: An irregular lesion (arrow) with spiculae, inhomogeneous enhancement, no oedema and a mean density value of 2148 (c). CEM—late recombined CC image of the right breast: The lesion (arrow) shows a mean density value of 2113, a decrease of more than 10 units, which indicates washout. It is considered strongly suggestive of malignancy (d). Histopathological analysis—In a 60-year-old patient, a needle biopsy was performed because of a formation, located in the upper lateral quadrant of the right breast, measuring 3.3 × 1.7 cm, that was radiologically scored as BI-RADS 5. Four cylinders, with a total length of 6 cm were obtained by biopsy. Histologically invasive breast carcinoma was proven, composed of canaliculi and strings, with solid clusters of atypical epithelial cells, showing moderate cell atypia and a moderate number of mitoses. Such a histological finding was categorized as invasive carcinoma, B5b category of B-diagnostic categories (HE, ×100) (e).
Figure 4
Figure 4
ROC, sensitivity/specificity curves and distribution graphs for MRI Kaiser score; dashed line shows Youden index cut-off (6).
Figure 5
Figure 5
ROC, sensitivity/specificity curves and distribution graphs for CEM-derived Kaiser score; dashed line shows Youden index cut-off (6).
Figure 6
Figure 6
ROC curves depicting differences between Area Under the ROC Curve (ROC-AUC) of magnetic resonance imaging (MRI) and contrast-enhanced mammography (CEM)-derived Kaiser score (KS).

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