Comparison of Biopsy Results and Imaging Methods, in the Diagnosis of Breast Cancer

doi:10.4236/ss.2012.39088

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Surgical Science, 2012, 3, 445-451

http://dx.doi.org/10.4236/ss.2012.39088 Published Online September 2012 (http://www.SciRP.org/journal/ss)

Comparison of Biopsy Results and Imaging Methods,

in the Diagnosis of Breast Cancer

Mehmet Ali Eryılmaz1*, Özgür Öner2, Ahmet Okuş1, Ömer Karahan1, Said Bodur3,

Serden Ay1, Seher Civcik4

1General Surgery Clinic, Konya Training and Research Hospital, Konya, Turkey

2Radyology Clinic, Konya Training and Research Hospital, Konya, Turkey

3Department of Public Health, Meram Faculty of Medicine, Selçuk University, Konya, Turkey

4Konya Early Diagnosis of Cancer-Screening and Education Center,

Kanser Erken Teşhis-Tarama ve Eğitim Merkezi (KETEM) , Konya, Turkey

Email: *[email protected]

Received July 13, 2012; revised August 14, 2012; accepted September 2, 2012

ABSTRACT

Purpose: In this study, we aimed at comparing the sensitivity and selectivity rates of Ultrasonography (USG), Mamography

(MG) and Magnetic Resonance (MR), based on the biopsy results of breast mass lesions. Materials and Methods:

Between January 2009 and December 2010 in Konya Training and Research Hospital the biopsy results and reports of

imaging tecniques such as USG, MG and MR, were obtained from the hospital automation. The sensitivity and

selectivity of the USG, MG and MR were calculated. Results: The avarage age of the 112 patients included in this

study is 49 ± 10 (23 - 71). 27 (24%) of the patients were found to have breast cancer after the histopathologic

examination. USG was used with the 95 (94%) of the patients and 17 (18%) of the patients were diagnosed to have

cancer. MG was used with the 75 (67%) of the patients and 15 (20%) of the patients were diagnosed to have cancer, and

MR was used with the 112 (100%) of the patients and 25 (22%) of the patients were diagnosed to have cancer. In the

pathologic diagnosis of cancer, the sensitivity of USG was found 85%, the sensitivity of MG was found 89%, and the

sensitivity of MR was found 92%. The selectivity of these tecniques were 58%, 87% and 57% respectively. Conclusion:

MR and MG have similar sensitivity rates in the diagnosis of breast cancer. Breast MR is an appropriate imaging

tecnique that can be used in suitable indications in addition to USG and MG.

Keywords: Breast Cancer; Magnetic Resonance; Mamography; Ultrasonography

1. Introduction

Breast cancer is still at the top of list of morbidity and

mortality besides being one of the most common type of

cancer among women both in the World and in our country

[1]. MG is still the basic method for scanning and the

determining the breast lesions with its 90% sensitivity

rate [2-4]. Some researchs reveal that MG cannot determine

the breast cancer with a 10% - 30% rate [5]. USG is the

first method to be used when mamography is insufficient

with sclerosing breast tissue [6]. USG is more sensitive

with women who are under the age of 40 and who have

dens breast tissue [7]. USG and MG is insufficient in

evaluating the behavioral characteristics of the determined

lesions, determining the focus occurance of the multifocal-

multicentric (mf-mc) pre-breast conserving surgery, diff-

erentiating between the residue lesion and the granulation

tissue and the post treatment monitoring and in such

situations MR examination is required to solve the problem

in routine applicaitons [2,8,9]. With the use of contrast

agent in MR, it is easier to differentiate between the belign

and malign lesions.

Procedures that are suitable to age or the characteristics

of the mass and efficient examinations increases the dete-

rmination rate of the cancer, whereas redundant tests and

procedures decreases this rate [10].

This research aims at comparing the sensitivity and

selectivity rates USG, MG and MR based on the biosy

results of the breast mass lesions.

2. Materials and Methods

2.1. Patients

The files that belong to the patients who consulted to Konya

Training and Research Hospital with a breast complaint

and were applied breast MR were studied retrocpectively.

It was determined that, every patient that consulted to

*Corresponding author.

