Surgical Science, 2012, 3, 445-451
http://dx.doi.org/10.4236/ss.2012.39088 Published Online September 2012 (http://www.SciRP.org/journal/ss)
Comparison of Biopsy Results and Imaging Methods,
in the Diagnosis of Breast Cancer
Mehmet Ali Eryılmaz1*, Özgür Öner2, Ahmet Okuş1, Ömer Karahan1, Said Bodur3,
Serden Ay1, Seher Civcik4
1General Surgery Clinic, Konya Training and Research Hospital, Konya, Turkey
2Radyology Clinic, Konya Training and Research Hospital, Konya, Turkey
3Department of Public Health, Meram Faculty of Medicine, Selçuk University, Konya, Turkey
4Konya Early Diagnosis of Cancer-Screening and Education Center,
Kanser Erken Teşhis-Tarama ve Eğitim Merkezi (KETEM) , Konya, Turkey
Received July 13, 2012; revised August 14, 2012; accepted September 2, 2012
ABSTRACT
Purpose: In this study, we aimed at comparing the sensitivity and selectivity rates of Ultrasonography (USG), Mamography
(MG) and Magnetic Resonance (MR), based on the biopsy results of breast mass lesions. Materials and Methods:
Between January 2009 and December 2010 in Konya Training and Research Hospital the biopsy results and reports of
imaging tecniques such as USG, MG and MR, were obtained from the hospital automation. The sensitivity and
selectivity of the USG, MG and MR were calculated. Results: The avarage age of the 112 patients included in this
study is 49 ± 10 (23 - 71). 27 (24%) of the patients were found to have breast cancer after the histopathologic
examination. USG was used with the 95 (94%) of the patients and 17 (18%) of the patients were diagnosed to have
cancer. MG was used with the 75 (67%) of the patients and 15 (20%) of the patients were diagnosed to have cancer, and
MR was used with the 112 (100%) of the patients and 25 (22%) of the patients were diagnosed to have cancer. In the
pathologic diagnosis of cancer, the sensitivity of USG was found 85%, the sensitivity of MG was found 89%, and the
sensitivity of MR was found 92%. The selectivity of these tecniques were 58%, 87% and 57% respectively. Conclusion:
MR and MG have similar sensitivity rates in the diagnosis of breast cancer. Breast MR is an appropriate imaging
tecnique that can be used in suitable indications in addition to USG and MG.
Keywords: Breast Cancer; Magnetic Resonance; Mamography; Ultrasonography
1. Introduction
Breast cancer is still at the top of list of morbidity and
mortality besides being one of the most common type of
cancer among women both in the World and in our country
[1]. MG is still the basic method for scanning and the
determining the breast lesions with its 90% sensitivity
rate [2-4]. Some researchs reveal that MG cannot determine
the breast cancer with a 10% - 30% rate [5]. USG is the
first method to be used when mamography is insufficient
with sclerosing breast tissue [6]. USG is more sensitive
with women who are under the age of 40 and who have
dens breast tissue [7]. USG and MG is insufficient in
evaluating the behavioral characteristics of the determined
lesions, determining the focus occurance of the multifocal-
multicentric (mf-mc) pre-breast conserving surgery, diff-
erentiating between the residue lesion and the granulation
tissue and the post treatment monitoring and in such
situations MR examination is required to solve the problem
in routine applicaitons [2,8,9]. With the use of contrast
agent in MR, it is easier to differentiate between the belign
and malign lesions.
Procedures that are suitable to age or the characteristics
of the mass and efficient examinations increases the dete-
rmination rate of the cancer, whereas redundant tests and
procedures decreases this rate [10].
This research aims at comparing the sensitivity and
selectivity rates USG, MG and MR based on the biosy
results of the breast mass lesions.
2. Materials and Methods
2.1. Patients
The files that belong to the patients who consulted to Konya
Training and Research Hospital with a breast complaint
and were applied breast MR were studied retrocpectively.
It was determined that, every patient that consulted to
*Corresponding author.
