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Table 1 Semantic criteria of predictive/prognostic breast MRI

From: The potential of predictive and prognostic breast MRI (P2-bMRI)




Pathophysiological correlate

Predictive/prognostic value




Amount of fibroglandular tissue


Visual (American College of Radiology classes from a to d) or automated

Fibroglandular tissue, stromal matrix, dense connective tissue, collagen, elastin, lobules, and ducts

One of the strongest independent biomarkers of breast cancer incidence. The prognostic value is proven only for mammography. Similar effect for MRI is expected

Relative risk (%: amount of fibroglandular tissue on mammograms) for the four classes: a) 1.79 (< 25%)

b) 2.11 (25–50%)

c) 2.92 (50–75%)

d) 4.64 (> 75%)


Background of parenchymal enhancement


Visual (1st dynamic scan) or automated

Tissue perfusion due to hormonal stimulation and proliferative activity

For high-risk women, positive correlation with BC incidence. No association among women with average risk

High risk and at least mild background parenchymal enhancement: odds ratio 2.1


Adjacent vessel sign





Presence of adjacent vessel sign indicates invasive cancer. It is less common in DCIS

Invasive cancer or DCIS? DOR 2.7; specificity 72.6%

[50, 51]

Destruction of nipple line


Visual (Fig. 8)

Invasion of the nipple-areola complex

“Destruction of nipple line” is associated with nodal-positive breast cancer

Is this cancer likely to show lymph node metastasis? DOR 2.5; specificity 88.5%

[52, 53]



Visual (Fig. 6)





Changes in the tumour habitat

Cytokine effects

Vessel permeability

Lymphovascular dissemination

Pitfalls: double check with patient history; renal, cardiac origin (possible bilateral diffuse oedema of non-neoplastic origin); treatment-related (surgery, radiation therapy)

Presence of “diffuse unilateral oedema” is a strong predictor of nodal-positive and high-grade breast cancer

Is this cancer likely to show lymph node metastasis? Specificity 94.9%; DOR2.6

Is this cancer high grade (G3) or not (G1 or G2)?

Specificity 95.5%; DOR 2.4

[39, 52, 54,55,56,57]

Perifocal oedema is also an independent predictor of disease recurrence

Is this patient likely to develop disease recurrence? Hazard ratio 2.48

Lesion type


Visual according to breast imaging reporting and Data system descriptors: mass, non-mass, or “mixed” (mass and non-mass)


Cancers revealing both mass and non-mass enhancement (“mixed”) are more often associated with lymphovascular invasion (compared to mass or non-mass)

Is this cancer associated with lymphovascular invasion? DOR 2.4; specificity 82.7%


Cancers revealing mass-like enhancement are more likely to be HER2-positive (compared to non-mass and mixed)

Is this cancer HER2-positive? DOR 2.7; specificity 85.7%

Non-mass invasive ductal cancers are more likely to be low grade (compared to mass and mixed)

Is this invasive ductal cancer low grade (G1) or not (G2 or G3)? DOR 9.3; specificity 85.3%


Necrosis sign


Visual: hypointense lesion with hyperintense centre

Central colliquative (liquid) necrosis

Presence of necrosis sign indicates high-grade invasive cancers

Is this cancer high grade (G3) or not (G1 or G2)?

Specificity 94.3%; DOR 3.7


Skin thickening

Unenhanced T1WI


Subcutaneous tumour spread, inflammatory tumour

Presence of skin thickening indicates high-grade invasive cancers. It is less common in G1 and G2 cancers

Presence of skin thickening is also a strong predictor of lymph node metastasis

Is this cancer likely to show lymph node metastasis? DOR 5.9; specificity 94.5%

[52, 53]

Rim sign



High microvessel density in the peripheral zone of the vital tumour. Connective tissues, fibrosis, and/or necrosis at central part of the tumour centre

Presence of rim sign is associated with an increased risk of lymph node metastasis and high-grade cancer

Is this cancer likely to show lymph node metastasis? DOR 2.7; specificity 57.1%

Is this cancer high grade (G3) or not (G1 or G2)?

DOR 6.1; specificity 57.5%


Signal intensity


Visual (Fig. 7): compared to unaffected breast gland parenchyma: hypointense, isointense, or hyperintense

Water content of the lesion

Hyperintensity on T2WI is associated with elevated Ki-67 and increased cellular proliferation

Is this cancer likely to show high (Ki-67 ≥ 14%) or low proliferative activity (Ki-67 < 14)? DOR 2.2; specificity 59.8%




Visual, region of interest, or computer-assisted



Arteriovenous shunts (anarchic vascularisation)

A high washout rate (> 40%) is associated with an increased risk of metachronous metastasis

Is this patient likely to develop metachronous metastasis? Sensitivity 100%; negative predictive value 100%

[63, 64]

  1. Values reported in the “statistics” column express the probability of a certain outcome (e.g., “nodal metastasis present”), when the given MRI criterion is present (e.g., “washout present”, “mass lesion present”) derive from the referenced literature
  2. DCE Dynamic contrast-enhanced study, DOR Diagnostic odds ratio, HER2 Human epidermal growth factor receptor 2, T1WI T1-weighted imaging, T2WI T2-weighted imaging