Distinguishing Benign and Malignant Breast Mass using kinetic Curve of Dynamic contrast Enhanced MRI Scanning in Comparison with Histopathological Results

Ban Abbas Semander Al-Maammory,Huda Ali Rasool Hussain
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Keywords : MRI -magnetic resonance imaging, DCE= dynamic contrast enhancement, TSI- time signal intensity .
Medical Journal of Babylon  14:3 , 2018 doi:1812-156X-14-3
Published :06 January 2018


MRI is now emerging as a very exciting and potentially powerful tool for the imaging of breast abnormalities in addition to the conventional modalities such as mammography and sonography. MRI imaging with its rich soft-tissue contrast and excellent tissue differentiation, thin-section, multiplanar capability, with no ionizing radiation, offers the possibility of better lesion characterization than can be obtained with conventional imaging methods. This study was conducted to assess the accuracy & the diagnostic value of the TSI - curve (kinetic curve) of DCI MRI in distinguishing benign and malignant breast mass in comparison with histopathological results. Sample of 40 female patients aged from 30-70 years with a mean age of 49 year having breast mass with clinical suspicion were subjected to mammographic and ultrasonic classification after clinical examination in the breast clinic and referred to the MRI unit. MRI were done and breast masses assessed according to their shape, pattern of enhancement and kinetic curve. Histopathological confirmation was obtained for all patients .twenty nine cases show kinetic curve of type 3 while type 2 curve in 9 cases and 2 cases revealed type 1 curve.by histopathological study, 28 case of type 3 curve are malignant, one case is benign. 4 case of type 2 are malignant and 5 cases are benign . Two cases of type 1 curve are benign . So MRI is good technique for assessment of breast masses and extension to other tissue and sensitive for detection of multifocal breast lesions and bilateral breast masses and local recurrence.


Advancement in fighting cancer of the breast has been obvious by improvement of effective, less invasive techniques for diagnosis and treatment .MRI is diagnostic technique that uses a mixture of a huge magnet radio waves, and a supercomputer to create meticulous images of the body organs and structures, major improvement has been made in the development for the breast MRI [1]. Breast DCE-MRI is discovery widespread clinical application as an addition diagnostic method to Mammography and US. DCE-MRI offers spatial three-dimensional data and time-based resolution, and has revealed very high sensitivity for breast cancer [1,2]. It has been particularly valuable in indicating the extent of biopsy-proven cancers, specially invasive lobular carcinoma (ILC) and ductal carcinoma in situ (DCIS), which historically were not well imaged with other imaging techniques. In such situations, the MRI may be useful in guiding both the surgeon and the patient regarding the appropriate choice of breast conservation versus mastectomy [2-4]. The early enhancement rate of lesion in the post -contrast phase (also called as ‘‘slope of enhancement’’ or ‘‘enhance-ment velocity’’ works as a differential diagnostic measure, with malignant lesions showing faster and stronger enhancement than benign lesions [2]. Our study expressed a new technique to improve the extraction of kinetic types from dynamic enhanced-MRI breast lesions, which possibly will support radiologists in their interpretation [3]. Kinetic curve (fig.1) is categorized as type-1a if the lesion remains to enhance over the whole providing time. and It is named as type-1b if in the late post-contrast period the signal obtain is slowed down, producing a bowing of the curve. [5]. The curve is categorized as type 2 if the signal after the early increase is plateau. [5] A curve type 3 is expressed in cases where there is rapid wash-out of contrast material taking place directly after the signal intensity highest [5]. Type 1 (1a and 1b) were more expected to be benign, while lesions with type 2 (suspicious) and with type 3a rapid wash-out of contrast have a tendency to be malignant [1,2].