C
opyright © 2012 SciRes. SS

M. A. ERYILMAZ ET AL.
446
General Surgery Clinic with a breast complaint was first
applied Clinical Breast Examination (CBE). After that,
bilaretal Breast USG examination was done to patients
under the age of 40 and bilateral MG examination was
done to patients over the age of 40. USG and MG reports
were arranged according to BIRADS classification. Breast
MR was done to patients who were found to have
BIRADS-0, BIRADS 4 and 5 in USG and MG, who has
a breast cancer history in the family and dense breast
tissue. Moreover, MR was done to patients who were
diagnosed to have breast cancer and planned to be applied
breast concerving surgery, in order to determine the mul-
ticentric-multifocal focuses and evaluate the pectoral phaisa
or breast-wall invasion.
Breast MR was also done to patients who have lesions
suspected to have breast cancer defined as BIRADS-3 in
USG and MG in order to define the characteristics of the
lesion, in the cases which were found to be suspected in
the CBE but no tumors were deifned mamographically
and sonographically and the patients who were found to
have structural distortion in the mamographies but not in
sonographies.
BIRADS classification was used to define the lesions
found the breast MR. Tru-cut biopsy with USG was applied
to patients whose breast lesions were suspected to be
BIRADS-4 or 5 in at least one of USG, MG and MR.
The patients who were suspected to have microcalcifica-
tions suspected to malign in MG were send to an epicenter
to be applied steraotaxic marked biopsy and those patients
were not included in the study.
2.2. Breast Ultrasonography (USG)
USG examination was applied to the patients in the supine
position with Siemens Antares device and lineer prob
with a 5 - 15 MHz wide frequency. BIRADS classification
was used defining the lesions found in the USG.
2.3. Mammography (MG)
Mammographical examination was done to both breasts
in two standard positions (MLO and CC). Visions acquired
using Cintek Glory MG device were transformed into
digital visions using Agfa CR85-X CR(computerized radi-
ology) system. BIRADS classification was used defining
the lesions determined in the MG.
2.4. Breast Magnetic Resonance (MR)
Examination
Breast MR was done after the USG and/or MG examina-
tions with the request of radiologist or general surgery
specialist. In the cases that are not urgent, MR examina-
tions were done in the 2nd week of the menstrual cycle.
Dynamic enhanced Breast MR examination were done
in prone position using 1.5 Tesla Siemens Avanto MR
device and 4 channel breast coil. After the localizer visions
were acquired, T1-weighted spin eco fat supressed free
coronal sequence (TR: 313, TE: 4.5, FOV 350 mm, Matrix
256 × 230, Section Thickness 3 mm), T2-weighted fast
spin eco fat supressed free axial sequence (TR:9710, TE:
190, FOV: 350 mm, Matrix 384 × 288, Section Thick-
ness 3 mm), T2-weighted TRIM axial sequence sekans
(TR: 2770, TE: 68, FOV: 350 mm, Matrix 320 × 272,
Section Thickness 3 mm) and T1-weighted 3D gradient
eco dynamic sequnece in the axial plan (TR: 4.43, TE:
1.35, FOV: 330 mm, Matrix 448 × 313, Section Thickness
1 mm) were acquired. In the dynamic examination, un-
enhanced fat supressed free T1-weighted base vision was
acquired first. Then, 0.1 mmol gadolinium-DTPA/kg was
given as intravenous and enhanced sequence was re-
peated 5 times consequetively. Substraction visions were
acquired excluding the base visions from the enhanced
visions. Signaltime curve was formed using the substrac-
tion visions. The breast masses were evaluated taking
their morphological and contrast agent involvement cha-
racteristics into consideration. The lesions smaller than 5
mm were evaluated as focus, whereas lesions bigger than 5
mm were evaluated as mass lesion. The shape of the mass
(round, oval, lobular or irregular), the contours of the mass
(smooth, irregular, spicule) and contrast involvment cha-
racteristics of the mass (homogenous, heterogenous, an-
nular or central) were used evaluating the lesion. Evaluat-
ing the non-massive contrast involvment zones, disper-
sion (focal, multifocal, lineer, ductal, segmental or dif-
fuse), contrast involvement characteristics (homogenous,
heterogenous, punctual, nodular interreptus or reticular)
and either they are symmetrical or not were taken into con-
sideration. In the kinetic evaluation, contrasting rate (slow,
medium or fast), and contrasting pattern (increasing in
due course, forming plateaus or forming swift contrast loss)
were used acquiring time-signal curve. Defining the lesions
determined in MR, BIRADS classification was used.
