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

Dear Editor:

I read the article (11. 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/e18...
) “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 (11. 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/e18...
). 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 (22. 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...
). 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 (33. 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-...

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.016...
-55. 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....
), as shown in the study by Pereira at al. (11. 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/e18...
). Furthermore, several studies have suggested that MRI could be used as a problem-solving tool in cases of suspicious clinical and radiological findings (66. 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...
-88. 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.019...
).

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 (99. 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...
,1010. 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...
). The specificity shown in this study was low (11. 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/e18...
); 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
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