Original Article

Acta Radiologica
2015, Vol. 56(3) 260–268
! The Foundation Acta Radiologica
Magnetic resonance imaging of breast 2014
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DOI: 10.1177/0284185114524089
of preoperative lesion sizing acr.sagepub.com

Simone Mennella1, Alessandro Garlaschi2, Francesco Paparo3,

Marco Perillo1, Matteo Celenza1, Tiberio Massa2,
Gian Andrea Rollandi3 and Giacomo Garlaschi1

Abstract
Background: Accurate preoperative sizing of breast cancer with imaging modalities has a great importance in the
surgical planning.
Purpose: To assess the influence of tumor size and histology on the accuracy of measurement of cancer local extension
by magnetic resonance imaging (MRI).
Material and Methods: One hundred and eighty-six patients with primary breast cancer, for a total of 221 lesions,
were included in this retrospective study. Tumors were divided into five histological groups: invasive ductal carcinoma
(IDC), IDC with extensive intraductal component (EIC), invasive lobular carcinoma (ILC), ductal carcinoma in situ
(DCIS), and ‘‘other histology’’ (mucinous, papillary, medullary, tubular, and apocrine breast cancer). Microscopic meas-
urement of the largest diameter of tumors at pathology was chosen as reference standard and compared with MRI
measurement. Concordance was defined as a difference  5 mm between MRI and pathology.
Results: The mean size of tumors at pathology was 24.8  19.4 mm, while at MRI it was 29.7  20 mm (P < 0.05), with a
significant overestimation of MRI. MRI–pathology concordance was found in 98/221 cases (44.3%), while MRI over-
estimated the size of 81/221 tumors (36.7%). The extent of overestimation was significantly different among the five
histological groups (P < 0.05). At multivariate analysis, DCIS histology was the factor more significantly associated with
MRI–pathology discordance (P ¼ 0.0005), while the influence of tumor dimension at pathology was less significant
(P ¼ 0.0073).
Conclusion: DCIS histology is strongly associated with discordance between MRI and pathology sizing of breast cancer.
Lesion size can also influence the accuracy of MRI measurements, but to a lesser extent.

Keywords
MRI, invasive breast cancer, ductal carcinoma in situ, tumor size, pathology
Date received: 22 September 2013; accepted: 24 January 2014

margins at initial surgery decreases the chance of tumor

Introduction
recurrence, MRI is employed in the preoperative
A precise preoperative assessment of tumor extension
with imaging techniques plays a central role in breast 1
School of Radiology, University of Genoa, Genoa, Italy
surgery, and the choice of breast-conserving treatment 2
Department of Radiology, IRCCS A.O.U. San Martino–IST, Genoa, Italy
3
significantly depends on the relationship between Radiology Unit, Diagnostic Imaging Department, E.O. Ospedali Galliera,
tumor-to-breast size (1). Magnetic resonance imaging Genoa, Italy
(MRI) has been shown to be more accurate than ultra-
Corresponding author:
sound (US) and mammography in estimating the local Matteo Celenza, School of Radiology, University of Genoa, Via Leon
extension of both invasive breast cancer and ductal car- Battista Alberti 4, 16132 Genoa, Italy.
cinoma in situ (DCIS) (2,3). Since achieving negative Email: matteocelenza@hotmail.it

