Diagnostic Accuracy of Mammography, Clinical Examination, US, and MR Imaging in Preoperative Assessment of Breast Cancer

PURPOSE: To prospectively assess accuracy of mammography, clinical examination, ultrasonography (US), and magnetic resonance (MR) imaging in preoperative assessment of local extent of breast cancer.

MATERIALS AND METHODS: Institutional review board approval and informed patient consent were obtained. Results of bilateral mammography, US, and contrast-enhanced MR imaging were analyzed from 111 consecutive women with known or suspected invasive breast cancer. Results were correlated with histopathologic findings.

RESULTS: Analysis included 177 malignant foci in 121 cancerous breasts, of which 89 (50%) foci were palpable. Median size of 139 invasive foci was 18 mm (range, 2–107 mm). Mammographic sensitivity decreased from 100% in fatty breasts to 45% in extremely dense breasts. Mammographic sensitivity was highest for invasive ductal carcinoma (IDC) in 89 of 110 (81%) cases versus 10 of 29 (34%) cases of invasive lobular carcinoma (ILC) (P < .001) and 21 of 38 (55%) cases of ductal carcinoma in situ (DCIS) (P < .01). US showed higher sensitivity than did mammography for IDC, depicting 104 of 110 (94%) cases, and for ILC, depicting 25 of 29 (86%) cases (P < .01 for each). US showed higher sensitivity for invasive cancer than DCIS (18 of 38 [47%], P < .001). MR showed higher sensitivity than did mammography for all tumor types (P < .01) and higher sensitivity than did US for DCIS (P < .001), depicting 105 of 110 (95%) cases of IDC, 28 of 29 (96%) cases of ILC, and 34 of 38 (89%) cases of DCIS. In anticipation of conservation or no surgery after mammography and clinical examination in 96 breasts, additional tumor (which altered surgical approach) was present in 30. Additional tumor was depicted in 17 of 96 (18%) breasts at US and in 29 of 96 (30%) at MR, though extent was now overestimated in 12 of 96 (12%) at US and 20 of 96 (21%) at MR imaging. After combined mammography, clinical examination, and US, MR depicted additional tumor in another 12 of 96 (12%) breasts and led to overestimation of extent in another six (6%); US showed no detection benefit after MR imaging. Bilateral cancer was present in 10 of 111 (9%) patients; contralateral tumor was depicted mammographically in six and with both US and MR in an additional three. One contralateral cancer was demonstrated only clinically.

CONCLUSION: In nonfatty breasts, US and MR imaging were more sensitive than mammography for invasive cancer, but both MR imaging and US involved risk of overestimation of tumor extent. Combined mammography, clinical examination, and MR imaging were more sensitive than any other individual test or combination of tests.