M. A. ERYILMAZ ET AL.

446

General Surgery Clinic with a breast complaint was first

applied Clinical Breast Examination (CBE). After that,

bilaretal Breast USG examination was done to patients

under the age of 40 and bilateral MG examination was

done to patients over the age of 40. USG and MG reports

were arranged according to BIRADS classification. Breast

MR was done to patients who were found to have

BIRADS-0, BIRADS 4 and 5 in USG and MG, who has

a breast cancer history in the family and dense breast

tissue. Moreover, MR was done to patients who were

diagnosed to have breast cancer and planned to be applied

breast concerving surgery, in order to determine the mul-

ticentric-multifocal focuses and evaluate the pectoral phaisa

or breast-wall invasion.

Breast MR was also done to patients who have lesions

suspected to have breast cancer defined as BIRADS-3 in

USG and MG in order to define the characteristics of the

lesion, in the cases which were found to be suspected in

the CBE but no tumors were deifned mamographically

and sonographically and the patients who were found to

have structural distortion in the mamographies but not in

sonographies.

BIRADS classification was used to define the lesions

found the breast MR. Tru-cut biopsy with USG was applied

to patients whose breast lesions were suspected to be

BIRADS-4 or 5 in at least one of USG, MG and MR.

The patients who were suspected to have microcalcifica-

tions suspected to malign in MG were send to an epicenter

to be applied steraotaxic marked biopsy and those patients

were not included in the study.

2.2. Breast Ultrasonography (USG)

USG examination was applied to the patients in the supine

position with Siemens Antares device and lineer prob

with a 5 - 15 MHz wide frequency. BIRADS classification

was used defining the lesions found in the USG.

2.3. Mammography (MG)

Mammographical examination was done to both breasts

in two standard positions (MLO and CC). Visions acquired

using Cintek Glory MG device were transformed into

digital visions using Agfa CR85-X CR(computerized radi-

ology) system. BIRADS classification was used defining

the lesions determined in the MG.

2.4. Breast Magnetic Resonance (MR)

Examination

Breast MR was done after the USG and/or MG examina-

tions with the request of radiologist or general surgery

specialist. In the cases that are not urgent, MR examina-

tions were done in the 2nd week of the menstrual cycle.

Dynamic enhanced Breast MR examination were done

in prone position using 1.5 Tesla Siemens Avanto MR

device and 4 channel breast coil. After the localizer visions

were acquired, T1-weighted spin eco fat supressed free

coronal sequence (TR: 313, TE: 4.5, FOV 350 mm, Matrix

256 × 230, Section Thickness 3 mm), T2-weighted fast

spin eco fat supressed free axial sequence (TR:9710, TE:

190, FOV: 350 mm, Matrix 384 × 288, Section Thick-

ness 3 mm), T2-weighted TRIM axial sequence sekans

(TR: 2770, TE: 68, FOV: 350 mm, Matrix 320 × 272,

Section Thickness 3 mm) and T1-weighted 3D gradient

eco dynamic sequnece in the axial plan (TR: 4.43, TE:

1.35, FOV: 330 mm, Matrix 448 × 313, Section Thickness

1 mm) were acquired. In the dynamic examination, un-

enhanced fat supressed free T1-weighted base vision was

acquired first. Then, 0.1 mmol gadolinium-DTPA/kg was

given as intravenous and enhanced sequence was re-

peated 5 times consequetively. Substraction visions were

acquired excluding the base visions from the enhanced

visions. Signaltime curve was formed using the substrac-

tion visions. The breast masses were evaluated taking

their morphological and contrast agent involvement cha-

racteristics into consideration. The lesions smaller than 5

mm were evaluated as focus, whereas lesions bigger than 5

mm were evaluated as mass lesion. The shape of the mass

(round, oval, lobular or irregular), the contours of the mass

(smooth, irregular, spicule) and contrast involvment cha-

racteristics of the mass (homogenous, heterogenous, an-

nular or central) were used evaluating the lesion. Evaluat-

ing the non-massive contrast involvment zones, disper-

sion (focal, multifocal, lineer, ductal, segmental or dif-

fuse), contrast involvement characteristics (homogenous,

heterogenous, punctual, nodular interreptus or reticular)

and either they are symmetrical or not were taken into con-

sideration. In the kinetic evaluation, contrasting rate (slow,

medium or fast), and contrasting pattern (increasing in

due course, forming plateaus or forming swift contrast loss)

were used acquiring time-signal curve. Defining the lesions

determined in MR, BIRADS classification was used.