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Mennella et al.
surgical planning to evaluate the local extent of the
disease and to assess the presence of synchronous
tumors. The potential for under- or overestimation of
tumor size on MR images has been investigated in dif-
ferent previous studies, which yielded mixed results
(4–9). In more recent works (8,9), there is evidence
that lesion size can influence the accuracy of MRI
measurements. In a retrospective study on 77 patients,
Onesti et al. (8) compared the preoperative tumor size
measured on MR images to the tumor size at final path-
ology. Stratifying their patient cohort according to the
MRI tumor size ( 2.0 cm and >2.0 cm), the authors
found a greater difference between the two measure-
ments (i.e. MRI/pathology difference) in the group of
lesions larger than 2.0 cm.
Grimsby et al. (9) investigated on 190 patients the
correlation between MRI and pathology tumor sizing,
finding concordance within 0.5 cm in 53% of cases,
while MRI overestimated 33% and underestimated
15% of tumors. Among tumors overestimated by
MRI, 65% had additional significant findings in the
breast tissue around the main lesion: satellite lesions,
DCIS, and/or lymphovascular invasion, but tumor
histology was not found to be a source of discordance
between MRI and pathology tumor sizing. The aim of
our study was to re-assess on a large number of lesions
the hypothesis that histological subtype may influence
the discrepancy between MRI and pathology measure-
ments. The second objective was to verify if the discrep-
ancy between MRI and pathology tumor sizing is
more affected by tumor dimensions or histological
subtype.
Material and Methods
This was a retrospective, single-center, institutional
review board approved study within a breast surgery
specialty practice. All women who had a newly diag-
nosed, biopsy-proven, primary breast cancer with a
positive MRI before surgical treatment were identified
by performing a search in our single-institution radi-
ology database from January 2007 to December 2012.
Different data were collected for all patients, including
age, tumor size on both MRI and final pathology,
histological characteristics of the tumor, type of surgi-
cal intervention (i.e. lumpectomy, quadrantectomy, or
mastectomy), and the presence of neoadjuvant chemo-
therapy. Patients who received neoadjuvant chemother-
apy before surgery were excluded, since it has been
previously demonstrated that this factor is a source of
discordance between preoperative MRI tumor sizing
and final pathology measurements (9). To compare
cancer sizing by MRI with pathology, only the largest
diameter of lesion size was used. Patients without a
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261
clear and precise measurement of the largest diameter
of the lesion size in the postoperative pathology report
were excluded.
Pathology
Histopathological reports of all enrolled patients were
retrieved from our institutional pathology database
and carefully reviewed. Patients with bilateral, multi-
focal, and multicentric lesions were identified. The
presence of two or more foci of cancer within the
same breast quadrant was defined as multifocal dis-
ease, while the presence of two or more foci of cancer
in different quadrants of the same breast was defined
as multicentric disease. Tumors were classified accord-
ing to five histological subgroups, including invasive
ductal carcinoma (IDC), invasive ductal carcinoma
with extensive intraductal component (EIC), invasive
lobular carcinoma (ILC), ductal carcinoma in situ
(DCIS), and other histological types (mixed IDC/
ILC, mucinous, papillary, medullary, tubular, and
apocrine breast carcinoma). The second subgroup,
represented by EIC, was defined, according to Berg
et al. (10), as ductal carcinoma with an invasive com-
ponent, where at least 25% of the tumor was DCIS
with or without additional discrete foci of DCIS out-
side the main tumor mass. Consistent with the
common practice of the pathology service of our insti-
tution, all surgical specimens were received with orien-
tation and examined in fresh state. Specimens were cut
into 5-mm thick levels along their longest axis (i.e.
5-mm slicing technique), according to Egan et al.
(11). Formalin fixation happened only after the cut
sections of each specimen were obtained. In this
way, tissue shrinkage and the potential change in
size of tumors did not occur as a result of specimen
fixation prior to cut. The measurements were then
calculated by multiplying number of levels showing
cancer by the thickness of each level. In situ compo-
nents were included in the analysis. The largest dimen-
sion of tumor size was used as reference standard. In
the case of multifocal disease, the final pathology size
was obtained by summing the major microscopic
dimension of different tumor foci within the same
breast quadrant. On the other hand, in the case of
multicentric disease, different tumor foci were con-
sidered and measured as separate lesions.
MRI technique
Written informed consent was obtained from all
patients before MRI. Breast MRI examinations were
performed on a 1.5 T MRI scanner (Avanto, Siemens,
262 Acta Radiologica 56(3)