© RSNA, 2004


  • 1 Burhenne HJ, Burhenne LW, Goldberg F, et al. Interval breast cancers in the Screening Mammography Program of British Columbia: analysis and classification. AJR Am J Roentgenol 1994; 162:1067-1071; discussion, 1072–1075.
  • 2 Robertson CL. A private breast imaging practice: medical audit of 25,788 screening and 1,077 diagnostic examinations. Radiology 1993; 187:75-79.
  • 3 Kerlikowske K, Grady D, Barclay J, Sickles EA, Ernster V. Effect of age, breast density, and family history on the sensitivity of first screening mammography. JAMA 1996; 276:33-38.
  • 4 Mandelson MT, Oestreicher N, Porter PL, et al. Breast density as a predictor of mammographic detection: comparison of interval- and screen-detected cancers. J Natl Cancer Inst 2000; 92:1081-1087.
  • 5 Kolb TM, Lichy J, Newhouse JH. Comparison of the performance of screening mammography, physical examination, and breast US and evaluation of factors that influence them: an analysis of 27,825 patient evaluations. Radiology 2002; 225:165-175.
  • 6 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.
  • 7 Orel SG, Schnall MD, Powell CM, et al. Staging of suspected breast cancer: effect of MR imaging and MR-guided biopsy. Radiology 1995; 196:115-122.
  • 8 Liberman L, Morris EA, Dershaw DD, Abramson AF, Tan LK. MR imaging of the ipsilateral breast in women with percutaneously proven breast cancer. AJR Am J Roentgenol 2003; 180:901-910.
  • 9 Berg WA, Gilbreath PL. Multicentric and multifocal cancer: whole-breast US in preoperative evaluation. Radiology 2000; 214:59-66.
  • 10 Moon WK, Noh DY, Im JG. Multifocal, multicentric, and contralateral breast cancers: bilateral whole-breast US in the preoperative evaluation of patients. Radiology 2002; 224:569-576.
  • 11 Fischer U, Kopka L, Grabbe E. Breast carcinoma: effect of preoperative contrast-enhanced MR imaging on the therapeutic approach. Radiology 1999; 213:881-888.
  • 12 Hlawatsch A, Teifke A, Schmidt M, Thelen M. Preoperative assessment of breast cancer: sonography versus MR imaging. AJR Am J Roentgenol 2002; 179:1493-1501.
  • 13 Fischer U, Kopka L, Brinck U, Korabiowska M, Schauer A, Grabbe E. Prognostic value of contrast-enhanced MR mammography in patients with breast cancer. Eur Radiol 1997; 7:1002-1005.
  • 14 American College of Radiology. Breast imaging reporting and data system 3rd ed. Reston, Va: American College of Radiology, 1998.
  • 15 Nunes LW, Schnall MD, Orel SG, et al. Correlation of lesion appearance and histologic findings for the nodes of a breast MR imaging interpretation model. RadioGraphics 1999; 19:79-92.
  • 16 Kuhl CK, Mielcareck P, Klaschik S, et al. Dynamic breast MR imaging: are signal intensity time course data useful for differential diagnosis of enhancing lesions? Radiology 1999; 211:101-110.
  • 17 Berg WA, Jaeger B, Campassi C, Kumar D. Predictive value of specimen radiography for core needle biopsy of noncalcified breast masses. AJR Am J Roentgenol 1998; 171:1671-1678.
  • 18 Kopans DB. Clip placement during sonographically guided breast biopsy. AJR Am J Roentgenol 2001; 176:1076-1077.
  • 19 Egan RL. Multicentric breast carcinomas: clinical-radiographic-pathologic whole organ studies and 10-year survival. Cancer 1982; 49:1123-1130.
  • 20 Ellis IO, Pinder SE, Lee AH, Elston CW. A critical appraisal of existing classification systems of epithelial hyperplasia and in situ neoplasia of the breast with proposals for future methods of categorization: where are we going? Semin Diagn Pathol 1999; 16:202-208.
  • 21 Schnitt SJ, Connolly JL, Harris JR, Hellman S, Cohen RB. Pathologic predictors of early local recurrence in stage I and II breast cancer treated by primary radiation therapy. Cancer 1984; 53:1049- 1057.
  • 22 Connolly JL, Boyages J, Nixon AJ, et al. Predictors of breast recurrence after conservative surgery and radiation therapy for invasive breast cancer. Mod Pathol 1998; 11:134-139.
  • 23 Ikeda DM, Baker DR, Daniel BL. Magnetic resonance imaging of breast cancer: clinical indications and breast MRI reporting system. J Magn Reson Imaging 2000; 12:975-983.