2.5. Biopsy Procedure

For pathological examination, at least 3 pieces of sample

were taken with a full-automatic tru-cut needle with the

angled-prob of the USG, from the patients whose mass

lesions were found to be BIRADS 4 - 5 in the USG, MG

and MR. These were sent to pathology laboratory in the

10% formol with the material biopsy container.

All the USG, MG and MR monitoring reports and

pathology results of all the patients were acquired from

the hospital automation. The sensitivity and selectivity of

USG, MG and MR examinations of these patients in the

pathological diagnosis were computed.

M. A. ERYILMAZ ET AL.

447

2.6. Statistics

Sensitivity, Specifitiy, Positive Predictive value, Negative

Predictive value, Total Truth values were used. P value

was calculated using SPSS (SPSS Inc.16 2009, Chicago,

IL, USA) statistics software. P < 0.05 was accepted as

significant.

3. Results

The avarage age of the 112 patients included in this study

is 49 ± 10 (23 - 71). In the histopathological examinations

of the biopsies taken with the suspect of cancer, 27 (24%)

of the patients were found to have breast cancer. 21 (77%)

of these have invasive ductal carcinoma (Table 1). USG

was applied to 95 (94%) of the patients and 17 (18%) of

these were found to have cancer. MG was applied to 75

(67%) of the patients and 15 (20%) of these were found to

have cancer. MR was applied to 112 (100%) of the patients

and 25 (22%) of these were found to have cancer. The sen-

sitivity of the USG is 85%, MG is 94% and MR is 92%

in the pathological cancer diagnosis. The selectivity rates

of these respectively are; 58%, 83% and 57% (Table 2).

USG examination was done to 95 (94%) of the 112

patients. MR was done to 2 breasts defined as BIRADS-0

additionally, evaluated as BIRADS-4 and the biopsy results

showed that these were benign. MR was applied and

biopsy was taken from 46 (41%) of the breasts defined as

BIRADS-4 and 5 additionally and 16 (14%) of these were

found to have cancer (Table 3).

MG was done to 75 (67%) of the 112 patients. MR

was done to 48 (42%) of the patients who were evaluated

as BIRADS-0 additionally. 19 (40%) of these were

evaluated as BIRADS-4 and 9 (18%) of them were

evaluated as BIRADS-5 in the MR and biopsies were

taken from these patients (Figure 1). 10 (21%) of these

patients were found to have cancer (Table 3).

Both MG and USG was done to a single patient and

evaluated as BIRADS-5 in USG and BIRADS-2 in MG.

The same patient was evaluated as BIRADS-2 in MR and

with the biopsy, she was diagnosed to have cancer. 1 (4%)

of the 27 cancer diagnoses were reached at the correct

diagnosis in the USG evaluation.

MR was done to 5 patients additionally who were

evaluated as BIRADS-4 in MG and 3 of these were

evaluated as BIRADS-2 (Figure 2). Biopsy was taken

from these patients as MG results were suspected to be

malign, however the result was benign. The other 2 of

these were evaluated as BIRADS-5 in MR and biopsy

was taken from these patients and these patients were

diagnosed to have cancer. With the cases diagnosed as

BIRADS-4 in MG, Breast MR examination was found to

be significant in diagnosing the cancer (P < 0.05).

MR was done to 3 patients who were defined as

BIRADS-5 in MG, in order to examine the occurance of

multifocal-multicentric lesions and 2 breasts were evaluated

as BIRADS-5 and unifocal cancer was diagnosed after

the biopsy an done of these patients were found to have

multifocality and with the biopsy, she was diagnosed to

have multifocal cancer.

Breast MR was applied to 112 patients. Biopsy was taken

from 38 breasts that were evaluated as BIRADS-4 and 5

of these were diagnosed to have breast cancer. Biopsy

was taken from the 23 breasts evaluated as BIRADS-5

and 20 of these breasts were diagnosed to have cancer.

Two breasts were defined as benign with MR and with

the biopsy these were evaluated as cancer. Two of these

cancers were determined with only USG and the other

was determined with MG (ductal carcinoma insitu) (Table

4). After the breast reduction surgery, two breasts were

evaluated as BIRADS-5 with USG and as BIRADS-0

with MG. The MR results of these patients were evaluated

as BIRADS-2 and the biopsy results were reported as

benign.

