{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T19:44:58Z","timestamp":1790797498610,"version":"4.1.0"},"reference-count":27,"publisher":"Springer Science and Business Media LLC","issue":"5","license":[{"start":{"date-parts":[[2023,11,7]],"date-time":"2023-11-07T00:00:00Z","timestamp":1699315200000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2023,11,7]],"date-time":"2023-11-07T00:00:00Z","timestamp":1699315200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"DOI":"10.13039\/501100008252","name":"Universit\u00e0 degli Studi di Udine","doi-asserted-by":"crossref","id":[{"id":"10.13039\/501100008252","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Eur Radiol"],"abstract":"<jats:title>Abstract<\/jats:title><jats:sec>\n                <jats:title>Objectives<\/jats:title>\n                <jats:p>To investigate whether using the diffusion levels (DLs) proposed by the European Society of Breast Imaging (EUSOBI) improves the diagnostic accuracy of breast MRI.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Materials and methods<\/jats:title>\n                <jats:p>This retrospective study included 145 women who, between September 2019 and June 2020, underwent breast 1.5-T MRI with DWI. Reader 1 and reader 2 (R1-R2) independently assessed breast lesions using the BI-RADS on dynamic contrast-enhanced imaging and T2-weighted imaging. DWI was subsequently disclosed, allowing readers able to measure lesions ADC and subjectively express the overall risk of malignancy on a 1\u20135 Likert scale. ADCs were interpreted as a range of values corresponding to the EUSOBI DLs. The analysis evaluated the inter-reader agreement in measuring ADC and DLs, the per-DL malignancy rate, and accuracy for malignancy using ROC analysis against histological examination or a 3-year follow-up.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Results<\/jats:title>\n                <jats:p>Lesions were malignant and showed non-mass enhancement in 67.7% and 76.1% of cases, respectively. ADC was measurable in 63.2%\/66.7% of lesions (R1\/R2), with a minimal discrepancy on Bland\u2013Altman analysis and 0.948 (95%CI 0.925\u20130.965)\/0.989 (95%CI 0.988\u20130.991) intraclass correlation coefficient in measuring ADC\/DLs. The malignancy rate (R1\/R2) increased from 0.5\/0.5% (\u201cvery high\u201d DL) to 96.0\/96.8% (\u201cvery low\u201d DL), as expected. Likert categorization showed larger areas under the curve than the BI-RADS for both R1 (0.91 versus 0.87; <jats:italic>p<\/jats:italic>\u2009=\u20090.0208) and R2 (0.91 versus 0.89; <jats:italic>p<\/jats:italic>\u2009=\u20090.1171), with improved specificity (81.5% versus 78.5% for R1 and 84.4% versus 81.2% for R2).<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Conclusion<\/jats:title>\n                <jats:p>Though ADC was not measurable in about one-third of lesions, DLs were categorized with excellent inter-reader agreement, improving the specificity for malignancy.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Clinical relevance statement<\/jats:title>\n                <jats:p>DLs proposed by the EUSOBI are a reproducible tool to interpret the ADC of breast lesions and, in turn, to improve the specificity of breast MRI and reduce unnecessary breast biopsies.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Key Points<\/jats:title>\n                <jats:p><jats:italic>\u2022 The European Society of Breast Imaging proposed diffusion levels for the interpretation of the apparent diffusion coefficient in diffusion-weighted imaging of the breast.<\/jats:italic><\/jats:p>\n                <jats:p><jats:italic>\u2022 Adding diffusion levels to the interpretation of magnetic resonance imaging improved the diagnostic accuracy for breast cancer, especially in terms of specificity.<\/jats:italic><\/jats:p>\n                <jats:p><jats:italic>\u2022 Diffusion levels can favor a more widespread and standardized use of diffusion-weighted imaging of the breast.