Materials and methods

During the period from December 2016 to July2017, 40 women with  suspected breast cancers referred from the breast clinic at the Hilla- teaching general hospital to the MRI unit where breast DCE-MRI done.
 We classified  our patients into 3 age  groups ,group 1( 30-39 year ) group 2 ( 40-49 year) and group 3 ( 50 and above ) all patients  ages range from 30-70 years with a mean age of 49years. Marital state, obstetrical history  and breast feeding, family history  of breast cancer or other, previous breast problems,  and history of contraceptive pills or any HRT. were added to the data of each patient.
Patients complain and Clinical presentation, physical breast examinations were performed Mammography and US were done for all .patients  and FNAC were done for most  patients of the suspected malignant masses.MRI done  for patients with BI-RADS III, IV  and V were carried out using Philips-MR System Achevia machine 1.5 Tesla  unite magnet strength.
Every patient was examined in a prone position on the MR table with her  both breasts emerge  within  a special breast coil  and bilateral breasts where examined  according to the following breast MRI protocol : 3 mm slice thickness  and 1mm gap was applied in certain  sequences staring with T2 axial,T1axial, DWI, T2 fat suppression  and sometimes coronal T2 ( when needed) , then a dynamic study  with IV contrast; gadolinium-diethylenetriaminepenta-acetic acid (Gd-DTPA) 0.1-0.2mmol/ kg with20ml normal saline ; by  injector devise and post contrast sequence  of bilateral 3D spatial and temporal resolution (eTHRIV ) and (VISTA  ).
The total  examination time  takes about 40-60 minutes  for each patient, then the curve is displayed by choosing the area of maximum enhancement or ROI( region of interest ) and data were transformed to the work station where they were studied carefully  and reported by an expert specialist ; who  described the site, morphology, multiplicity of the lesion , pattern of enhancement  and the type of curve displayed for each detected mass as well as extension of the lesion, any axillary LAP  and/ or chest wall invasion and finally gave the conclusion by applying the BIRADS classification .
Histopathological studies  following excisional biopsies  and/ or mastectomy were obtained 31cases show malignant cell and 9 cases show benign cells .


Patients referred to MRI unite with the age distribution as follow 22.5% of patients of group 1 ( 30-39year) , 32.5% within group2 ( 40-49year) and 45 % were group3 ( 50 year and above) . the higher frequency of breast cancer was( 51.6% ) seen in group 3 and lowest frequency was (16.1%) seen in group 1 . Our study show that patients referred with different breast clinical presentation , Painless palpable mass was the predominant features of 29 patients " 68 % " of cases . According to anatomical distributions of breast masses, the UOQ ( upper outer quadrant) of breast have more predominance of malignancy seen in 62.5 % of breast cancer in our samples. A comparison between the mean size and standard deviation between MRI and US is shown a mean size measured by US was 18.2 mm while MRI mean size of breast masses was 25.5mm . There was significant difference between US and MRI in size of breast mass (P<0.05). LAP had been found in 20 patients of our sample , all take malignant curves ( type 3 curve ) . in histopatology 9 patients proved to be malignant and other 11 patients had benign reactive enlarged lymph nodes (55%).with high false positive rate as 11 . MRI BIRADS classification :32cases were classified as BIRADS V, 5 cases as BIRADS IV ,one case was BIRADS VI and 2 was BIRAD III as shown in table 2 and figure 2. Table 2. MRI BIRADSclassification in the study sample.


