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BREAST IMAGING Table of Contents   
Year : 2005  |  Volume : 15  |  Issue : 3  |  Page : 381-387
Magentic resonance imaging of breast masses: Comparison with mammography


Department of Radiological Imaging, Institute of Nuclear Medicine And Allied Sciences, Brig. S.K. Mazumdar Marg, Timarpur, Delhi, India

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   Abstract 

Breast cancer is the second most common cancer in Indian women. The aim of this study was to compare the diagnostic accuracy of Magnetic Resonance Imaging (MRI) in detecting the malignant nature of the breast masses with that of Mammography. Fifty patients with suspected breast mass lesion (40 palpable and 10 nonpalpable) were included in this study. Both Mammography and MRI (Plain and Contrast enhanced) were performed in every patient. Ultrasonography and galactorgraphy were performed in few patients wherever required. Following this fine needle aspiration of the breast mass was done and the materials were studied Cytopathologically. For nonpalpable lesions sensitivity of mammography and MRI was 65% and 90%, while the specificity was 25% and 50% respectively. For palpable lesions both the methods showed high sensitivity (Mammography 90% and MRI 95%) and MRI demonstrated comparatively higher specificity (Mammography 30% and MRI 50%). In two mammographically negative patients MRI showed positive result. With the complementary use of MRI, it is possible to increase the sensitivity for detection of breast cancer and multicentric disease. In patients in whom the status of a palpable breast mass remains unclear but where strong clinical suspicion exists, MRI may help to reduce the amount of unnecessary biopsies.

Keywords: Breast cancer, Mammography, Magnetic Resonance Imaging. Fine needle aspiration.

How to cite this article:
Chakraborti K L, Bahl P, Sahoo M, Ganguly S K, Oberoi C. Magentic resonance imaging of breast masses: Comparison with mammography. Indian J Radiol Imaging 2005;15:381-7

How to cite this URL:
Chakraborti K L, Bahl P, Sahoo M, Ganguly S K, Oberoi C. Magentic resonance imaging of breast masses: Comparison with mammography. Indian J Radiol Imaging [serial online] 2005 [cited 2020 Sep 23];15:381-7. Available from: http://www.ijri.org/text.asp?2005/15/3/381/29160

   Introduction Top


Breast cancer is the second most common cancer in Indian women. According to the National Cancer Registry project report about 52,000 women develop breast cancer in India per year [1],[2]. This gives breast cancer a high emotional, political and media profile.

Breast care presents a challenge to the entire health care delivery system, payor and provider alike. It's relative importance extends far beyond it's cost in that one in eight women in the U.S. will become a victim of breast cancer during her life time and virtually every women has relative or close acquaintance who has had breast cancer.

Early menarche, late menopause, nulliparity, elderly primi, diminished lactation, family history of breast cancer, previous personal history of breast cancer and other breast diseases such as fibrocystic disease etc. are the different epidemiological and environmental risk factors, generally associated with the breast cancer [3],[4]. Other known potential risk factors identified are excessive exposure to ionising radiation, history of cancer endometrium, ovary or colon [5].

An early accurate diagnosis of breast cancer has a favourable prognosis than that of late detection. Lack of awareness, fear of disease and different psychological reasons are the main causes for ignoring and hiding the disease and by the time the patients report to the hospital, the disease is in it's late stage. Over 90% of the diagnosed cases are in the stage II, III and IV [6].

Strong clinical suspicion, family history of breast cancer, discovery of a breast mass, either by the patient or detection of an abnormality on screening mammography signals the beginning of diagnosis of breast cancer. In most of the cases, the suspicious physical or radiological findings turn to be benign [7],[8]. Most of these women are referred for multiple diagnostic tests which can include additional mammography, galactography, ultrasound, colour doppler ultrasound study, fine needle aspiration, and in some cases open surgical biopsy [9],[10]. Low specificity of current screening and diagnostic modalities appear to be responsible for such unnecessary testing of benign symptoms and results in anxiety for patients and

excessive health care expenditure [11],[12]. Thus there is need for a cost effective means of safely reducing the number of diagnostic procedures undergone by these women.