Erlangen, Germany) with the patient in the prone pos-
ition in a dedicated phased-array breast coil, using the
following MRI protocol:
. T2-weighted Turbo Inversion Recovery Magnitude
(TIRM) axial sequence (repetition time, 8950.00 ms;
echo time, 87.00 ms; matrix size, 380  384; elliptical
filter; slice thickness, 4.00 mm; interval, 0.00 mm; dis-
tance factor, 25%; overlapping, 1 mm; field of view
[FOV], 340 mm; FOV phase, 100%; flip angle, 120 ;
voxel size, 0.9  0.9  1.6 mm)
. T1-weighted (T1W) three-dimensional (3D) fat-
suppressed FLASH (fast low-angle shot pulse
sequence) imaging of both breasts in the axial
plane (repetition time, 3.99 ms; echo time, 1.36 ms;
flip angle, 12 ; single acquisition of signal; rectangu-
lar FOV, 32–36 cm; matrix size, 400  400; slice
thickness, 1.6 mm; interval, 0.00 mm). Contrast-
enhanced dynamic breast MRI was performed with
the acquisition of one precontrast 3D FLASH
sequence and five sequences during the intravenous
injection of paramagnetic contrast medium
(0.1 mmol/kg of gadobenate dimeglumine [Gd-
BOPTA]). Imaging volumes were acquired at 1, 2,
3, 4, and 5 min after injection. Contrast medium
speed injection was standardized at 3 mL/s and fol-
lowed by injection of a 20 mL saline flush at same
flow rate.
The overall acquisition time of the MRI protocol was
17–20 min. It is well known that increased enhancement
after biopsy can make it difficult to differentiate breast
lesions from surrounding parenchyma (12). On the
other hand, what should be the best time interval for
performing MRI after a biopsy procedure remains
unclear, and no previous work has given a precise
response to this question. On the use of MRI in assess-
ing residual disease after positive tumor margins in
breast-conserving surgery, EUSOBI (European
Society of Breast Imaging) suggests to respect a time
interval of 1 month between surgery and diagnostic
MRI (13), since postsurgical inflammatory edema can
artificially increase lesion’s size. In the case of VABB,
which can be considered quite an invasive procedure,
we routinely respect this time interval of 1 month.
Interpretation of MRI examinations
All breast MRI examinations were reviewed in consen-
sus on a dedicated workstation by two radiologists (AG
and TM) with 8 and 20 years of experience in the field
of breast diseases, who had access to previous imaging
records of each patient.
The dynamic sequence was examined with subtrac-
tion and maximum intensity projection (MIP) tech-
niques. Time-enhancement kinetic curves were
generated to assist in the interpretation. Cancer exten-
sion on MR images was defined in the early phase of
dynamic studies as well-enhanced areas, including
linear or clumped enhanced areas, according to
Kuroki et al. (6). The greatest dimension of tumor
size was measured by means of an electronic
digital caliper and compared with the microscopic size
(Figs. 1 and 2).

Fig. 1. Transverse T1W 3D FLASH subtraction MR image (a) shows an irregular-shaped periareolar lesion in the left breast, with a
largest diameter of 80.12 mm. (b) The surgical specimen. (c) The histopathologic section (hematoxylin and eosin, 10x) reveals an
invasive ductal carcinoma not otherwise specified with high grade of nuclear polymorphism, low grade of differentiation (Nottingham
grading: G3), and no appreciable intraductal spread (DCIS component < 25%). It was ER (estrogen-receptor) negative, and Ki-67
positive (proliferative activity: 42%).

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Mennella et al. 263

Fig. 2. Transverse T1W 3D FLASH subtraction MR image (a) shows a lobulated lesion in the outer quadrants of the right breast, with
a largest diameter of 26.49 mm. (b) The surgical specimen. (c) The histopathologic section (hematoxylin and eosin, 20x) reveals an
invasive lobular carcinoma with the typical pattern of linear growth. It is characterized by high grade of nuclear polymorphism, low
grade of differentiation (Nottingham grading: G3), negativity for ER (estrogen receptors), and positivity for Ki-67 (proliferative
activity: 15%).