  • 24 Mendelson EB, Berg WA, Merritt CR. Toward a standardized breast ultrasound lexicon, BI-RADS: ultrasound. Semin Roentgenol 2001; 36:217-225.
  • 25 Fisher ER, Sass R, Fisher B. Pathologic findings from the National Surgical Adjuvant Project for Breast Cancers (protocol no 4). X. Discriminants for tenth year treatment failure. Cancer 1984; 53(suppl 3):712-723.
  • 26 Nagao Y, Kawaguchi Y, Sugiyama Y, Saji S, Kashiki Y. Relationship between mammographic density and the risk of breast cancer in Japanese women: a case-control study. Breast Cancer 2003; 10:228-233.
  • 27 Ursin G, Ma H, Wu AH, et al. Mammographic density and breast cancer in three ethnic groups. Cancer Epidemiol Biomarkers Prev 2003; 12:332-338.
  • 28 Berg WA. Rationale for a trial of screening breast ultrasound: American College of Radiology Imaging Network (ACRIN) 6666. AJR Am J Roentgenol 2003; 180:1225-1228.
  • 29 Stomper PC, D’Souza DJ, DiNitto PA, Arredondo MA. Analysis of parenchymal density on mammograms in 1353 women 25–79 years old. AJR Am J Roentgenol 1996; 167:1261-1265.
  • 30 Carney PA, Miglioretti DL, Yankaskas BC, et al. Individual and combined effects of age, breast density, and hormone replacement therapy use on the accuracy of screening mammography. Ann Intern Med 2003; 138:168-175.
  • 31 Wazer DE, Schmidt-Ullrich RK, Ruthazer R, et al. The influence of age and extensive intraductal component histology upon breast lumpectomy margin assessment as a predictor of residual tumor. Int J Radiat Oncol Biol Phys 1999; 45:885-891.
  • 32 Bartelink H, Horiot JC, Poortmans P. Recurrence rates after treatment of breast cancer with standard radiotherapy with or without additional radiation. N Engl J Med 2001; 345:1378-1387.
  • 33 Hilleren DJ, Andersson IT, Lindholm K, Linnell FS. Invasive lobular carcinoma: mammographic findings in a 10-year experience. Radiology 1991; 178:149-154.
  • 34 Butler RS, Venta LA, Wiley EL, Ellis RL, Dempsey PJ, Rubin E. Sonographic evaluation of infiltrating lobular carcinoma. AJR Am J Roentgenol 1999; 172:325-330.
  • 35 Houssami N, Irwig L, Simpson JM, McKessar M, Blome S, Noakes J. Sydney Breast Imaging Accuracy Study: comparative sensitivity and specificity of mammography and sonography in young women with symptoms. AJR Am J Roentgenol 2003; 180:935-940.
  • 36 Moy L, Slanetz PJ, Moore R, et al. Specificity of mammography and US in the evaluation of a palpable abnormality: retrospective review. Radiology 2002; 225:176-181.
  • 37 Heywang-Köbrunner SH, Bick U, Bradley WG, Jr, et al. International investigation of breast MRI: results of a multicentre study (11 sites) concerning diagnostic parameters for contrast-enhanced MRI based on 519 histopathologically correlated lesions. Eur Radiol 2001; 11:531-546.
  • 38 Ikeda DM, Andersson I. Ductal carcinoma in situ: atypical mammographic appearances. Radiology 1989; 172:661-666.
  • 39 Dershaw DD, Abramson A, Kinne DW. Ductal carcinoma in situ: mammographic findings and clinical implications. Radiology 1989; 170:411-415.
  • 40 Stomper PC, Margolin FR. Ductal carcinoma in situ: the mammographer’s perspective. AJR Am J Roentgenol 1994; 162:585-591.
  • 41 Yang WT, Tse GM. Sonographic, mammographic, and histopathologic correlation of symptomatic ductal carcinoma in situ. AJR Am J Roentgenol 2004; 182:101-110.
  • 42 Soo MS, Baker JA, Rosen EL. Sonographic detection and sonographically guided biopsy of breast microcalcifications. AJR Am J Roentgenol 2003; 180:941-948.
  • 43 Soderstrom CE, Harms SE, Farrell RS, Jr, Pruneda JM, Flamig DP. Detection with MR imaging of residual tumor in the breast soon after surgery. AJR Am J Roentgenol 1997; 168:485-488.
  • 44 Orel SG, Reynolds C, Schnall MD, Solin LJ, Fraker DL, Sullivan DC. Breast carcinoma: MR imaging before re-excisional biopsy. Radiology 1997; 205:429-436.
  • 45 Hungness ES, Safa M, Shaughnessy EA, et al. Bilateral synchronous breast cancer: mode of detection and comparison of histologic features between the 2 breasts. Surgery 2000; 128:702-707.