We assess the diagnostic accuracy and impaction of breast DCE- MRI with the kinetic curve for early detection of breast cancer to take good surgical planning and appropriate treatment .This aim will affected by many factors including the selection of good sample size , appropriate indications [6] ,good technical factors like : strength of the field, thin slice , suitable surface coil , pulse sequences ,and efficient staff . [8,9] Also depend on criteria used on the interpretation of the image which must include morphology of the lesion , pattern of enhancement and kinetic analysis with histopathological results . [8 ,10] After selected 40 patients depend on the technical factors and protocol selection as well as the interpretation criteria; morphology and its pattern of enhancement. all were comparatively analogous to those cases used by Hey wang K. el al and Nunes LW et al . [8,10] . The predominant clinical presentation in our study sample was a painless palpable mass seen in 68% of cases and the anatomical distribution 62.5% were found in the UOQ in harmonization with other studied that show the tumor location is higher in the UOQ(50-58%) among multiple population , including United Kingdom ,Chinese and Danish . [11,12 , 13,14] Also go with Hadi A.M. study who found that 58.06% of malignant breast lesions situated at the UOQ [15] .and practically comparable with Ellsworth et al ,who demonstrate an increased levels of genomic instability of outer breast quadrants . [16] Tumor size in MRI has a mean of 25.5mm , while the mean size with US measurement was 18.2 . About 7.3 mm increase of the mean size in MRI and this is relatively in agreement with the other studies made by N. Hylton [17] Weather all PT [18] and Wasif N.et al. [19] who observed that MRI is more accurate in assessing the size and extent in patients with recent diagnosis of breast cancer. LAP had been seen in 20 patients . 9 cases show malignant infiltration proved pathologically while benign reactive lymph nodes were seen in 11 cases .MRI showed type 3 "malignant curve " so high false positive rate ( 55 %) which mean that the kinetic analysis is not useful in detecting malignant lymph node infiltration . However the morphology may be helpful in suspecting the nature of LAP such as the malignant nodes show peripheral enhancement in dynamic CE- MRI, while benign reactive enlarged lymph nodes show fatty center that appear hyperintense signal on non enhanced T1 weighted image . [5]. MRI is more sensitive in identifying multifocal and / or bilateral breast cancers ; in complete agreement with a study by Sardanelli F, et al who conclude that MRI has additional sensitivity than mammographyfor the discovery of multiple malignant centers in fibroglandular or dense breasts and mammography overlooked larger and more invasive cancer lesion than MRI.[3,5 , 20 ,21] In our study there was one case show false positive results according to MRI –kinetic curve as the patient presented with nipple discharge and pain , mammographywas inconclusive due to dense breast and US expressed prominent glandular tissue with non homogenous echo texture and was categorized as BIRADS III , in DCE-MRI show type 3 kinetic curve, but in histopathology there was no malignant cell . In connection with clinical data the patient was at second half of her cycle ( proliferative phase ) so this condition is explained by the hormonal effect on enhancement pattern and temporal resolution of the normal tissue of the breast , this result go with available literatures that displayed false positive nodular of diffuse or nodular enhancement occur mainly in the 1st and 4th weeks during the cycle .[22,23] In our study the kinetic analysis , done to all patients . where type 3 shown in 29 patients and type 2 in 9 cases and type 1 in 2 cases of unifocal & multifocal cases. Type 3 and type 2 curves displayed in 73.5% and 20.6% respectively and type 1 curve found in 5.9% in patients with unifocal breast cancer and 66.7% type 3 and 33.3 % type 2 in multifocal breast cancer masses. 29 cases of type 3 ( 28 case show malignant cell on histopathology and one case not ), 9 cases with type 2 ( three of them show malignant cells and other six show benign cells in histopathology ) while 2 cases of type 1 show benign cells .this is comparable with many studies that reported the importance of the curve shape in differentiating between benign and malignant lesions . So use of this curve is dramatically increase the discrimination between benign and malignant lesions , type 3 is more suspicious of malignancy where type 2 is either indicator of malignancy or benign while the last type ( type1)is associated with benign lesions.Schnall et al .[ 24] Kuhl et al. expressed the importance of determining enhancement curve shape as a method to add specificity to breast contrast-enhanced MRI. And have demonstrated the importance of the accuretly measuring TSI- curve shape, not as a morphological replacement , but to be evaluated in combination with morphology. [25] In our study the DCE-MRI sensitivity in detecting breast cancer found to be 93.5% in correlation with histopathological diagnosis that was agreement to most studies that show the sensitivity of MRI for detection of breast cancer is very high ,with 90 % the value being reported [ 26,27] . It also increased the sensitivity of other combined modalities(MRI , mammography& US ) up to 100 % versus sensitivity of mammography of 51.6 % and sensitivity of US 67.7% while sensitivity of combined (mammography and US) together did not exceed 83.87% in our sample. MRI and cytology diagnostic validity including MRI sensitivity, specificity, accuracy and positive predictive value were 93.5%, 55.5%, 85 % and 87.87 % respectively and is well comparative with related articles. As there is overlap in enhancement appearances between benign and malignant lesions, dependence on a kinetics assessment alone is not recommended. While The specificity of breast MRI is improvedwhen both morphologic and kinetic features are evaluated in the interpretation . [21] It has been supposed that MRI is a very sensitive technique for discovering even small cancers that cannot be detected by conventional imaging modalities in complete agreement with most of other literatures and studies . [ 5, 10 , 28 , 29] Our outcomes document that DCE- MRI is obviously superior to both mammographyand US for early recognition and grouping ofbreast cancers.


Dynamic breast MRI produce information on both aspects cross-sectional morphology and functional lesion features such as vascularity/perfusion and vessel permeability. According to kinetic curve The shape of TSI- curve is an import criterion in differentiating benign and malignant enhancing lesions . 3 types of kinetic curve ,type Iassociated with benign lesion , type II curve which is indictor of either benign or malignant lesion and type III for more suspicion of malignancy. All these done to increase the accuracy of imaging modalities to be use in the early detection of breast cancer and to avoid unnecessary surgical intervention ( mastectomy ,or even exceptional biopsy for benign lesion ). DCE-MRI is more accurate than US for assessing the size and extent of breast cancer presenting as a mass ; consequently assessing the efficacy of local staging and planning surgical treatment . DCE-MRI has a useful role in detecting local recurrence .


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