a statistically significant difference between the medians

Statistical analysis
Categorical data were expressed as number and per-
centage, while continuous data as mean and standard
deviation (SD). The normal distribution of MRI and
pathology measurements was assessed by means of the
D’Agostino-Pearson test (14) in each histological sub-
group. Since some data-sets (e.g. MRI and/or path-
ology tumor size in the different histological
subgroups) did not follow the normal distribution,
non-parametric tests were used instead of parametric
ones.
Concordance between MRI and pathology was
defined as a difference  5 mm.
The degree of relationship between two independent
variables was determined using the Spearman’s rank
correlation. Spearman’s rho values were interpreted as
follows:
of more than two different groups. After a positive
Kruskal-Wallis test (P value < 0.05), a post-hoc ana-
lysis was conducted performing pairwise comparison
of subgroups. The number of lesions under- and over-
estimated by MRI was calculated, as well as the mean
value of under- and overestimation  SD. Bland-
Altman analysis was used to determine to what extent
the MRI tumor size correlated with the histopatho-
logical tumor size. In addition, the absolute difference
between MRI and pathology measurements was calcu-
lated, and the presence (or absence) of MRI–pathology
discordance (i.e. an MRI–pathology difference > 5 mm)
was put as dichotomous dependent variable in a multi-
variate logistic regression model, using the histological
subgroup of lesions and the pathology size as independ-
ent variables.

. for values of rho of 0.9–1, the correlation is very

strong;
. for values of rho 0.7–0.89, correlation is strong;
. for values of rho 0.5–0.69, correlation is moderate;
. for values of rho 0.3–0.4.9, correlation is moderate
to low;
. for values of rho 0.16–0.29, correlation is weak
to low;
. for values of rho < 0.16, correlation is too low to be
meaningful.
Mann-Whitney test was used to assess the difference
between the medians of two independent groups.
Kruskal-Wallis test was used to verify the presence of
Results
A total of 186 women (mean age 52.2510.63) were
included for a total of 221 lesions. This discrepancy
was due to four patients with bilateral tumors, 30
(16.1%) patients with multicentric disease and one
patient with a peculiar bifocal disease. This latter
patient had two lesions in the same breast quadrant
with different histology (i.e. IDC and invasive mucin-
ous carcinoma), which were separately considered and
measured. Sixty-three patients (33.9%) had multifocal
disease. Fifteen women were excluded from an initial
cohort of 201 patients, since they received neoadjuvant
chemotherapy before surgery. A total of 190 surgical
procedures were performed on 186 patients: this