2.5. Biopsy Procedure
For pathological examination, at least 3 pieces of sample
were taken with a full-automatic tru-cut needle with the
angled-prob of the USG, from the patients whose mass
lesions were found to be BIRADS 4 - 5 in the USG, MG
and MR. These were sent to pathology laboratory in the
10% formol with the material biopsy container.
All the USG, MG and MR monitoring reports and
pathology results of all the patients were acquired from
the hospital automation. The sensitivity and selectivity of
USG, MG and MR examinations of these patients in the
pathological diagnosis were computed.

M. A. ERYILMAZ ET AL.
447
2.6. Statistics
Sensitivity, Specifitiy, Positive Predictive value, Negative
Predictive value, Total Truth values were used. P value
was calculated using SPSS (SPSS Inc.16 2009, Chicago,
IL, USA) statistics software. P < 0.05 was accepted as
significant.
3. Results
The avarage age of the 112 patients included in this study
is 49 ± 10 (23 - 71). In the histopathological examinations
of the biopsies taken with the suspect of cancer, 27 (24%)
of the patients were found to have breast cancer. 21 (77%)
of these have invasive ductal carcinoma (Table 1). USG
was applied to 95 (94%) of the patients and 17 (18%) of
these were found to have cancer. MG was applied to 75
(67%) of the patients and 15 (20%) of these were found to
have cancer. MR was applied to 112 (100%) of the patients
and 25 (22%) of these were found to have cancer. The sen-
sitivity of the USG is 85%, MG is 94% and MR is 92%
in the pathological cancer diagnosis. The selectivity rates
of these respectively are; 58%, 83% and 57% (Table 2).
USG examination was done to 95 (94%) of the 112
patients. MR was done to 2 breasts defined as BIRADS-0
additionally, evaluated as BIRADS-4 and the biopsy results
showed that these were benign. MR was applied and
biopsy was taken from 46 (41%) of the breasts defined as
BIRADS-4 and 5 additionally and 16 (14%) of these were
found to have cancer (Table 3).
MG was done to 75 (67%) of the 112 patients. MR
was done to 48 (42%) of the patients who were evaluated
as BIRADS-0 additionally. 19 (40%) of these were
evaluated as BIRADS-4 and 9 (18%) of them were
evaluated as BIRADS-5 in the MR and biopsies were
taken from these patients (Figure 1). 10 (21%) of these
patients were found to have cancer (Table 3).
Both MG and USG was done to a single patient and
evaluated as BIRADS-5 in USG and BIRADS-2 in MG.
The same patient was evaluated as BIRADS-2 in MR and
with the biopsy, she was diagnosed to have cancer. 1 (4%)
of the 27 cancer diagnoses were reached at the correct
diagnosis in the USG evaluation.
MR was done to 5 patients additionally who were
evaluated as BIRADS-4 in MG and 3 of these were
evaluated as BIRADS-2 (Figure 2). Biopsy was taken
from these patients as MG results were suspected to be
malign, however the result was benign. The other 2 of
these were evaluated as BIRADS-5 in MR and biopsy
was taken from these patients and these patients were
diagnosed to have cancer. With the cases diagnosed as
BIRADS-4 in MG, Breast MR examination was found to
be significant in diagnosing the cancer (P < 0.05).
MR was done to 3 patients who were defined as
BIRADS-5 in MG, in order to examine the occurance of
multifocal-multicentric lesions and 2 breasts were evaluated
as BIRADS-5 and unifocal cancer was diagnosed after
the biopsy an done of these patients were found to have
multifocality and with the biopsy, she was diagnosed to
have multifocal cancer.
Breast MR was applied to 112 patients. Biopsy was taken
from 38 breasts that were evaluated as BIRADS-4 and 5
of these were diagnosed to have breast cancer. Biopsy
was taken from the 23 breasts evaluated as BIRADS-5
and 20 of these breasts were diagnosed to have cancer.
Two breasts were defined as benign with MR and with
the biopsy these were evaluated as cancer. Two of these
cancers were determined with only USG and the other
was determined with MG (ductal carcinoma insitu) (Table
4). After the breast reduction surgery, two breasts were
evaluated as BIRADS-5 with USG and as BIRADS-0
with MG. The MR results of these patients were evaluated
as BIRADS-2 and the biopsy results were reported as
benign.
