Double reading of diffusion-weighted magnetic resonance imaging for breast cancer detection



To estimate the performance of diffusion-weighted imaging (DWI) for breast cancer detection.


Consecutive breast magnetic resonance imaging examinations performed from January to September 2016 were retrospectively evaluated. Examinations performed before/after neoadjuvant therapy, lacking DWI sequences or reference standard were excluded; breasts after mastectomy were also excluded. Two experienced breast radiologists (R1, R2) independently evaluated only DWI. Final pathology or > 1-year follow-up served as reference standard. Mc Nemar, χ2, and κ statistics were applied.


Of 1,131 examinations, 672 (59.4%) lacked DWI sequence, 41 (3.6%) had no reference standard, 30 (2.7%) were performed before/after neoadjuvant therapy, and 10 (0.9%) had undergone bilateral mastectomy. Thus, 378 women aged 49 ± 11 years (mean ± standard deviation) were included, 51 (13%) with unilateral mastectomy, totaling 705 breasts. Per-breast cancer prevalence was 96/705 (13.6%). Per-breast sensitivity was 83/96 (87%, 95% confidence interval 78–93%) for both R1 and R2, 89/96 (93%, 86–97%) for double reading (DR) (p = 0.031); per-lesion DR sensitivity for cancers ≤ 10 mm was 22/31 (71%, 52–86%). Per-breast specificity was 562/609 (93%, 90–94%) for R1, 538/609 (88%, 86–91%) for R2, and 526/609 (86%¸ 83–89%) for DR (p < 0.001). Inter-observer agreement was substantial (κ = 0.736). Acquisition time varied from 3:00 to 6:22 min:s. Per-patient median interpretation time was 46 s (R1) and 51 s (R2).


DR DWI showed a 93% sensitivity and 88% specificity, with 71% sensitivity for cancers ≤ 10 mm, pointing out a potential for DWI as stand-alone screening method.

This is a preview of subscription content, log in to check access.

Access options

Buy single article

Instant unlimited access to the full article PDF.

US$ 39.95

Price includes VAT for USA

Subscribe to journal

Immediate online access to all issues from 2019. Subscription will auto renew annually.

US$ 199

This is the net price. Taxes to be calculated in checkout.

Fig. 1
Fig. 2
Fig. 3
Fig. 4


  1. 1.

    Zhang L, Tang M, Min Z, Lu J, Lei X, Zhang X (2016) Accuracy of combined dynamic contrast-enhanced magnetic resonance imaging and diffusion-weighted imaging for breast cancer detection: a meta-analysis. Acta Radiol 57:651–660.

  2. 2.

    Saslow D, Boetes C, Burke W et al (2007) American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin 57:75–89

  3. 3.

    Sardanelli F, Boetes C, Borisch B et al (2010) Magnetic resonance imaging of the breast: recommendations from the EUSOMA working group. Eur J Cancer 46:1296–1316.

  4. 4.

    Lee CH, Dershaw DD, Kopans D et al (2010) Breast cancer screening with imaging: recommendations from the Society of Breast Imaging and the ACR on the use of mammography, breast MRI, breast ultrasound, and other technologies for the detection of clinically occult breast cancer. J Am Coll Radiol 7:18–27.

  5. 5.

    Melnikow J, Fenton JJ, Whitlock EP et al (2016) Supplemental screening for breast cancer in women with dense breasts: a systematic review for the U.S. preventive services task force. Ann Intern Med 164:268–278.

  6. 6.

    Houssami N, Turner RM (2016) Rapid review: estimates of incremental breast cancer detection from tomosynthesis (3D-mammography) screening in women with dense breasts. Breast 30:141–145.

  7. 7.

    Monticciolo DL, Newell MS, Moy L et al (2018) Breast cancer screening in women at higher-than-average risk: recommendations from the ACR. J Am Coll Radiol 15(3 Pt A):408–414.

  8. 8.