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264
Fig. 3. The scatter diagram graphically shows the relation
between tumor size measured on MR images (MRI, horizontal
axis) and microscopic measurement of the greatest dimension of
tumor size at final pathology (pathology, vertical axis). The MRI/
pathology correlation, tested by the Spearman’s rank correlation,
was strong (rho ¼ 0.792, P < 0.05).
discrepancy was due to four patients with bilateral
breast cancer who underwent bilateral mastectomy
(each surgical procedure was separately considered).
Surgical interventions consisted of 89/190 (46.8%) mas-
tectomies, 59/190 (31.1%) quadrantectomies, and 42/
190 (22.1%) lumpectomies. Tumor histology was as
follows: 112 IDC (50.68%); 23 EIC (10.41%); 31 ILC
(14.03%); 30 DCIS (13.57%); other histological types
included 12 mixed IDC/ILC (5.43%), seven mucinous
(3.17%), three papillary (1.36%), one medullary
(0.45%), one tubular (0.45%), and one apocrine carcin-
oma (0.45%).
All lesions underwent biopsy prior to MRI, but only
for 101 women (a total of 101 tumors) it was possible to
retrieve precise information about the method of pre-
operative biopsy (vacuum-assisted breast biopsy
[VABB], core biopsy, fine-needle aspiration cytology
[FNAC]). For the remaining patients this information
was not accessible in a retrospective setting, since they
were referred to our breast surgery specialty practice
from other centers, and data regarding their biopsy
procedure were not present in our institutional data-
base. A total of 49 patients underwent FNAC prior
to MRI, 32 underwent VABB, and, in the remaining
20, a core biopsy procedure was performed.
The mean size of tumors at pathology was
24.819.4 mm, while at MRI it was 29.720 mm
(two-tailed probability with the Kruskall-Wallis test,
P < 0.05), with a global significant overestimation of
MRI. The overall correlation between pathology and
MRI measurements was strong (Spearman’s
rho ¼ 0.792, 95% CI for rho 0.737–0.837, P < 0.05)
(Fig. 3). MRI–pathology concordance within 5 mm
was found in 111/221 cases (50.2%). Perfect concord-
ance (MRI–pathology difference ¼ 0) between MRI
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Acta Radiologica 56(3)
and breast cancer size at pathology was found in only
13/221 cases (5.9%). MRI overestimated the size of 81/
221 tumors (36.7 %) with a mean value of overesti-
mation of 16.8  12.9 mm. MRI underestimated the
size of 29/221 tumors (13.1%) with a mean value of
underestimation of 14.2  7.1 mm.
Effect of tumor dimension on the difference between
MRI and pathology measurements
All the 221 tumors were stratified into two groups on
the basis of their MRI size, according to Onesti et al. (8)
(Group A consisting of 98 tumors  20 mm and Group
B consisting of 123 tumors > 20 mm), and Bland-
Altman statistics were performed in each group to
assess the mean MRI–pathology difference and the cor-
responding limits of agreement (Fig. 4). The mean
MRI–pathology difference was higher in Group B
(6.6) than in Group A (1.7), and the limits of agreement
were wider in Group B (lower limit 21 [95% CI 25.4
to 16.7]; upper limit 34.3 [95% CI 30–38.7]) than in
Group A (lower limit 8.1 [95%CI 9.9 to 6.4];
upper limit 11.6 [95% CI 9.9–13.3]).
The 81/221 tumors overestimated by MRI were then
stratified into two groups according to their MRI size
(Group 1 consisting of 16 tumors  20 mm and Group 2
consisting of 65 tumors > 20 mm), and the mean value
of overestimation was calculated in each group: it
resulted to be significantly higher in Group 2 than in
Group 1 (Group 1 ¼ 9  2.5; Group 2 ¼ 18.7  13.7;
P < 0.05 with the Mann-Whitney test for independent
samples).
Effect of histology of tumors on the correlation
between pathology and MRI measurements
The correlation between pathology and MRI was sep-
arately tested for each histological subgroup: IDC
(rho ¼ 0.864, 95% CI for rho 0.808–0.904, P < 0.05),
EIC (rho ¼ 0.642, 95% CI for rho 0.312–0.833,
P < 0.05), ILC (rho ¼ 0.856, 95% CI for rho 0.719–
0.928, P < 0.05), DCIS (rho ¼ 0.56, 95% CI for rho
0.250–0.766, P < 0.05), other histological types
(rho ¼ 0.612, 95% CI for rho 0.286–0.811, P < 0.05).
The best correlation was found for IDC (rho ¼ 0.864),
and the worst for the DCIS subgroup (rho ¼ 0.56). The
221 lesions were further divided according to their
histological type. The Kruskal-Wallis test demon-
strated a significant difference of overestimation
among the five histological subgroups (P < 0.05)
(Fig. 5). Results of the post-hoc analysis showed that
the median overestimation in the EIC group was sig-
nificantly higher than that of the IDC group, while the
median overestimation in DCIS group was higher than
that of all the other histological groups, excluding EIC.
Mennella et al. 265

Fig. 4. Bland-Altman plots for Group 1 (lesions  20 mm) (a) and Group 2 (lesions > 20 mm) (b). The graphs display a scatter diagram
of the differences plotted against the averages of the two measurements. Horizontal lines are drawn at the mean difference, and at the
limits of agreement, which are defined as the mean difference plus and minus 1.96 times the standard deviation of the differences. The
mean difference between MRI and pathology sizing is greater for Group 1 than for Group 2.

