2. CONFLICTS OF INTEREST
NONE

3. PREVIOUS PUBLICATIONS
NONE

4. AIMS AND OBJECTIVES
 Purpose is
1. To study the morphological characteristics and
enhancement patterns of probably malignant breast
lesions on dynamic contrast enhanced MRI and to
correlate the findings with Color Doppler imaging and
histopathologically.
2. To evaluate importance of DWI in improving
specificity of MR Breast.

5. INTRODUCTION
 The challenge -
 Breast cancer is the most common cancer
in women in India, way ahead of cervical cancer.
Both, the incidence, as well as deaths, due
to breast cancer are more than cervical cancer.(
GLOBOCAN 2012). For every 2 women newly
diagnosed with breast cancer, one woman dies of it
in India.
 The road ahead – our action plan –
 Risk and prevention
 Early detection and diagnosis:
 Treatments:
 Secondary breast cancer:

6. CURRENT STATUS
 Ultrasound is a basic method of approaching breast
masses and an important tool in interventional breast
procedures.
 Combination of mammogram and ultrasound
examinations when indicated is an effective method in
increasing rate of cancer detection.
 Second-look ultrasound is an effective method to
localize lesions missed in the initial scanning.
 The contribution of color Doppler in the study of breast
cancer remains a topic of discussion. However, in the
daily clinical practice it has become an indispensable
tool, and an integral part of the breast ultrasound (US).

7. CURRENT STATUS
 MRI is an established supplementary technique to
mammography and ultrasound for the evaluation
of suspicious breast lesions.
 However, it is still relatively rarely used in clinical
practice as an alternative to proceeding directly to
breast biopsy for suspicious lesions because of its
insufficient specificity.
 Although MRI has extremely high sensitivity in the
diagnosis of breast cancer, as high as 89–100%
for invasive cancers, the specificity is only
moderate.

8. MATERIAL AND METHODS
Quantitative criteria - Resistive index greater than 0.7
peak systolic velocity (threshold of 20 cm/s),
Qualitative assessment – Location of vessels centrally
Higher velocity flow as manifested by color aliasing
Proportion of mass mapped in color
A prospective study of 38 patients, with suspicion of probably malignant breast
mass clinically or on USG from April-15-2015 to 2016. All patients underwent
USG color doppler with GE-LOGIQ P5,and MR mammography with 1.5T Philips
ACHIEVA. followed by histopathological correlation.
COLOR DOPPLER - Both quantitative and qualitative criteria were used in
arriving at an impression of benign or malignant flow.

9. MR IMAGE ANALYSIS
 Index lesion identification done on T2 SPAIR and
subtraction.
 In multiple lesions most suspicious lesion is
studied.
 For kinetic analysis ROI is placed on most
enhancing area of lesion. DCE upto 6th dynamic.
 For first 2 mins wash in rate was
 rapid> 80 % of peak , 50- 80%intermediate and
slow <50 %
 More than 10% decrease in peak SI was
considered wash out.
 DWI done in precontrast scan . ADC mapping
with b value 0,1000

10. MATERIAL AND METHODS
LESS SUSPICIOUS FEATURES MAJOR SUSPICIOUS
FEATURES
Round / irregular shape Spiculated margins
Hetrogeneous internal
enhancement.
Rim enhancememnt without
smooth margins
Irregular margins Non mass – segmental/clumped
Low to intermediate T2 density. Low ADC(<1x10-3 mm2 /s )without
benign morphology
Type II or III kinetics
Non mass – linear/
regional/heterogenous
Joao et al. AJR 2015

11. MATERIAL AND METHODS
BIRADS 3 ; if
Newly diagnosed lesion
oval shape.
Smooth/lobulated
margins.
Slow initial enhancemnt
Pattern.
Type I washout curve.
Absence of any
suspicious features.
BIRADS 4a
If 1 less suspicious feature
+
ADC value - >1.25
BIRADS 4b
If 2 or 3 less suspicious
feature +
ADC -1to1.25
BIRADS 4c
If > 3 less suspicios + /
1major feature+
ADC- <1
BIRADS 5
If two or more major
features present.
If associated findings *
present
Associted findings
Metastatic
lymphadenopathy,
skin/chest wall/
pectoral/nipple areola
complex invasion

12. OBSERVATIONS &RESULTS
 COLOR DOPPLER IMAGING
 Sensitivity - 56%
 Specificity – 92.3%
 PPV– 93.33% ,NPV – 52%
 Diagnostic accuracy - 68%
 Chi square : 8.354, df=1, P value= 0.004. AUC –
0.742, p value= 0.016
 RI > or = 0.70 was consistently proven to be an
indicator of malignancy with high sensitivity
(87.5%) and a specificity of 85.7% with a PPV of
93.33%. This result is concordant with previous
studies.
 Although high PI and PSV are signs of malignancy
the difference is not statistically significant.