4. Discussion

Breast Cancer is one of the most important reasons of the

deaths of cancer among women [11]. To decrase the death

rate of the breast cancer, it is important to diagnose at an

Table 1. Histopathological distribution of the breast cancers.

Histopathology N (number) %

Invasive ductal carcinoma 21 77.8

Invasive ductal carcinoma + Invasive

lobular carcinoma 3 11.1

Invasive lobular carcinoma 1 3.7

Medullar carcinoma 1 3.7

DCIS 1 3.7

Total 27 100.0

Table 2. The sensitivity and selectivity rates of the monitoring methods in the diagnosis of breast cancer.

İmaging methods Sensitivity (%) Specifity (%) Positive predictive value (%)Negative predictive value (%) Truth value (%)

USG 85.0 58.3 36.2 93.3 64.1

MG 94.4 83.3 85.0 93.8 88.9

MR 92.6 56.8 41.7 95.8 65.7

M. A. ERYILMAZ ET AL.

448

Table 3. Consistency of the BIRADS classification with the diagnosis of breast cancer.

BIRADS-0 BIRADS-1-2-3 BIRADS-4 BIRADS-5

İmaging

methods

Number

(n) Ca %

Number

(n) Ca %

Number

(n) Ca %

Number

(n) Ca %

USG 2 0 0.0 47 3 6.9 34 4 11.7 12 10 83.3

MG 48 10 20.8 19 2 10.5 5 2 40.0 3 3 100.0

MR 0 0 0.0 51 2 3.8 38 5 13.2 23 20 87.0

Figure 1. Glandular tissues and suspicious nodular opacities that cannot be qualified as net superimposition are present in

mammography of left breast subareolar area. In the US and MR examination, 21 × 19 mm sized mass lesion with a malign

outlook in the left breast lower quadrant and numerous nodular lesions smaller than 5 mm than can be compliant with satellite

lesions in the left breast were detected.

Figure 2. 2 cm diameters of asymmetric density is observed in the CC graphy outer quadrant of left breast in the mammography.

With the MR, no pathologies but a couple of millimetric cysts were observed. With the US, the result of the biopsy got from the

heterogenous area which cannot be lined off precisely in the periareolar area of left breast revealed situ carcinoma (2nd degree).

M. A. ERYILMAZ ET AL.

449

Table 4. The number of the lesions that were found to have

cancer with biopsy but cannot be monitored with monitoring

methods (n = 27).

İmaging methods n %

USG 3 11.1

MG 2 7.4

MR 2 7.4

USG + MG 2 7.4

MG + MR 1 3.7

USG + MR 1 3.7

USG + MG + MR 0 0.0

early stage and correctly. Mammography is a monitoring

method that decreases the death rate of the breast cancer

[12]. Death rate of the breast cancer from the age of 40

has decreased at a 31% rate with the breast cancer scanning

with mammography [13]. It is adviced for every woman

to have a CBE with mammography once a year [14,15].

Mammography has a high sensitivity rate in routine scans

and patients with breast symptoms. The use of mammo-

graphy with USG increases the sensitivity rate and changes

the follow-up procedures [16]. None of the methods has

the adequate sensitivity, specifity and diagnostically corre-

ctness rate in the diagnosis of the breast lesions. Therefore,

it is not true to use one single method in the diagnosis of

the breast lesions and combining a couple of methods

together increases the diagnostical correctness rate. In

this study, diagnosing the patients suspected to have

cancer in the anamnesis and physical examinations, when

at one of CBE, USG, MG and MR methods indicated the

occurance of cancer, biopsy was applied with USG.

About 20% of the breast cancers are observed under

the age of 40, whereas 30% of these are observed under

the age of 50. To minimise the number of the redundant

tests, the age and the characteristics of the breasts should

be taken into consideration. Because of the dense charac-

teristics of the breast tissue, not MG but USG is more

significant with the women patients under age of 40. MG

is more significant with the women over the age of 40

and it is suggested to be applied once a year [10,12]. In

this study, 18% of the patients diagnosed to have cancer

are under the age of 40 and the 33% of these are under

the age 50.

Diagnostical MG has a 89% rate sensitivity in the

determining the breast cancer and the masses that can be

felt with hand is normal in the 9% - 20% of the breast

cancers [10]. In this study, a mass lesion that can be felt

with hand was found in 1 (4%) of the patients. However,

this mass lesion could not be determined with neither

MG nor MR and could be realised only with USG and

diagnosed to have cancer with biopsy.

