Does size matter? Positive predictive value of MRI-detected breast lesions as a function of lesion size

The purpose of this study was to determine the impact of lesion size on the positive predictive value (PPV) of biopsy in MRI-detected breast lesions.

A retrospective review was performed of 666 consecutive nonpalpable, mammographically occult lesions that had MRI-guided localization. MRI examinations were performed using a 1.5-T magnet. Lesions were measured by the interpreting radiologist before biopsy. Malignancy rate versus lesion size was determined.

The median MRI lesion size was 1 cm (range, 0.3-7.0 cm). Malignancy was present in 149/666 (22%) lesions, of which 80 (54%) were ductal carcinoma in situ (DCIS), 66 (44%) were invasive cancer, and three (2%) were lymphoma. The frequency of malignancy increased significantly (p = 0.0005) with lesion size, with malignancy found in one (3%) of 37 lesions less than 5 mm, 44 (17%) of 254 lesions 5-9 mm, 37 (25%) of 151 lesions 10-14 mm, 21 (28%) of 74 lesions 15-19 mm, and 46 (31%) of 150 lesions 20 mm or larger. Lesions less than 5 mm accounted for 37 (6%) of 666 lesions that had a biopsy and one (< 1%) of 149 cancers (one DCIS). Among lesions less than 10 mm, the likelihood of malignancy was highest in postmenopausal women (22% malignant) and in the extent of disease setting (22% malignant), and lowest in premenopausal women (10% malignant) and in the high-risk screening setting (10% malignant).

The PPV of biopsy for lesions identified at breast MRI using a 1.5-T magnet significantly increased with increasing lesion size. Biopsy is rarely necessary for lesions smaller than 5 mm because of their low (3%) likelihood of cancer. Further work is needed to develop an algorithm that uses size in addition to other patient and lesion factors to guide biopsy recommendations for MRI-detected breast lesions.