13. 4%
20%
16%
20%
12%
12%
12%
4%
HPE DIAGNOSIS
DUCTAL CARCINOMA
IN SITU
INVASIVE DUCTAL
CARCINOMA
(IDC)(GRADE 1)
IDC (GRADE 2)
IDC (GRADE 3)
0
1
2
3
4
5
6
7
8
BENIGN
MALIGNANT
MOST COMMON AGE GROUP 40- 50
YRS
MOST COMMON HPE DIAGNOSIS

14. RESULTS
0
2
4
6
8
10
12
14
16
>0.7 <0.7
14
2
1
6
Benign
Malignant
Resistivity index (RI) Benign Malignant
>0.7 1 14
<0.7 6 2
TOTAL 7 16

15. RESULTS
 Both central and peripheral flow is seen in
most of the malignant masses whereas
only peripheral flow was most common
pattern in benign .
0
5
10
15
20
25
Benign
Malignant
13
25

16. MR – MAMMOGRAPHY
 Sensitivity - 100%
 Specificity – 53.8%
 PPV– 80.12%,NPV - 100%
 Diagnostic accuracy - 84%
 Fisher exact p value=0.001. AUC -0.769. P value 0.007
0 5 10 15
TYPE I
TYPE II
TYPEIII
1
14
8
9
3
0
BENIGN
MALIGNANT
MOST COMMON WASH OUT CURVE IN
MALIGNANT LESION IS TYPE II
0
5
10
15
20
25
BENIGN MALIGNANT
5
21
7
2
RAPID
SLOW
MOST COMMON INITIAL
ENHANCEMENT PATTERN IN
MALIGNANT LESION IS RAPID

17. 0
5
10
15
20
25
Oval
Round
Irregular
6
1
5
0 2
21
SMOOTH
LOBULATED
IRREGULAR
SPICULATED
0
5
10
15
4
5
3
0
2
0
6
15
MALIGNANT BENIGN

18. RESULTS - DWI
 ADC cut off value -< 1.25x10-3 mm2 /s
for malignancy
 Sensitivity - 88%Specificity – 85 %,PPV
– 91% ,NPV - 75%
 Diagnostic accuracy - 81%
 Chi square 5.7, p value0.0006
 At ADC cut off value of - <1x10-3
mm2 /s , sensitivity 69%, specificity –
92%. ( p value- 0.016) PPV – 94%,,NPV
– 57%

19. ROLE OF DWI
0
5
10
15
20
25
MALIGNANT
BENIGN
HPE /ADC
MALIGNANT ADC
(< 1.25X10 -3
mm2/s)
(malignant)
BENIGN
0
2
4
6
8
10
12
14
16
MALIGNANT
BENIGN
HPE /ADC
MALIGNANT ADC
(< 1X10 -3 mm2/s)
(malignant)
BENIGN(> 1X10 -3
mm2/s)

20. FINAL RESULTS
 COMPARISON OF SENSITIVITIES OF MR
MAMMOGRAPHY AND COLOR DOPPLER -
Difference was statistically significant ( MC –
Nemar test p value – 0.00001)
 COMPARISON OF SENSITIVITIES OF (DCE
+MORPHO+DWI) MR MAMMOGRAPHY AND
DCE +MORPHO - Difference was statistically
significant ( MC – Nemar test p value – 0.007)

21. DISCUSSION
 Till date BIRADS 4 subcategorization
is not available for MRI. We tried to
classify BIRADS 4 into 4a, 4b and 4c
with the help of DWI and kinetic
study. in this study rate of
malignancy in BIRADS 4a,4b and 4c
is 20%,50% and 100%.

23. COLOUR DOPPLER & SPECTRAL IMAGE
70 Yr female with breast
lump

24. ontrast Enhanced Image T2W SPAIR

26. CONCLUSION
1. COLOR DOPPLER IMAGING has high PPV so it should be
used as a adjunct to gray scale US for detection of malignant
breast lesions. Although because of low sensitivity it can not
be used as a sole modality .
2. MR- MAMMOGRAPHY showed higher sensitivity for detection
of malignant breast lesions and can be used as a screening
tool but has low specificity . By adding kinetic analysis and DWI,
specificity is improved and now it can be used as a problem
solving modality.
3. A standardized MR BIRADS 4 subcategorization should be
developed. to inform the level of concern for carcinoma As
suggested in our study. This subdivision also encourages
pathologists to aware of benign subcategory 4C lesions
4. It is very important to appropiately categorize BIRADS 3 to
avoid unnecessory invasive procedures without missing
malignancy.

27. REFERENCES
1. Choi HY, Kim HY, Baek SY, et al. Significance of
resistive index in color Doppler ultrasonogram:
differentiation between benign and malignant breast
masses. Clin Imaging. 1999;23:284-8.
2. Rosen EL, Baker JA, Soo MS. Malignant lesions
initially subjected to short-term mammographic
follow-up. Radiology 2002; 223:221–228
3. Harms SE, Flamig DP, Hesley KL, et al. MR
imaging of the breast with rotating delivery of
excitation off resonance: clinical experience with
pathologic correlation. Radiology 1993; 187:493–
501

28. THANK U