Breast MR can functionally demonstrate the breast

parencyma and the mass perfusion characteristics of the

mass lesions at this base besides the morphological char-

acteristics of the breast lesions such as; shape, contour

and size [17]. In this research, radiological modalities such

as Breast USG and MG were evaluated with CBE findings

and additionally, in cases of BIRADS-3, BIRADS-4 and

BIRADS-5, Breast MR was applied with the view of a

radiologist and/or general surgery specialist. According

to the MR results applied to 48 (42%) of the patients

defined as BIRADS-0 with MG, 10 (21%) of the patients

were diagnosed to have breast cancer. With this finding,

MR is claimed to be a problem solving method in cases

in which MG is restricted in defining (Table 3).

MR has become a commonly used monitoring method

in differentiating between benign and malign in breast

lesions. It has the highest specifity and sensitivity rate

among the monitoring methods. It is indisputebly a useful

method, especially in the cases where other monitoring

methods are insufficient in providing required information.

MR is definitely superior to other methods in determining

the occurance of multifocal-multicentric cancer, with pat-

ients who need breast conserving surgery and evaluating

scar tissue that occur after surgery [18,19]. In this research,

multifocality occurance was determined with MR in a

patient who was found to have BIRADS-5 single focus

with MG and mastectomy was applied to this patient.

USG defined BIRADS-5 lesions in two patients who had

a breast reduction surgery and MG defined the lesions of

these patients as BIRADS-0 and MR defined these as

BIRADS-2 and the biopsy results were evaluated as benign.

According to the guidelines published by American

Cancer Association in 2007, MR applied in addition to

mammography can determine the high rish breast cancer

at early stages, especially in cases in which MG has low

sensitivity [20]. Breast MR is the most sensitive method

in determining the breast cancer. Especially the conven-

tional monitoring methods cannot easily differentiate

between malign and benign cases. In such cases Breast

MR is used as the problem solving method. Cases that

are suspected to be malign and classified as BIRADS 3

and 4 with USG and MG can be diagnosed with MR with

a high sensitivity [21,22]. In the invasive breast tumors,

MR can give the size closest to the pathological size [23].

In this research Breast MR was done to 5 patients who

were defined as BIRADS-4 with MG, and two of them

were defined to have BIRADS-5 and the biopsy results

revealed breast cancer and three of the patients were

found to have BIRADS-2, 3 in Breast MR. The biopsies

of these three patients were found to be benign.

Breast MR has a high sensitivity rate (83% - 100%),

but the specifitiy rate of it is low (23% - 80%). MR

should be used, when USG and MG are inefficient in

defining the breast mass lesions [24]. As the specifity

rate of MR is low, biopsy procedures to be carried as the

result of MR will not always be sufficient in diagnosing

M. A. ERYILMAZ ET AL.

450

the cancer. In this research, 35 (31%) of the patients, to

who biopsy was done because MR defined them as

BIRADS-4 and BIRADS-5, were examined hispatholo-

gically and the results were benign.

Breast MR is inefficient in defining the breast insitu

cancers and suspicious lesions under 3 mms (14). In this

research, breast insitu cancer could not be defined with

MR in one of the patients and it was defined with MG.

One of the patients was defined as BIRADS-5 with USG

and the cancer found in the biopsy was not determined in

MR (Table 4).

Cor biopsy is a more widely used method in breast

cancer diagnosis. It has many advantages such as; acquiring

adequate tissue sample, diagnosing fast, allowing receptor

use and being cheaper than the open biopsy. The imple-

mentation of the procedure accompanied with USG decr-

eases the false negativity rate to 0.2%. This application

allows breast conserving surgery and sentinel lymph node

mapping while open biopsy doesn’t, because the lympha-

tics remain unharmed [25,26]. In this research, all the

112 biopsies were done accompanied with USG and 27

(24%) of the patients were diagnosd to have cancer. All

of these patients were surgically operated.

5. Conclusion

USG and MR are prominent monitoring methods evalua-

ting the breast diseases. Breast MR is a monitoring method

that can be used in addition to USG and MG in suitable

indications. Breast MR has a sensitivity rate close to MG.

It is a problem solving method with cases of BIRADS-0

and BIRADS-4 breast lesions, where MG is inefficient.

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