pathology size as independent variables. Results of

Fig. 5. Box-and-whisker plot showing how the median value of
MRI/pathology difference in tumor sizing varies among the
different histological subgroups. The central box represents the
values from the lower to upper quartile (25 to 75 percentile).
The middle line represents the median. The horizontal line
extends from the minimum to the maximum value, excluding
outside and far out values, which are displayed as separate points.
An outside value is defined as a value that is larger than the upper
quartile plus 1.5 times the interquartile range (inner fences),
while a far out value is defined as a value that is larger than the
upper quartile plus 3x the interquartile range (outer fences).
These values are plotted using a different marker in the warning
color. The median value of the absolute MRI/pathology difference
was significantly higher in the histological groups B and D. Legend:
A, IDC; B, EIC; C, ILC; D, DCIS; E, other histological types.
Multivariate logistic regression
The absolute difference between MRI and pathology
measurements was calculated, and the presence of a
difference > 5 mm was put as dichotomous dependent
variable in a multivariate logistic regression model,
using the histological subgroup of lesions and the
the multivariate logistic regression with stepwise inclu-
sion method are shown in Table 1. In our study, tumor
dimension at MRI and two peculiar histological types
(EIC and DCIS) are factors that significantly influence
the discrepancy between MRI and pathology measure-
ments of tumor size. In particular, DCIS histology
was the independent factor more significantly asso-
ciated with an MRI–pathology difference  5 mm
(P ¼ 0.0005, odds ratio ¼ 6.03), while the influence of
tumor dimension was less significant (P ¼ 0.0073,
odds ratio ¼ 1.02).
Discussion
MRI is often used, in addition to conventional imaging,
for the preoperative assessment of breast cancer size to
determine the optimal surgical strategy. Recent studies
have suggested that MRI is superior to mammography
in determining invasive tumor size, depicting multifo-
cality, as well as evaluating the intraductal component.
In the present study, breast cancer size at histopath-
ology has been used as reference standard, and com-
pared to the MRI measurements performed by two
breast radiologists working in consensus. The most
recent works comparing MRI and pathology in the
assessment of size and local extension of breast cancer
confirmed a trend of overestimation by MRI (8,9). In
their work, Onesti et al. (8) found that MRI signifi-
cantly overestimated mean tumor size (P < 0.05), pro-
posing that this result was primarily due to tumors
measuring > 20 mm at MRI. Also Grimsby et al. (9)
suggested that discordance between MRI and path-
ology tumor sizing is strongly affected by tumor size
at MRI. In addition, they found that other factors,
including patient age, multifocal disease, and

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266 Acta Radiologica 56(3)

Table 1. Multivariate logistic regression

Coefficients and SEs
Variable Coefficient SE P

Size at pathology 0.021458 0.0079946 0.0073

EIC 1.23618 0.53746 0.0214
DCIS 1.79775 0.51792 0.0005
Constant 0.6310
Variables not included in the model
ILC
Other tumours

ORs and 95% CIs

Variable OR 95% CI

Size at pathology 1.0217 1.0058 to 1.0378

EIC 3.4425 1.2005 to 9.8711
DCIS 6.0360 2.1872 to 16.6577
A variable was removed from the model if its associated significance level was greater than the P value of 0.1 (variables
not included in the model: ILC, other tumors). The Wald criterion demonstrated that tumor size at pathology, EIC, and
DCIS histological subgroups made a significant contribution to prediction of the dependent variable, which was defined
as a difference between MRI and microscopic sizing of lesions  5 mm. DCIS histology was the strongest significant
predictor (P < 0.0005). When tumor histology is DCIS, the OR is 6 times larger.
CI, confidence interval; OR, odds ratio; SE, standard error.

