Comments on “Evaluation of the Accuracy of Mammography, Ultrasound and Magnetic Resonance Imaging in Suspect Breast Lesions”

Dear Editor:

I read the article (¹) “Evaluation of the accuracy of mammography, ultrasound and magnetic resonance imaging in suspect breast lesions” (Pereira et al.) with great interest; however, I am left confused by the study and believe some issues must be discussed.

The aim of this study was to compare the diagnostic performance of three imaging methods for breast cancer (¹). However, all patients showed a suspect breast lesion on evaluation by at least one of the methods. Based on the Breast Imaging-Reporting and Data System (BI-RADS), biopsy or surgical resection was recommended; however, the positive predictive value for BI-RADS categories 4 and 5 varies depending on the imaging modality. For instance, almost 90% of the suspect lesions detected by ultrasound eventually show negative results, leading to unnecessary biopsies (²). In this setting, the role of other imaging modalities is to evaluate whether a suspected lesion is truly malignant. Hence, magnetic resonance imaging (MRI) is the superior modality as it shows high sensitivity for breast cancer detection and has a high negative predictive value for the exclusion of malignancy (³-⁵), as shown in the study by Pereira at al. (¹). Furthermore, several studies have suggested that MRI could be used as a problem-solving tool in cases of suspicious clinical and radiological findings (⁶-⁸).

Finally, I do not agree with the statement that MRI has low specificity owing to high breast density. Breast density has a vital impact on the interpretation of mammography findings, but not on that of MRI findings. On dynamic contrast-enhanced MRI, both morphology and kinetics are key for the diagnosis of breast lesions, although there is considerable overlap between signs of benign and malignant lesions, resulting in false-positive findings. Several studies have revealed that diffusion-weighted imaging can improve the specificity of breast MRI and help avoid unnecessary biopsies (⁹,¹⁰). The specificity shown in this study was low (¹); hence, I wonder whether diffusion-weighted imaging was integrated into breast MRI. I would be interested in receiving responses to my comments.

REFERENCES

• ¹
  PereiraRO, LuzLAD, ChagasDC, AmorimJR, Nery-JúniorEJ, AlvesACBR, et al. Valuation of the accuracy of mammography, ultrasound and magnetic resonance imaging in suspect breast lesions. Clinics. 2020;75:e1805. https://doi.org/10.6061/clinics/2020/e1805
  » https://doi.org/10.6061/clinics/2020/e1805
• ²
  BergWA, ZhangZ, LehrerD, JongRA, PisanoED, BarrRG, et al. Detection of breast cancer with addition of annual screening ultrasound or a single screening MRI to mammography in women with elevated breast cancer risk. JAMA. 2012;307(13):1394-404. https://doi.org/10.1001/jama.2012.388
  » https://doi.org/10.1001/jama.2012.388
• ³
  MannRM, BalleyguierC, BaltzerPA, BickU, ColinC, CornfordE, et al. Breast MRI: EUSOBI recommendations for women's information. Eur Radiol. 2015;25(12):3669-78. https://doi.org/10.1007/s00330-015-3807-z
  » https://doi.org/10.1007/s00330-015-3807-z
• ⁴
  Bennani-BaitiB, Bennani-BaitiN, BaltzerPA. Diagnostic Performance of Breast Magnetic Resonance Imaging in Non-Calcified Equivocal Breast Findings: Results from a Systematic Review and Meta-Analysis. PLoS One. 2016;11(8):e0160346. https://doi.org/10.1371/journal.pone.0160346
  » https://doi.org/10.1371/journal.pone.0160346
• ⁵
  SpickC, SzolarDHM, PreidlerKW, TillichM, ReittnerP, BaltzerPA. Breast MRI used as a problem-solving tool reliably excludes malignancy. Eur J Radiol. 2015;84(1):61-4. https://doi.org/10.1016/j.ejrad.2014.10.005
  » https://doi.org/10.1016/j.ejrad.2014.10.005
• ⁶
  StrobelK, SchradingS, HansenNL, BarabaschA, KuhlCK. Assessment of BI-RADS category 4 lesions detected with screening mammography and screening US: utility of MR imaging. Radiology. 2015;274(2):343-51. https://doi.org/10.1148/radiol.14140645
  » https://doi.org/10.1148/radiol.14140645
• ⁷
  GiessCS, ChikarmaneSA, SippoDA, BirdwellRL. Clinical Utility of Breast MRI in the Diagnosis of Malignancy After Inconclusive or Equivocal Mammographic Diagnostic Evaluation. AJR Am J Roentgenol. 2017;208(6):1378-85. https://doi.org/10.2214/AJR.16.16751
  » https://doi.org/10.2214/AJR.16.16751
• ⁸
  SpickC, SzolarDHM, PreidlerKW, ReittnerP, RauchK, BraderP, et al. 3 Tesla breast MR imaging as a problem-solving tool: Diagnostic performance and incidental lesions. PLoS One. 2018;13(1):e0190287. https://doi.org/10.1371/journal.pone.0190287
  » https://doi.org/10.1371/journal.pone.0190287
• ⁹
  DijkstraH, DorriusMD, WielemaM, PijnappelRM, OudkerkM, SijensPE. Quantitative DWI implemented after DCE-MRI yields increased specificity for BI-RADS 3 and 4 breast lesions. J Magn Reson Imaging. 2016;44(6):1642-9. https://doi.org/10.1002/jmri.25331
  » https://doi.org/10.1002/jmri.25331
• ¹⁰
  RahbarH, ZhangZ, ChenevertTL, RomanoffJ, KitschAE, HannaLG, et al. Utility of Diffusion-weighted Imaging to Decrease Unnecessary Biopsies Prompted by Breast MRI: A Trial of the ECOG-ACRIN Cancer Research Group (A6702). Clin Cancer Res. 2019;25(6):1756-65. https://doi.org/10.1158/1078-0432.CCR-18-2967
  » https://doi.org/10.1158/1078-0432.CCR-18-2967

Publication Dates

• Publication in this collection
  27 Nov 2020
• Date of issue
  2020