Grading System to Categorize Breast MRI in BI-RADS 5th Edition: A Multivariate Study of Breast Mass Descriptors in Terms of Probability of Malignancy

The purpose of this study is to analyze the association between the probability of malignancy and breast mass descriptors in the BI-RADS 5th edition and to devise criteria for grading mass lesions, including subcategorization of category 4 lesions with or without apparent diffusion coefficient (ADC) values. A total of 519 breast masses in 499 patients were selected. Breast MRI was performed with a 1.5-T MRI scanner using a 16-channel dedicated breast radiofrequency coil. Two radiologists determined the morphologic and kinetic features of the breast masses. Mean ADC values were measured on ADC maps by placing round ROIs that encircled the largest possible solid mass portions. An optimal ADC threshold was chosen to maximize the Youden index. Corresponding pathologic diagnoses were obtained by either biopsy or surgery. A total of 472 masses were malignant. Multivariate model analysis showed that shape (irregular, p < 0.001), margin type (not circumscribed, p < 0.001), internal enhancement (rim enhancement and heterogeneous enhancement, p = 0.0001), and delayed phase (washout, p = 0.0003) were the significant explanatory variables. The 3-point scoring system for findings suspicious for malignancy and the proposed classification system for breast mass descriptors (with points for category designation ranging from 0 to > 4) were significant with respect to malignancy (p < 0.01). The inclusion of ADC values improved the positive predictive values for categories 3, 4A, and 4B. The 3-point scoring system for findings suspicious for malignancy and the proposed classification system for breast mass descriptors would be valid as a categorization system. ADC values may be used to downgrade benign lesions in categories 3, 4A, and 4B.