A simple classification system (the Tree flowchart) for breast MRI can reduce the number of unnecessary biopsies in MRI-only lesions

Ramona Woitek,Thomas H Helbich,Katja Pinker,Claudio Spick,Maria Bernathova,Margaretha Rudas,Panagiotis Kapetas,Julia Furtner,Melanie Schernthaner,Pascal A T Baltzer

doi:10.1007/s00330-017-4755-6

Ramona Woitek, Thomas H Helbich + Show 8 more

Open Access

https://doi.org/10.1007/s00330-017-4755-6

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Journal: European radiology	Publication Date: Mar 8, 2017
Citations: 62	License type: open-access

Affiliation: Medical University of Vienna

Abstract

ObjectivesTo assess whether using the Tree flowchart obviates unnecessary magnetic resonance imaging (MRI)-guided biopsies in breast lesions only visible on MRI.MethodsThis retrospective IRB-approved study evaluated consecutive suspicious (BI-RADS 4) breast lesions only visible on MRI that were referred to our institution for MRI-guided biopsy. All lesions were evaluated according to the Tree flowchart for breast MRI by experienced readers. The Tree flowchart is a decision rule that assigns levels of suspicion to specific combinations of diagnostic criteria. Receiver operating characteristic (ROC) curve analysis was used to evaluate diagnostic accuracy. To assess reproducibility by kappa statistics, a second reader rated a subset of 82 patients.ResultsThere were 454 patients with 469 histopathologically verified lesions included (98 malignant, 371 benign lesions). The area under the curve (AUC) of the Tree flowchart was 0.873 (95% CI: 0.839–0.901). The inter-reader agreement was almost perfect (kappa: 0.944; 95% CI 0.889–0.998). ROC analysis revealed exclusively benign lesions if the Tree node was ≤2, potentially avoiding unnecessary biopsies in 103 cases (27.8%).ConclusionsUsing the Tree flowchart in breast lesions only visible on MRI, more than 25% of biopsies could be avoided without missing any breast cancer.Key Points• The Treeflowchart may obviate >25% of unnecessary MRI-guided breast biopsies.• This decrease in MRI-guided biopsies does not cause any false-negative cases.• The Treeflowchart predicts 30.6% of malignancies with >98% specificity.• The Tree’shigh specificity aids in decision-making after benign biopsy results.

Highlights

Using the Tree flowchart in breast lesions only visible on magnetic resonance imaging (MRI), more than 25% of biopsies could be avoided without missing any breast cancer
Breast lesions rated as suspicious for cancer according to the American College of Radiology Breast Imaging and Reporting Data System (ACR BI-RADS) that were detected on breast magnetic resonance imaging (MRI) require tissue sampling and histopathological workup [1,2,3]
MR-guided vacuum-assisted breast biopsy (VABB) is a safe and accurate procedure in the diagnostic workup, but its application is limited by availability, relatively high costs compared to other biopsy techniques, and the necessity to administer gadolinium-containing contrast agent intravenously [9]

Summary

Introduction

Breast lesions rated as suspicious for cancer according to the American College of Radiology Breast Imaging and Reporting Data System (ACR BI-RADS) (e.g. assigned an ACR BI-RADS ≥ 4 category) that were detected on breast magnetic resonance imaging (MRI) require tissue sampling and histopathological workup [1,2,3]. Unless these lesions are visible on other imaging modalities, they require dedicated MRI-guided, vacuum-assisted breast biopsy (VABB) to provide representative tissue sampling [1, 2, 4]. Numerous efforts have been made to decrease the number of false-positive results in standard breast MRI using additional imaging techniques, such as diffusion-weighted

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