    Kuhl CK, Schrading S, Strobel K et al (2014) Abbreviated breast magnetic resonance imaging (MRI): first postcontrast subtracted images and maximum-intensity projection—a novel approach to breast cancer screening with MRI. J Clin Oncol 32:2304–2310.

  9. 9.

    Grimm LJ, Soo MS, Yoon S et al (2015) Abbreviated screening protocol for breast MRI: a feasibility study. Acad Radiol 22:1157–1162.

  10. 10.

    Ko ES, Morris EA (2019) Abbreviated magnetic resonance imaging for breast cancer screening: concept, early results, and considerations. Korean J Radiol 20:533–541.

  11. 11.

    Mahoney MC, Newell MS (2013) Screening MR imaging versus screening ultrasound: pros and cons. Magn Reson Imaging Clin N Am 21:495–508.

  12. 12.

    Costa AF, van der Pol CB, Maralani PJ et al (2018) Gadolinium deposition in the brain: a systematic review of existing guidelines and policy statement issued by the Canadian Association of Radiologists. Can Assoc Radiol J 69:373–382.

  13. 13.

    Gulani V, Calamante F, Shellock FG, Kanal E, Reeder SB (2017) Gadolinium deposition in the brain: summary of evidence and recommendations. Lancet Neurol 16:564–570.

  14. 14.

    European Medicines Agency (2017) Human medicines. Gadolinium-containing contrast agents. Accessed 8 Aug 2019

  15. 15.

    U.S. Food and Drug Administration (2017). Medical imaging drug advisory committee. Accessed 8 Aug 2019

  16. 16.

    Le Bihan D, Breton E, Lallemand D, Grenier P, Cabanis E, Laval-Jeantet M (1986) MR imaging of intravoxel incoherent motions: application to diffusion and perfusion in neurologic disorders. Radiology 161:401–407.

  17. 17.

    Chen X, Li WL, Zhang YL, Wu Q, Guo YM, Bai ZL (2010) Meta-analysis of quantitative diffusion-weighted MR imaging in the differential diagnosis of breast lesions. BMC Cancer 10:693.

  18. 18.

    Dorrius MD, Dijkstra H, Oudkerk M, Sijens PE (2014) Effect of b value and pre-admission of contrast on diagnostic accuracy of 1.5-T breast DWI: a systematic review and meta-analysis. Eur Radiol 24:2835–2847.

  19. 19.

    Sardanelli F, Carbonaro LA, Montemezzi S, Cavedon C, Trimboli RM (2016) Clinical breast MR using MRS or DWI: who is the winner? Front Oncol 6:217.

  20. 20.

    Clauser P, Mann R, Athanasiou A et al (2018) A survey by the European Society of Breast Imaging on the utilisation of breast MRI in clinical practice. Eur Radiol 28:1909–1918.

  21. 21.

    Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33:159–174

  22. 22.

    Shi RY, Yao QY, Wu LM, Xu JR (2018) Breast lesions: diagnosis using diffusion weighted imaging at 1.5T and 3.0T—systematic review and meta-analysis. Clin Breast Cancer 18:e305–e320.

  23. 23.

    Bickelhaupt S, Laun FB, Tesdorff J et al (2016) Fast and noninvasive characterization of suspicious lesions detected at breast cancer X-ray screening: capability of diffusion-weighted MR imaging with MIPs. Radiology 278:689–697.

  24. 24.

    Yabuuchi H, Matsuo Y, Sunami S et al (2011) Detection of non-palpable breast cancer in asymptomatic women by using unenhanced diffusion-weighted and T2-weighted MR imaging: comparison with mammography and dynamic contrast-enhanced MR imaging. Eur Radiol 21:11–17.

  25. 25.

    Wu LM, Chen J, Hu J, Gu HY, Xu JR, Hua J (2014) Diffusion-weighted magnetic resonance imaging combined with T2-weighted images in the detection of small breast cancer: a single-center multi-observer study. Acta Radiol 55:24–31.

  26. 26.