<\/jats:italic><\/jats:p>\n              <\/jats:sec>","DOI":"10.1007\/s00330-023-10418-4","type":"journal-article","created":{"date-parts":[[2023,11,7]],"date-time":"2023-11-07T03:02:01Z","timestamp":1699326121000},"page":"3352-3363","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":3,"title":["Added value of the EUSOBI diffusion levels in breast MRI"],"prefix":"10.1007","volume":"34","author":[{"given":"Chiara","family":"Zuiani","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Iris","family":"Mansutti","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Guido","family":"Caronia","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anna","family":"Linda","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Viviana","family":"Londero","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0904-5147","authenticated-orcid":false,"given":"Rossano","family":"Girometti","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2023,11,7]]},"reference":[{"key":"10418_CR1","doi-asserted-by":"publisher","first-page":"377","DOI":"10.1002\/jmri.26654","volume":"50","author":"RM Mann","year":"2019","unstructured":"Mann RM, Kuhl CK, Moy L (2019) Contrast-enhanced MRI for breast cancer screening. J Magn Reson Imaging 50:377\u2013390","journal-title":"J Magn Reson Imaging"},{"key":"10418_CR2","doi-asserted-by":"publisher","first-page":"632","DOI":"10.1148\/radiol.2019182510","volume":"291","author":"GC Baxter","year":"2019","unstructured":"Baxter GC, Graves MJ, Gilbert FJ, Patterson AJ (2019) A metaanalysis of the diagnostic performance of difusion MRI for breast lesion characterization. Radiology 291:632\u2013641","journal-title":"Radiology"},{"key":"10418_CR3","doi-asserted-by":"publisher","first-page":"693","DOI":"10.1186\/1471-2407-10-693","volume":"10","author":"X Chen","year":"2010","unstructured":"Chen X, Li W-l, Zhang Y-l, Wu Q, Guo Y-m, Bai Z-l (2010) Metaanalysis of quantitative difusion-weighted MR imaging in the diferential diagnosis of breast lesions. BMC Cancer 10:693\u2013693","journal-title":"BMC Cancer"},{"key":"10418_CR4","doi-asserted-by":"publisher","first-page":"60","DOI":"10.1148\/radiol.2020202465","volume":"298","author":"ES McDonald","year":"2021","unstructured":"McDonald ES, Romanof J, Rahbar H et al (2021) Mean apparent difusion coefcient is a sufcient conventional difusion-weighted MRI metric to improve breast MRI diagnostic performance: results from the ECOG-ACRIN Cancer Research Group A6702 Difusion Imaging Trial. Radiology 298:60\u201370","journal-title":"Radiology"},{"key":"10418_CR5","doi-asserted-by":"publisher","first-page":"6588","DOI":"10.1007\/s00330-022-08833-0","volume":"32","author":"R Lo Gullo","year":"2022","unstructured":"Lo Gullo R, Sevilimedu S, Baltzer P et al (2022) A survey by the European Society of Breast Imaging on the implementation of breast diffusion-weighted imaging in clinical practice. Eur Radiol 32:6588\u20136597","journal-title":"Eur Radiol"},{"key":"10418_CR6","unstructured":"D\u2019Orsi CJ SE, Mendelson EB, Morris EA et\u00a0al (2013) ACR BI-RADS\u00ae atlas, breast imaging reporting and data system. American College of Radiology, Reston, VA"},{"key":"10418_CR7","doi-asserted-by":"publisher","first-page":"1436","DOI":"10.1007\/s00330-019-06510-3","volume":"30","author":"P Baltzer","year":"2020","unstructured":"Baltzer P, Mann RM, Iima M et al (2020) Diffusion-weighted imaging of the breast \u2013 a consensus and mission statement from the EUSOBI International Breast Diffusion-Weighted Imaging working group. Eur Radiol 30:1436\u20131450","journal-title":"Eur Radiol"},{"key":"10418_CR8","doi-asserted-by":"publisher","first-page":"70","DOI":"10.1002\/jmri.26908","volume":"52","author":"M Iima","year":"2020","unstructured":"Iima M, Honda M, Sigmund EE et al (2020) Diffusion MRI of the breast: current status and future directions. J Magn Reson Imaging 52:70\u201390","journal-title":"J Magn Reson Imaging"},{"key":"10418_CR9","doi-asserted-by":"publisher","first-page":"5398","DOI":"10.1007\/s00330-023-09752-4","volume":"33","author":"M Honda","year":"2023","unstructured":"Honda M, Iima M (2023) Is the breast ADC category system a useful addition to BI-RADS? Eur Radiol 33:5398\u20135399","journal-title":"Eur Radiol"},{"key":"10418_CR10","doi-asserted-by":"publisher","first-page":"e305","DOI":"10.1016\/j.clbc.2017.06.011","volume":"18","author":"R Shi","year":"2018","unstructured":"Shi R, Yao Q, Wu L, Xu J (2018) Breast lesions: diagnosis using diffusion weighted imaging at 1.5T and 3.0T-systematic review and meta-analysis. Clin Breast Cancer 18:e305\u2013e320","journal-title":"Clin Breast Cancer"},{"key":"10418_CR11","doi-asserted-by":"publisher","first-page":"5400","DOI":"10.1007\/s00330-023-09675-0","volume":"33","author":"H Bickel","year":"2023","unstructured":"Bickel H, Clauser P, Pinker K et al (2023) Introduction of a breast apparent difusion coefcient category system (ADC-B) derived from a large multicenter MRI database. Eur Radiol 33:5400\u20135410","journal-title":"Eur