Diffusion weighted imaging for improving the diagnostic performance of screening breast MRI: impact of apparent diffusion coefficient quantitation methods and cutoffs

Abstract

Introduction: Diffusion weighted MRI (DWI) has emerged as a promising adjunct to reduce unnecessary biopsies prompted by breast MRI through use of apparent diffusion coefficient (ADC) measures. The purpose of this study was to investigate the effects of different lesion ADC measurement approaches and ADC cutoffs on the diagnostic performance of breast DWI in a high-risk MRI screening cohort to identify the optimal approach for clinical incorporation.

Methods: Consecutive screening breast MRI examinations (August 2014-Dec 2018) that prompted a biopsy for a suspicious breast lesion (BI-RADS 4 or 5) were retrospectively evaluated. On DWI, ADC (b=0/100/600/800s/mm²) measures were calculated with three different techniques for defining lesion region-of-interest (ROI; single slice('2D'), whole volume('3D') and lowest ADC region('hotspot')). An optimal data-derived ADC cutoff for each technique was retrospectively identified to reduce benign biopsies while avoiding any false negatives, inherently producing cutoffs with 100% sensitivity in this particular cohort. Further, diagnostic performance of these measures was validated using two prespecified ADC cutoffs: 1.53x10^-3mm²/s from the ECOG-ACRIN A6702 trial and 1.30x10^-3mm²/s from the international EUSOBI group. Diagnostic performance was compared between ADC maps generated with 2(0/800s/mm²) and 4(0/100/600/800s/mm²) b-values. Benign biopsy reduction rate was calculated (number of benign lesions with ADC >cutoff)/(total number of benign lesions).

Results: 137 suspicious lesions (in 121 women, median age 44 years [range, 20-75yrs]) were detected on contrast-enhanced screening breast MRI and recommended for biopsy. Of those, 30(21.9%) were malignant and 107(78.1%) were benign. Hotspot ADC measures were significantly lower (p<0.001) than ADCs from both 2D and 3D ROI techniques. Applying the optimal data-derived ADC cutoffs resulted in comparable reduction in benign biopsies across ROI techniques (range:16.8% -17.8%). Applying the prespecified A6702 and EUSOBI cutoffs resulted in benign biopsy reduction rates of 11.2-19.6%(with 90.0-100% sensitivity) and 36.4-51.4%(with 70.0-83.3% sensitivity), respectively, across ROI techniques. ADC measures and benign biopsy reduction rates were similar when calculated with only 2 b-values (0,800 s/mm²) versus all 4 b-values.

Discussion: Our findings demonstrate that with appropriate ADC thresholds, comparable reduction in benign biopsies can be achieved using lesion ADC measurements computed from a variety of approaches. Choice of ADC cutoff depends on ROI approach and preferred performance tradeoffs (biopsy reduction vs sensitivity).

Keywords: ADC cutoff; apparent diffusion coefficient (ADC); breast magnetic resonance imaging (MRI); diagnostic performance; diffusion weighted imaging (DWI); false positives; region-of-interest (ROI).