How to manage type 2 curve dilemma in dynamic contrast-enhanced magnetic resonance imaging of the breast: diffusion-weighted imaging or early phase enhancement kinetics?

Background: Type 2 time-intensity curves can indicate both malignant and benign breast lesions in dynamic contrast enhanced magnetic resonance imaging (DCE-MRI).Purpose: To investigate whether diffusion-weighted imaging (DWI) or early phase kinetics of DCE-MRI is practical to discriminate breast masses that depict type 2 curve in DCE-MRI.Material and methods: We retrospectively included 107 lesions in 97 patients with type 2 curves in DCE-MRI. Morphological characteristics, early phase dynamic parameters on DCE-MRI, and apparent diffusion coefficient (ADC) values on DWI were evaluated. Diagnostic thresholds of ADC and early phase maximum enhancement ratio (EPMER) to distinguish between benign and malignant masses were calculated. Strongest predictors of malignancy were determined to build the most effective diagnostic model.Results: DWI, EPMER, and all morphological features were found statistically significant to discriminate malignancy (P <0.05). The thresholds of ADC and EPMER were assigned as 1.0 x10(-3) mm(2)/s and 72%, respectively. The sensitivity and specificity were 80% and 97% for ADC, and 93% and 60% for EPMER, respectively. Two models were established. Model 1 comprised ADC and the lesion margin. Model 2 consisted of ADC, margin, and EPMER with a high specificity (99%) and positive predictive value (97%).Conclusion: When combined with DWI, early phase wash-in data provide diagnostic improvement of breast masses presenting type 2 curve in the late phase of DCE-MRI, especially for specificity. Future studies are required to support our findings for the need of a cross-validation.