  • 46 Broet P, de la Rochefordiere A, Scholl SM, et al. Contralateral breast cancer: annual incidence and risk parameters. J Clin Oncol 1995; 13:1578-1583.
  • 47 Healey EA, Cook EF, Orav EJ, Schnitt SJ, Connolly JL, Harris JR. Contralateral breast cancer: clinical characteristics and impact on prognosis. J Clin Oncol 1993; 11:1545-1552.
  • 48 Rieber A, Merkle E, Bohm W, Brambs HJ, Tomczak R. MRI of histologically confirmed mammary carcinoma: clinical relevance of diagnostic procedures for detection of multifocal or contralateral secondary carcinoma. J Comput Assist Tomogr 1997; 21:773-779.
  • 49 Liberman L, Morris EA, Kim CM, et al. MR imaging findings in the contralateral breast of women with recently diagnosed breast cancer. AJR Am J Roentgenol 2003; 180:333-341.
  • 50 Lee SG, Orel SG, Woo IJ, et al. MR imaging screening of the contralateral breast in patients with newly diagnosed breast cancer: preliminary results. Radiology 2003; 226:773-778.
  • 51 Mai KT, Yazdi HM, Ford JC, Matzinger FR. Predictive value of extent and grade of ductal carcinoma in situ in radiologically guided core biopsy for the status of margins in lumpectomy specimens. Eur J Surg Oncol 2000; 26:646-651.
  • 52 Rodenko GN, Harms SE, Pruneda JM, et al. MR imaging in the management before surgery of lobular carcinoma of the breast: correlation with pathology. AJR Am J Roentgenol 1996; 167:1415-1419.
  • 53 Weinstein SP, Orel SG, Heller R, et al. MR imaging of the breast in patients with invasive lobular carcinoma. AJR Am J Roentgenol 2001; 176:399-406.
  • 54 Fisher ER, Fisher B, Sass R, Wickerham L. Pathologic findings from the National Surgical Adjuvant Breast Project (Protocol No 4). XI. Bilateral breast cancer. Cancer 1984; 54:3002-3011.
  • 55 Dawson PJ. What is new in our understanding of multifocal breast cancer. Pathol Res Pract 1993; 189:111-116.
  • 56 Fisher ER, Anderson S, Tan-Chiu E, Fisher B, Eaton L, Wolmark N. Fifteen-year prognostic discriminants for invasive breast carcinoma. Cancer 2001; 91:1679-1687.
  • 57 Li CI, Anderson BO, Daling JR, Moe RE. Trends in incidence rates of invasive lobular and ductal breast carcinoma. JAMA 2003; 289:1421-1424.
  • 58 Fisher B, Dignam J, Wolmark N, et al. Lumpectomy and radiation therapy for the treatment of intraductal breast cancer: findings from National Surgical Adjuvant Breast and Bowel Project B-17. J Clin Oncol 1998; 16:441-452.
  • 59 Kurtz JM, Spitalier JM, Amalric R, et al. The prognostic significance of late local recurrence after breast-conserving therapy. Int J Radiat Oncol Biol Phys 1990; 18:87-93.
  • 60 La Trenta LR, Menell JH, Morris EA, Dershaw DD, Abramson AF, Liberman L. Histopathologic significance of sonographic identification of MRI-detected breast lesions (abstr). Radiology 2001; 221(P):232.
  • 61 Liberman L, Morris EA, Dershaw DD, Thornton CM, Van Zee KJ, Tan LK. Fast MRI-guided vacuum-assisted breast biopsy: initial experience. AJR Am J Roentgenol 2003; 181:1283-1293.
  • 62 Brown J, Smith RC, Lee CH. Incidental enhancing lesions found on MR imaging of the breast. AJR Am J Roentgenol 2001; 176:1249-1254.
  • 63 Teifke A, Lehr HA, Vomweg TW, Hlawatsch A, Thelen M. Outcome analysis and rational management of enhancing lesions incidentally detected on contrast-enhanced MRI of the breast. AJR Am J Roentgenol 2003; 181:655-662.
  • 64 Kuhl CK, Simon B, Sondermann E, Leutner CC, Shamsi K, Schild HH. Ultra-high resolution breast MR imaging using intravascular contrast agent (Gadomer17) (abstr). Radiology 2002; 225(P):652.
  • 65 Liberman L, Morris EA, Benton CL, Abramson AF, Dershaw DD. Probably benign lesions at breast magnetic resonance imaging: preliminary experience in high-risk women. Cancer 2003; 98:377-388.
  • 66 Krishnamurthy S, Sneige N, Bedi DG, et al. Role of ultrasound-guided fine-needle aspiration of indeterminate and suspicious axillary lymph nodes in the initial staging of breast carcinoma. Cancer 2002; 95:982-988.

Article History

Published in print: Dec 2004