4. Discussion
Breast Cancer is one of the most important reasons of the
deaths of cancer among women [11]. To decrase the death
rate of the breast cancer, it is important to diagnose at an
Table 1. Histopathological distribution of the breast cancers.
Histopathology N (number) %
Invasive ductal carcinoma 21 77.8
Invasive ductal carcinoma + Invasive
lobular carcinoma 3 11.1
Invasive lobular carcinoma 1 3.7
Medullar carcinoma 1 3.7
DCIS 1 3.7
Total 27 100.0
Table 2. The sensitivity and selectivity rates of the monitoring methods in the diagnosis of breast cancer.
İmaging methods Sensitivity (%) Specifity (%) Positive predictive value (%)Negative predictive value (%) Truth value (%)
USG 85.0 58.3 36.2 93.3 64.1
MG 94.4 83.3 85.0 93.8 88.9
MR 92.6 56.8 41.7 95.8 65.7

M. A. ERYILMAZ ET AL.
448
Table 3. Consistency of the BIRADS classification with the diagnosis of breast cancer.
BIRADS-0 BIRADS-1-2-3 BIRADS-4 BIRADS-5
İmaging
methods
Number
(n) Ca %
Number
(n) Ca %
Number
(n) Ca %
Number
(n) Ca %
USG 2 0 0.0 47 3 6.9 34 4 11.7 12 10 83.3
MG 48 10 20.8 19 2 10.5 5 2 40.0 3 3 100.0
MR 0 0 0.0 51 2 3.8 38 5 13.2 23 20 87.0
Figure 1. Glandular tissues and suspicious nodular opacities that cannot be qualified as net superimposition are present in
mammography of left breast subareolar area. In the US and MR examination, 21 × 19 mm sized mass lesion with a malign
outlook in the left breast lower quadrant and numerous nodular lesions smaller than 5 mm than can be compliant with satellite
lesions in the left breast were detected.
Figure 2. 2 cm diameters of asymmetric density is observed in the CC graphy outer quadrant of left breast in the mammography.
With the MR, no pathologies but a couple of millimetric cysts were observed. With the US, the result of the biopsy got from the
heterogenous area which cannot be lined off precisely in the periareolar area of left breast revealed situ carcinoma (2nd degree).

M. A. ERYILMAZ ET AL.
449
Table 4. The number of the lesions that were found to have
cancer with biopsy but cannot be monitored with monitoring
methods (n = 27).
İmaging methods n %
USG 3 11.1
MG 2 7.4
MR 2 7.4
USG + MG 2 7.4
MG + MR 1 3.7
USG + MR 1 3.7
USG + MG + MR 0 0.0
early stage and correctly. Mammography is a monitoring
method that decreases the death rate of the breast cancer
[12]. Death rate of the breast cancer from the age of 40
has decreased at a 31% rate with the breast cancer scanning
with mammography [13]. It is adviced for every woman
to have a CBE with mammography once a year [14,15].
Mammography has a high sensitivity rate in routine scans
and patients with breast symptoms. The use of mammo-
graphy with USG increases the sensitivity rate and changes
the follow-up procedures [16]. None of the methods has
the adequate sensitivity, specifity and diagnostically corre-
ctness rate in the diagnosis of the breast lesions. Therefore,
it is not true to use one single method in the diagnosis of
the breast lesions and combining a couple of methods
together increases the diagnostical correctness rate. In
this study, diagnosing the patients suspected to have
cancer in the anamnesis and physical examinations, when
at one of CBE, USG, MG and MR methods indicated the
occurance of cancer, biopsy was applied with USG.
About 20% of the breast cancers are observed under
the age of 40, whereas 30% of these are observed under
the age of 50. To minimise the number of the redundant
tests, the age and the characteristics of the breasts should
be taken into consideration. Because of the dense charac-
teristics of the breast tissue, not MG but USG is more
significant with the women patients under age of 40. MG
is more significant with the women over the age of 40
and it is suggested to be applied once a year [10,12]. In
this study, 18% of the patients diagnosed to have cancer
are under the age of 40 and the 33% of these are under
the age 50.
Diagnostical MG has a 89% rate sensitivity in the
determining the breast cancer and the masses that can be
felt with hand is normal in the 9% - 20% of the breast
cancers [10]. In this study, a mass lesion that can be felt
with hand was found in 1 (4%) of the patients. However,
this mass lesion could not be determined with neither
MG nor MR and could be realised only with USG and
diagnosed to have cancer with biopsy.