histological type, do not seem to influence MRI–path-
ology discordance. However, the authors did not per-
form a multivariate or logistic regression analysis. In
the present study, we aimed to assess, on a relatively
large number of primary breast carcinomas (i.e. 221
lesions), what is the best predictor of MRI–pathology
discordance between tumor size and histology. Both
EIC and DCIS lesions were well represented in our
study cohort (10.41% and 13.57%, respectively), thus
allowing us to assess the influence of an ‘‘in situ’’ com-
ponent on the accuracy of MRI measurements. We
found that MRI overestimated the size of 81/221
tumors (36.7%); this figure of overestimation is similar
to those reported by Onesti et al. (8) (i.e. 35%) and by
Grimsby et al. (9) (i.e. 33%), since they defined con-
cordance between measurements as a difference within
5 mm, with a method similar to ours. Kuroki et al. cited
a 93.5% concordance using a limit of  15 mm, which
could represent a substantial discordance in the clinical
setting (6). In our study, the mean overestimation was
larger in the group of tumors >20 mm (P < 0.05), thus
underscoring the importance of lesion’s size in deter-
mining the accuracy of MRI measurements.
Interestingly, in a recent work (15), the authors found
that the mean difference in sizing between MRI and
histology was only 2 mm, which corresponded to a
non-significant size overestimation by MRI. Grimsby
et al. (9) found that, among patients with tumor size
overestimated by MRI, 65% had satellite lesions,
DCIS, and/or lymphovascular invasion in tissue sur-
rounding the main tumor. This observation encouraged
us to consider tumors with an extensive intraductal
component (EIC) as a distinct histological group,
according to Berg et al. (10). There is a robust evidence
that two major limitations of breast MRI are a signifi-
cant rate of false positives (16–21), and a trend of over-
estimation of lesion’s size by MRI (8,9). In previous
studies (6,20), lesions with ‘‘non-mass-like’’ enhance-
ment were identified as a challenging subgroup causing
a high proportion of false-positive diagnoses at diag-
nostic breast MRI. To this regard, MR-directed
‘‘second-look’’ US may help in avoiding false positives
and is a useful tool for decision-making as part of the
diagnostic workup. Nevertheless, a successful MRI–
ultrasound correlation is neither easy nor immediate
(22–24). We found that DCIS histology is the strongest
independent predictor of discrepancy between MRI
and pathology sizing of breast tumors, and this may
be due to different factors. DCIS lesions have been
found to exhibit ‘‘non-mass-like’’ enhancement at a
high rate, ranging between 69% and 90% in previous
studies (25–28). Despite the fact that we did not sys-
tematically consider lesion shape and morphology in
our analysis, we can reasonably hypothesize that also
this feature may have contributed to the MRI overesti-
mation of DCIS lesions (Figs 6 and 7). Another plaus-
ible explanation for MRI overestimation may be the
background contrast enhancement of breast

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Mennella et al. 267

Fig. 6. Transverse T1W 3D FLASH subtraction MR image (a) shows a lesion with a largest diameter of 20 mm in the outer quadrants
of the left breast, characterized by ‘‘non-mass-like’’ enhancement. (b) The surgical specimen. (c) The histopathologic section
(hematoxylin and eosin, 10x) reveals a pure DCIS. In the case of this relatively small lesion, MRI–pathology difference was 10 mm,
which corresponded to 50% of the MRI size of the tumor.

Fig. 7. Transverse T1W 3D FLASH subtraction MR image (a) shows a huge lesion with a largest diameter of 105 mm in the outer
quadrants of the right breast, characterized by ‘‘non-mass-like’’ enhancement. (b) The surgical specimen. (c) The histopathologic
section (hematoxylin and eosin, 20x) reveals a pure DCIS. This case was characterized by an important MRI–pathology difference
of 45 mm.

parenchyma adjacent to DCIS foci, which may become
more evident due to benign proliferation (i.e. adenosis,
fibrocystic changes), presence of high-risk lesions (i.e.
atypical ductal hyperplasia), granulation tissue, or foci
of liponecrosis (29).
A limitation of our study is related to the potentially
problematic nature of determining an accurate path-
ology size for DCIS lesions (30). However, the standar-
dized, accurate system of specimen analysis, which is
routinely performed by our pathology service, may
have reduced this source of bias. In addition, the micro-
scopic measurement has been shown to be more accur-
ate than tumor sizing on gross specimens (30).
In conclusion, the results of our study suggest that
DCIS histology is a factor independently and strongly
associated to discordance between MRI and pathology
sizing of breast cancer. Lesion size can also influence
the accuracy of MRI measurements, but to a lesser
extent.
Funding
This research received no specific grant from any
funding agency in the public, commercial, or not-for-profit
sectors.
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