Mammography is the most commonly used method and is the only currently known means of proven effectiveness especially in patients with non palpable carcinoma[13],[14]. In patients with palpable breast lesions and in patients younger than 50 years of age the diagnostic gain from mammography is less marked due to a low positive predictive value and a limited sensitivity in dense breast tissue [14],[15]. This results in a high rate of excisional biopsies without proof of malignancy. For patients younger than 50 years of age there is more often a delay in the diagnosis of breast cancer than for women older than 50 years of age [16].

Other complementary methods for detecting breast cancer are ultrasonography, colour doppler ultrasound study, scintimammography using technitium-99m methoxy isobutylisonitrite, thermography and Magnetic Resonance Imaging (MRI) [17]. 25% of unnecessary excisional biopsies can be reduced by ultrasonography using 7.5 to 10 MHz probe which can detect occult carcinomas [9],[18].

MRI seems to be ideally useful for breast imaging due to it's ability to depict excellent soft tissue contrast. This sensitivity of MRI appears to be higher than mammography [19],[20]. Plain (non-contrast enhanced) MRI may show fibrous tissue, fibroadenomas and cysts but it's diagnostic accuracy may be less. To the contrary contrast enhanced MRI and dynamic MRI have been found to be more accurate in detection of malignancy within dense breast tissue, differentiation of malignancy versus scarring and also in detection of implants. In addition MRI can also be used to assess axillary lymph mode metastasis. Hence, this study was undertaken to compare the diagnostic potentiality of MRI and mammography in detecting the malignant nature of the breast masses.


   Materials and methods Top


Fifty patients with clinically suspected breast mass lesions were studied. Out of them 40 patients had palpable mass and 10 patients had non palpable suspicious mass lesions. 30 patients were of 50 years of age and above. The remaining 20 patients were of below 50 years of age. Following completion of clinical examination, every patient underwent mammography examination, MRI study, ultrasonic examination (where ever required) and in few cases galactography (where history of single duct nipple discharge was available). Informed consent was obtained from every patient at the time of examination. Mammography was performed by state of art unit Philips mammography machine. Two views (craniocaudal and mediolateral oblique views) were taken for each breast. Additional magnified views were obtained as and when required. MRI examination of both breasts done simultaneously using 1.5 T MR system (Magnetom Vision, Siemens Medical System) and dedicated double breast coil. Initially non contrast MRI was performed. The imaging protocol included preliminary axial T1weighted spine echo imaging using the following parameters : repetition time 580m sec, echo time 14m sec, matrix 256 x 256, slice thickness 5mm, field of view (FOV) 220mm. 17 axial section were obtained. Total scan time was 4 minutes 23 seconds. Following this T1 weighted inversion recovery sequences in axial plane and fat suppression sequence in oblique sagittal plane were performed. After completion of T1 weighted sequences, the T2 weighted spin echo sequences were performed in axial plane using TR / TE= 4200/90m sec, slice thickness was 5mm and FOV was 220mm. A fast low angle shot pulse sequence was used with a TR/TE=715/5m sec, flip angle 900, FOV 350mm, slice thickness 5mm and a matrix of 256 x 256. T2 fat saturated sequences in oblique sagittal plane were performed. The slice number and thickness was maintained same as that of T1 weighted sequences. Following completion of acquisition of both T1 and T2 weighted images, MR contrast media gadopentate dimeglumine (OMNISCAN) was injected intravenously at a dose of 0.1mmol per kilogram body weight. Immediately after contrast administration the T1 weighted sequences were repeated keeping the parameters constant and in few cases the T1 weighted sequences were repeated after 5 minutes and after 10 minutes. During the MRI examination, breasts were held firmly in place by using cushions of varying sizes inserted in the coil openings to minimize motion artefacts. After completion of MRI examination, fine needle aspiration was done for the palpable breast lesions and in case of non palpable lesions stereotactic biopsy was performed after obtaining an informed consent from the patients. The aspirated materials and the biopsied material were sent for histopathological examination. The finding were analysed and correlated.