    Trimboli RM, VerardiN CF et al (2014) Breast cancer detection using double reading of unenhanced MRI including T1-weighted, T2-weighted STIR, and diffusion-weighted imaging: a proof of concept study. AJR Am J Roentgenol 203:674–681.

  27. 27.

    Baltzer PAT, Bickel H, Spick C et al (2018) Potential of noncontrast magnetic resonance imaging with diffusion-weighted imaging in characterization of breast lesions: intraindividual comparison with dynamic contrast-enhanced magnetic resonance imaging. Invest Radiol 53:229–235.

  28. 28.

    Harvey SC, Geller B, Oppenheimer RG et al (2003) Increase in cancer detection and recall rates with independent double interpretation of screening mammography. AJR Am J Roentgenol 180:1461–1467

  29. 29.

    Pisano ED, Gatsonis C, Hendrick E et al (2005) Diagnostic performance of digital versus film mammography for breast-cancer screening. N Engl J Med 353:1773–1783.

  30. 30.

    Moss SM, Wale C, Smith R et al (2015) Effect of mammographic screening from age 40 years on breast cancer mortality in the UK age trial at 17 years’ follow-up: a randomised controlled trial. Lancet Oncol 16:1123–1132.

  31. 31.

    Törnberg S, Kemetli L, Ascunce N et al (2010) A pooled analysis of interval cancer rates in six European countries. Eur J Cancer Prev 19:87–93.

  32. 32.

    Kuhl CK, Schrading S, Bieling HB et al (2007) MRI for diagnosis of pure ductal carcinoma in situ: a prospective observational study. Lancet 370:485–492.

  33. 33.

    Rahbar H, Partridge SC, Eby PR et al (2011) Characterization of ductal carcinoma in situ on diffusion weighted breast MRI. Eur Radiol 21:2011–2019.

  34. 34.

    Ding JR, Wang DN, Pan JL (2016) Apparent diffusion coefficient value of diffusion-weighted imaging for differential diagnosis of ductal carcinoma in situ and infiltrating ductal carcinoma. J Cancer Res Ther 12:744–750.

  35. 35.

    Imamura T, Isomoto I, Sueyoshi E et al (2010) Diagnostic performance of ADC for non-mass-like breast lesions on MR imaging. Magn Reson Med Sci 9:217–225.

  36. 36.

    Baltzer PA, Renz DM, Herrmann KH et al (2009) Diffusion-weighted imaging (DWI) in MR mammography (MRM): clinical comparison of echo planar imaging (EPI) and half-Fourier single-shot turbo spin echo (HASTE) diffusion techniques. Eur Radiol 19:1612–1620.

  37. 37.

    Tao WJ, Zhang HX, Zhang LM et al (2019) Combined application of pharmacokinetic DCE-MRI and IVIM-DWI could improve detection efficiency in early diagnosis of ductal carcinoma in situ. J Appl Clin Med Phys 20:142–150.

  38. 38.

    Surov A, Meyer HJ, Wienke A (2017) Correlation between apparent diffusion coefficient (ADC) and cellularity is different in several tumors: a meta-analysis. Oncotarget 8:59492–59499.

  39. 39.

    McDonald ES, Hammersley JA, Chou SH et al (2016) Performance of DWI as a rapid unenhanced technique for detecting mammographically occult breast cancer in elevated-risk women with dense breasts. AJR Am J Roentgenol 207:205–216.

  40. 40.

    Lauby-Secretan B, Scoccianti C, Loomis D et al (2015) Breast-cancer screening—viewpoint of the IARC Working Group. N Engl J Med 372:2353–2358.

  41. 41.

    Hendrick RE (2018) Obligate overdiagnosis due to mammographic screening: a direct estimate for U.S. women. Radiology 287:391–397.

  42. 42.

    Sardanelli F, Trimboli RM, Tot T (2018) Expert review of breast pathology in borderline lesions: a chance to reduce overdiagnosis and overtreatment? JAMA Oncol 4:1325–1326.

  43. 43.