Radiol"},{"key":"10418_CR12","doi-asserted-by":"publisher","first-page":"1909","DOI":"10.1007\/s00330-017-5121-4","volume":"28","author":"P Clauser","year":"2018","unstructured":"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\u20131918","journal-title":"Eur Radiol"},{"key":"10418_CR13","unstructured":"Fitzgibbons PL, Connolly JL, Bose S, et al (2020) Protocol for the examination of resection specimens from patients with invasive carcinoma of the breast. College of American Pathologists (CAP). https:\/\/documents.cap.org\/protocols\/cp-breast-invasive-resection-20-4400.pdf (Last Access August 30, 2023)"},{"key":"10418_CR14","unstructured":"Fitzgibbons PL, Connolly JL, Edgerton M, Simpson R (2020) Protocol for the examination of biopsy specimens from patients with invasive carcinoma of the breast. College of American Pathologists (CAP). https:\/\/documents.cap.org\/protocols\/cp-breast-invasive-biopsy-20-1100.pdf (Last Access August 30, 2023)"},{"key":"10418_CR15","doi-asserted-by":"publisher","first-page":"e012799","DOI":"10.1136\/bmjopen-2016-012799","volume":"6","author":"JF Cohen","year":"2016","unstructured":"Cohen JF, Korevaar DA, Altman DG et al (2016) STARD 2015 guidelines for reporting diagnostic accuracy studies: explanation and elaboration. BMJ Open 6:e012799","journal-title":"BMJ Open"},{"key":"10418_CR16","doi-asserted-by":"publisher","first-page":"284","DOI":"10.1037\/1040-3590.6.4.284","volume":"6","author":"DV Cicchetti","year":"1994","unstructured":"Cicchetti DV (1994) Guidelines criteria, and rules of thumb for evaluating normed and standardized assessment instruments in psychology. Psychol Assess 6:284\u2013290","journal-title":"Psychol Assess"},{"key":"10418_CR17","doi-asserted-by":"publisher","first-page":"410","DOI":"10.1016\/j.diii.2023.05.001","volume":"104","author":"L Saccenti","year":"2023","unstructured":"Saccenti L, de Margerie Mellon C, Scholer M et al (2023) Combining b2500 diffusion-weighted imaging with BI-RADS improves the specificity of breast MRI. Diagn Interv Imaging 104:410\u2013418","journal-title":"Diagn Interv Imaging"},{"key":"10418_CR18","doi-asserted-by":"crossref","unstructured":"Meng L, Zhao X, Guo J et al (2023) Improved differential diagnosis based on BI-RADS descriptors and apparent diffusion coefficient for breast lesions: a multiparametric MRI analysis as compared to Kaiser score. Acad Radiol 30(Suppl 2):S93\u2013S103","DOI":"10.1016\/j.acra.2023.03.035"},{"key":"10418_CR19","doi-asserted-by":"publisher","first-page":"84","DOI":"10.1148\/radiol.2019181780","volume":"292","author":"M Goto","year":"2019","unstructured":"Goto M, Le Bihan D, Yoshida M, Sakai K, Yamada K (2019) Adding a model-free diffusion MRI marker to BI-RADS assessment improves specificity for diagnosing breast lesions. Radiology 292:84\u201393","journal-title":"Radiology"},{"key":"10418_CR20","doi-asserted-by":"publisher","first-page":"1756","DOI":"10.1158\/1078-0432.CCR-18-2967","volume":"25","author":"H Rahbar","year":"2019","unstructured":"Rahbar H, Zhang Z, Chenevert TL et al (2019) Utility of diffusion-weighted imaging to decrease unnecessary biopsies prompted by breast MRI: a trial of the ECOG-ACRIN Cancer Research Group (A6702). Clin Cancer Res 25:1756\u20131765","journal-title":"Clin Cancer Res"},{"key":"10418_CR21","doi-asserted-by":"publisher","first-page":"95","DOI":"10.1097\/RLI.0000000000000104","volume":"50","author":"H Bickel","year":"2015","unstructured":"Bickel H, Pinker-Domenig K, Bogner W et al (2015) Quantitative apparent diffusion coefficient as a noninvasive imaging biomarker for the differentiation of invasive breast cancer and ductal carcinoma in situ. Invest Radiol 50:95\u2013100","journal-title":"Invest Radiol"},{"key":"10418_CR22","doi-asserted-by":"publisher","first-page":"618","DOI":"10.1148\/radiol.2018180273","volume":"289","author":"SC Partridge","year":"2018","unstructured":"Partridge SC, Zhang Z, Newitt DC et al (2018) Diffusion-weighted MRI findings predict pathologic response in neoadjuvant treatment of breast cancer: the ACRIN 6698 Multicenter Trial. Radiology 289:618\u2013627","journal-title":"Radiology"},{"key":"10418_CR23","doi-asserted-by":"publisher","first-page":"340","DOI":"10.1016\/j.eururo.2019.02.033","volume":"76","author":"B Turkbey","year":"2019","unstructured":"Turkbey B, Rosenkrantz AB, Haider MA et al (2019) Prostate imaging reporting and data system version 2.1: 2019 update of prostate imaging reporting and data system version 2. Eur Urol 