   Results Top


Out of total 50 patients studied, 40 were palpable and 10 were non palpable but clinically suspicious. 30 patients were above 50 years and 20 patients were below 50 years of age. 20 patients had family history of breast cancer (all 10 non palpable cases and 10 out of 40 palpable cases). Breast cancer was confirmed in 15 cases by histopathology. 10 of these cancers were palpable with a size ranging from 10mm to 80mm. Mammography was able to detect 10 cancers of the breast and MRI was able to detect 13. MRI yielded false negative scans in two ductal carcinomas with diameters of 7mm and 8mm (one palpable and one non palpable tumour). In both of the above patients the mammography results were suspicious (because of irregular out line and presence of microcalcification) but the malignant nature could not be diagnosed either by mammography or ultrasonography.

In two cases mammography results were totally negative nor ultra sound could indicate any abnormal findings. But because of strong clinical suspicions and family history of breast cancer the patients were subjected to both non contrast and contrast enhanced MRI. Suprisingly in post gradopentate dimeglumine contrast enhanced scans the lesions showed fast contrast enhancement [Figure - 1]. In one cancer case, mammography showed an asymmetric density of breast tissue but MRI demonstrated diffuse contrast enhancement of low intensity and with steadily increasing signal intensity. In case of dense breast parenchyma, the mammographic interpretation were difficult. In one case mammography showed only dense breast parenchyma but did not show any definite lesion whereas MRI showed multiple cystic changes [Figure - 2]. This finding was confirmed by ultrasonography. In few benign cases, mammography showed a mass lesion. Ultrasonography revealed the mass as hypoechoic and well marginated. T1 weighted and T2 weighted MR images also showed presence of well defined mass lesion. Post MR contrast scans showed MR contrast enhancement and well delineation of the mass lesion indicating the lesion to be a fibroadenoma [Figure - 3].

Mammography did not diagnose intra-ductal tumour growths where as galactography (done by injecting 60% urograffin in the dilated duct) could delineate 04 patients. In all these cases ultrasonography examination also did not reveal any abnormality. MRI (Both non contrast and contrast enhanced) diagnosed 03 cases. In one cancer case mammography showed malignant nature of the lesion where as MRI (both plain and contrast enhanced) could not indicate any definite malignant nature of the lesion except showing the lesion as a small cyst [Figure - 4].

Among 10 palpable breast cancers, mammography showed true positive result in 9 and MRI showed in 8 cases. This results in high sensitivity for mammography and for MRI. In five patients with non palpable breast cancer mammography detected only two tumour and MRI detected all five. 35 patients had benign alterations of the breast; in 30 patients were palpable while in 5 they were nonpalpable. In case of 15 patients with fibroadenomas both mammography and MRI showed false positive result in 50% of cases. In 15 patients with fibrocystic diseases mammography yielded false positive scan in 14 cases [93%] and MRI showed false positive in 11 cases [73%]. In five patients with inflammatory disease of breast, mammography revealed two false positive and MRI revealed one false positive result.