Breast MR can functionally demonstrate the breast
parencyma and the mass perfusion characteristics of the
mass lesions at this base besides the morphological char-
acteristics of the breast lesions such as; shape, contour
and size [17]. In this research, radiological modalities such
as Breast USG and MG were evaluated with CBE findings
and additionally, in cases of BIRADS-3, BIRADS-4 and
BIRADS-5, Breast MR was applied with the view of a
radiologist and/or general surgery specialist. According
to the MR results applied to 48 (42%) of the patients
defined as BIRADS-0 with MG, 10 (21%) of the patients
were diagnosed to have breast cancer. With this finding,
MR is claimed to be a problem solving method in cases
in which MG is restricted in defining (Table 3).
MR has become a commonly used monitoring method
in differentiating between benign and malign in breast
lesions. It has the highest specifity and sensitivity rate
among the monitoring methods. It is indisputebly a useful
method, especially in the cases where other monitoring
methods are insufficient in providing required information.
MR is definitely superior to other methods in determining
the occurance of multifocal-multicentric cancer, with pat-
ients who need breast conserving surgery and evaluating
scar tissue that occur after surgery [18,19]. In this research,
multifocality occurance was determined with MR in a
patient who was found to have BIRADS-5 single focus
with MG and mastectomy was applied to this patient.
USG defined BIRADS-5 lesions in two patients who had
a breast reduction surgery and MG defined the lesions of
these patients as BIRADS-0 and MR defined these as
BIRADS-2 and the biopsy results were evaluated as benign.
According to the guidelines published by American
Cancer Association in 2007, MR applied in addition to
mammography can determine the high rish breast cancer
at early stages, especially in cases in which MG has low
sensitivity [20]. Breast MR is the most sensitive method
in determining the breast cancer. Especially the conven-
tional monitoring methods cannot easily differentiate
between malign and benign cases. In such cases Breast
MR is used as the problem solving method. Cases that
are suspected to be malign and classified as BIRADS 3
and 4 with USG and MG can be diagnosed with MR with
a high sensitivity [21,22]. In the invasive breast tumors,
MR can give the size closest to the pathological size [23].
In this research Breast MR was done to 5 patients who
were defined as BIRADS-4 with MG, and two of them
were defined to have BIRADS-5 and the biopsy results
revealed breast cancer and three of the patients were
found to have BIRADS-2, 3 in Breast MR. The biopsies
of these three patients were found to be benign.
Breast MR has a high sensitivity rate (83% - 100%),
but the specifitiy rate of it is low (23% - 80%). MR
should be used, when USG and MG are inefficient in
defining the breast mass lesions [24]. As the specifity
rate of MR is low, biopsy procedures to be carried as the
result of MR will not always be sufficient in diagnosing

M. A. ERYILMAZ ET AL.
450
the cancer. In this research, 35 (31%) of the patients, to
who biopsy was done because MR defined them as
BIRADS-4 and BIRADS-5, were examined hispatholo-
gically and the results were benign.
Breast MR is inefficient in defining the breast insitu
cancers and suspicious lesions under 3 mms (14). In this
research, breast insitu cancer could not be defined with
MR in one of the patients and it was defined with MG.
One of the patients was defined as BIRADS-5 with USG
and the cancer found in the biopsy was not determined in
MR (Table 4).
Cor biopsy is a more widely used method in breast
cancer diagnosis. It has many advantages such as; acquiring
adequate tissue sample, diagnosing fast, allowing receptor
use and being cheaper than the open biopsy. The imple-
mentation of the procedure accompanied with USG decr-
eases the false negativity rate to 0.2%. This application
allows breast conserving surgery and sentinel lymph node
mapping while open biopsy doesn’t, because the lympha-
tics remain unharmed [25,26]. In this research, all the
112 biopsies were done accompanied with USG and 27
(24%) of the patients were diagnosd to have cancer. All
of these patients were surgically operated.
5. Conclusion
USG and MR are prominent monitoring methods evalua-
ting the breast diseases. Breast MR is a monitoring method
that can be used in addition to USG and MG in suitable
indications. Breast MR has a sensitivity rate close to MG.
It is a problem solving method with cases of BIRADS-0
and BIRADS-4 breast lesions, where MG is inefficient.
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