76:340\u2013351","journal-title":"Eur Urol"},{"key":"10418_CR24","doi-asserted-by":"publisher","first-page":"1664","DOI":"10.2214\/AJR.09.3534","volume":"194","author":"SC Partridge","year":"2010","unstructured":"Partridge SC, Mullins CD, Kurland BF et al (2010) Apparent diffusion coefficient values for discriminating benign and malignant breast MRI leisons: effects of lesion type and size. AJR Am J Roentgenol 194:1664\u20131673","journal-title":"AJR Am J Roentgenol"},{"key":"10418_CR25","doi-asserted-by":"publisher","first-page":"2011","DOI":"10.1007\/s00330-011-2140-4","volume":"21","author":"H Rahbar","year":"2011","unstructured":"Rahbar H, Partridge SC, Eby PE et al (2011) Characterization of ductal carcinoma in situ on diffusion weighted breast MRI. Eur Radiol 21:2011\u20132019","journal-title":"Eur Radiol"},{"key":"10418_CR26","doi-asserted-by":"publisher","first-page":"364","DOI":"10.1148\/radiol.11101892","volume":"260","author":"M Iima","year":"2011","unstructured":"Iima M, Le BIhan D, Okumura R, et al (2011) Apparent diffusion coefficient as an MR imaging biomarker of low-risk ductal carcinoma in situ: a pilot study. Radiology 260:364\u2013372","journal-title":"Radiology"},{"key":"10418_CR27","doi-asserted-by":"publisher","first-page":"744","DOI":"10.4103\/0973-1482.154093","volume":"12","author":"JR Ding","year":"2016","unstructured":"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\u2013750","journal-title":"J Cancer Res Ther"}],"container-title":["European Radiology"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s00330-023-10418-4.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1007\/s00330-023-10418-4\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s00330-023-10418-4.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,5,24]],"date-time":"2024-05-24T18:10:44Z","timestamp":1716574244000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1007\/s00330-023-10418-4"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,11,7]]},"references-count":27,"journal-issue":{"issue":"5","published-online":{"date-parts":[[2024,5]]}},"alternative-id":["10418"],"URL":"https:\/\/doi.org\/10.1007\/s00330-023-10418-4","relation":{},"ISSN":["1432-1084"],"issn-type":[{"value":"1432-1084","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,11,7]]},"assertion":[{"value":"28 July 2023","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"4 September 2023","order":2,"name":"revised","label":"Revised","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"21 September 2023","order":3,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"7 November 2023","order":4,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"17 November 2023","order":5,"name":"change_date","label":"Change Date","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"Update","order":6,"name":"change_type","label":"Change Type","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"Correspondence address has been changed.","order":7,"name":"change_details","label":"Change Details","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"The scientific guarantor of this publication is Rossano Girometti.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Guarantor"}},{"value":"The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article. Rossano Girometti is the Deputy Editor of European Radiology. As such, he had no role in handling this manuscript or finalizing decisions.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Conflict of interest"}},{"value":"Rossano Girometti has significant statistical expertise and performed statistical analysis. No advanced statistical methods were necessary for this paper.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Statistics and biometry"}},{"value":"Written informed consent was waived by the Institutional Review Board.","order":5,"name":"Ethics","group":{"name":"EthicsHeading","label":"Informed consent"}},{"value":"The study has been approved by the Institutional Review Board of the Department of Medicine, University of Udine (approval number 149\/2022).","order":6,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethical approval"}},{"value":"Study subjects have not been previously reported in other works.","order":7,"name":"Ethics","group":{"name":"EthicsHeading","label":"Study subjects or cohorts overlap"}},{"value":"\u2022 retrospective\u2022 cross-sectional, observational study\u2022 performed at one institution","order":8,"name":"Ethics","group":{"name":"EthicsHeading","label":"Methodology"}}]}}