   Discussion Top


Masses within the breast (whether symptomatic or asymptomatic) are being diagnosed frequently by mammography. It is essential to define exactly the constituent of the mass lesion so that the differentiation between benign & malignant lesion becomes easier. Mammography, the primary method of detection and diagnosis of breast disease has a proved sensitivity of 85% - 95% [8, 11, 13]. But additional diagnostic procedures become often necessary in view of it's low specificity [12],[21]. Younger women have denser breasts, the use of oestrogen replacement therapy increases breast density and oestrogen replacement therapy use is most common during and shortly after the begining of menopause and declines there after. In addition, dense breast parenchyma and younger age group are associated with lower mammographic sensitivity in some but not all [22],[23],[24].Presently non invasive imaging methods like magnetic resonance imaging (MRI), thermography and colour doppler ultrasound (USG) are being used as adjunctive procedures. Though a definitive diagnosis is possible with non invasive imaging procedures, for most lesions biopsy/fine needle aspiration cytology are essential for obtaining reliable results [10],[25]. In majority of cases surgical biopsy has detected the lesion as benign and has served only to provide diagnosis, since surgical removal of these lesions are not necessary unless the clinical signs and symptoms warrant for it. Breast cancers are associated with tumour angiogenesis. Increase in the number of blood vessels, increased vascular permeability, increased tumour blood volume, arteriovenous shunt formation, altered capillary bed transmit time, increased interstitial pressure due toabsent lymphatic vessels in tumours result form tumour angiogenesis and create characteristic, identifiable patterns including the distribution pattern of intravenously injected contrast medium that can be distinguished from those associated with benign lesions [2],[26],[27],[28]. This positive rim sign could also be delineated by colour Doppler ultrasound system. Vessel density in fibroademonas is more uniform throughout the tumour than it is incarcinomas, with no statistically significant difference between periphery and centre. In the study by Buadu et al rim enhancing carcinomas were observed to have varying degrees of central desmoplasia, associated with lower vessel density [26]. In the work of orel et al rim enhancement was observed in five of 16 carcinomas, but none of the rim enhancing carcinomas exhibited central necrosis [25].

In our study the overall sensitivity was higher for MRI than for mammography due to the high sensitivity of MRI inpatients with non palpable lesion. The specificity of mammography and MRI in the studied patient group was low. While in most of the situations mammography is unable to differentiate between benign and malignant breast lesions, it is not clear whether MRI can provide additional informations in these cases. Though some studies have reported good specificity of MRI [29], recent studies could not confirm these results and report aspecificity of 30%- 70% for MRI [19],[25],[29],[30]. Our study revealed low specificity probably due to special patient population which might have been pre selected.

Both mammography and MRI have shown high sensitivity for the detection of palpable breast cancer (Mammography90%, MRI 80%). MRI showed less sensitivity than mammography. In non palpable breast lesions, MRI appears to be more diagnostically informative than mammography. In our study, MRI diagnosed all five nonpalpable lesions where as mammography detected only two patients. In case of benign breast lesions, both mammography and MRI showed false positive results in50% of cases, where as in fibrocystic diseases mammography showed false positive scans in 93% cases and MRI showed in 73% cases. In inflammatory breast diseases, MRI showed less false positive result than mammography.

One potential limitation with mammographic interpretations are the dense breasts resulting from different factors like fibrocystic changes, changes during menstrual cycle, lactation and estrogen replacement therapy. Unfortunately, because density is not quantified and would be complex to fully describe, it is difficult to know where this effect is most pronounced. The potential limitation with MRI is it's long repetition time which does not optimize the T1 weighted images. Even with maximal flip angle of 900, this repetition time may not maximize the contrast owing to T1 shortening from intravenous gadolinium contrast material accumulating in the tumour. Recently, 3D volume spiral acquisitions have been described which offer similar or higher signal to noiseratios and that have much shorter repetition times [28,31].

We conclude that in case of non palpable lesions, the diagnostic accuracy of MRI is superior to mammography. Our results indicate that the sensitivity of breast imaging can be increased by complementary use of MRI. For patients in whom the status of breast lesion remains unclear, MRI, though costliest among all other complementary diagnostic modalities, may help to reducethe number of unnecessary biopsies and diagnostic ambiguities.

 
   References Top

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Correspondence Address:
K L Chakraborti
Flat No. 163, II Floor, DDA, SFS Flats, Mukherjee Nagar (East), Delhi - 110 009
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-3026.29160

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