    Iacconi C, Galman L, Zheng J et al (2016) Multicentric cancer detected at breast MR imaging and not at mammography: important or not? Radiology 279:378–384.

  44. 44.

    Bick U, Engel C, Krug B et al (2019) High-risk breast cancer surveillance with MRI: 10-year experience from the German consortium for hereditary breast and ovarian cancer. Breast Cancer Res Treat 175:217–228.

  45. 45.

    Leach MO, Boggis CR, Dixon AK et al (2005) Screening with magnetic resonance imaging and mammography of a UK population at high familial risk of breast cancer: a prospective multicentre cohort study (MARIBS). Lancet 365:1769–1778.

  46. 46.

    Kuhl C, Weigel S, Schrading S et al (2010) Prospective multicenter cohort study to refine management recommendations for women at elevated familial risk of breast cancer: the EVA trial. J Clin Oncol 28:1450–1457.

  47. 47.

    Sardanelli F, Podo F, Santoro F et al (2011) Multicenter surveillance of women at high genetic breast cancer risk using mammography, ultrasonography, and contrast-enhanced magnetic resonance imaging (the high breast cancer risk Italian 1 study): final results. Invest Radiol 46:94–105.

  48. 48.

    Evans DG, Kesavan N, Lim Y et al (2014) MRI breast screening in high-risk women: cancer detection and survival analysis. Breast Cancer Res Treat 145:663–672.

  49. 49.

    Saadatmand S, Obdeijn IM, Rutgers EJ et al (2015) Survival benefit in women with BRCA1 mutation or familial risk in the MRI screening study (MRISC). Int J Cancer 137:1729–1738.

  50. 50.

    Podo F, Santoro F, Di Leo G et al (2016) Triple-negative versus non-triple-negative breast cancers in high-risk women: phenotype features and survival from the HIBCRIT-1 MRI-including screening study. Clin Cancer Res 22:895–904.

  51. 51.

    Hunt CH, Hartman RP, Hesley GK (2009) Frequency and severity of adverse effects of iodinated and gadolinium contrast materials: retrospective review of 456,930 doses. AJR Am J Roentgenol 193:1124–1127.

  52. 52.

    Wisner DJ, Rogers N, Deshpande VS et al (2014) High-resolution diffusion-weighted imaging for the separation of benign from malignant BI-RADS 4/5 lesions found on breast MRI at 3T. J Magn Reson Imaging 40:674–681.

  53. 53.

    Barentsz MW, Taviani V, Chang JM et al (2015) Assessment of tumor morphology on diffusion-weighted (DWI) breast MRI: diagnostic value of reduced field of view DWI. J Magn Reson Imaging 42:1656–1665.

  54. 54.

    Baltzer PAT (2019) DWI, spectroscopy and other advanced breast MR techniques. Eur Congr Radiol 201910(Suppl 1):22.

  55. 55.

    Torre LA, Siegel RL, Ward EM et al (2016) Global cancer incidence and mortality rates and trends—an update. Cancer Epidemiol Biomarkers Prev 25:16–27.

  56. 56.

    Amornsiripanitch N, Bickelhaupt S, Shin HJ et al (2019) Diffusion-weighted MRI for unenhanced breast cancer screening. Radiology 293:504–520.

Download references

Author information

Correspondence to Anna Rotili.

Ethics declarations

Conflict of interest

A.R, R.M.T, S.P, F.P., P.T., and E.C. declare that they have no conflict of interest. F.S. has received grants from and is member of speakers’ bureau/advisory board for Bayer, Bracco, and General Electric companies.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee.

Informed consent

Informed consent was waived from all individual participants included in the study.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Rotili, A., Trimboli, R.M., Penco, S. et al. Double reading of diffusion-weighted magnetic resonance imaging for breast cancer detection. Breast Cancer Res Treat (2020).

Download citation


  • Breast neoplasms
  • Diffusion magnetic resonance imaging
  • Early detection of cancer
  • Observer variation
  • Sensitivity and specificity