الفهرس 
IntroductionOnly 14 pages are availabe for public view
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Abstract
Variable breast lesions benign or malignant can affect the women, Breast cancer is a disease that knows no boundaries and can strike women at any age(DS,Salem et al ,2013).Early diagnosis of the disease is an essential step towards successful treatment and for increasing the survival rate of breast cancer patients. Dynamic contrast enhanced magnetic resonance imaging (DCEMRI) of breast has become a standard technique for diagnosis of breast lesions . It has found important applications in the detection of mammographically occult lesions and in providing detailed morphological extent and kinetics of breast lesions. Combined use of both architectural and contrast enhanced kinetics features has significantly improved the diagnostic ability of DCEMRI . However, there are limitations in its specificity due to overlap between morphological features and kinetics patterns of benign and malignant lesions(Kuhl C ,et al 2007).
Functional MRI techniques can provide non invasive digital biomarkers of tissue properties that are highly relevant to the assessment of tumor progression (Enass M. Khattab,et al 2018 )The dynamic contrast –enhanced MRI (DCE- MRI) of the breast enables adequate assessment of the tumor angiogenesis which is too small to be proved by another imaging method .Additionally, the time – signal intensity curve (TIC ) from DCE- MRI reflects the hemodynamic features of a specific lesion , however its limited by its low specificity . Other functional MRI parameters as diffusion weighted MRI with quantitive apparent diffusion coefficient (ADC) mapping and the proton magnetic resonance spectroscopy (1H- MRS) may provide additional specificity(I.S. Haddadin,et al 2009).
Diffusion weighted imaging (DWI) is one of the recent additions in clinical MR workup. It provides information on diffusion of water molecules in the tissues, quantified as apparent diffusion coefficient (ADC) and has shown potential in characterizing breast lesions . Several studies have documented that malignant lesions were characterized by lower ADC values in comparison to benign lesions,(Sharma U,et al2016), (DWI ) has high sensitivity and specificity in detection &characterization of different suspicious breast lesions , even comparable to dynamic contrast –enhanced MRI (DCE)( M. Iima, et al 2011) .
Another MR technique, in- vivo magnetic resonance spectroscopy (MRS), offers unique information on the biochemical characteristics associated with the malignant transformation in a non- invasive manner . The diagnostic ability of MRS is essentially based on the detection of increased levels of choline containing compounds (tCho) in malignant breast lesions which have been shown to differentiate them from benign lesions and augment the specificity of MRI (MontemezziS ,et al 2017)
The sensitivity to detect malignancy was highest for DWI compared to MRS and DCEMRI. DWI was able to detect malignancy in all indeterminate DCEMRI cases. DCEMRI, DWI and MRS may complement each other and may play a significant role in establishing the final diagnosis of malignancy.( Uma Sharmaa, et al 2019) .
Our study included 50 female patients who have different breast lesions in need for efficient characterization and differentiation to detect their nature benign or malignant , every patient giving full history , clinical examination , consent for recommended imaging procedure , staring by US examination of both breast & axilla , reaching to preliminary impression with BIRADs category subtyping that
lead to further MRI breast study that involving the conventional methods with basic standard technique as T1WI,T2WI ,STIR axial &sagittal sequences , further DCE- MR to delineate the different breast lesions enhancement with classified different specific TIC kinetic curve of enhancement , the aim of our research (study ) is adding DWI with ADC signal & value assessment and IH- MRS single voxel spectroscopy to study their significance in discrimination & good differentiation in between benign and malignant breast lesions , also our study included differentiation in between recurrent breast cancer and postoperative changes and aids in assessment of residual lesions on chemo &radiotherapy , our study results revealed that DWI ,ADC assessment and with spectroscopy (adding ) a high degree of accuracy ,sensitivity and specificity of diagnosis in in comparison with conventional &DCE- MR assessment .
Most of malignant lesions are showing type II TIC of enhancement , restricted diffusion , low ADC signal , low ADC value less than or equal to 0.95 x10−3 mm2/s, moderate number of these malignant lesions can show high choline level in MRS study at 3.22 ppm up to or more than 0.9 mmol/L with irreliable SNR , Although most of the benign breast lesions showing type I curve (TIC ) of enhancement , free diffusion , high ADC value > 0.95x10−3 mm2/s , high or intermediate ADC signal , high number of these benign lesions can show high lipid levels at MRS or inconclusive findings with irreliable SNR .some breast lesions are showing overlap in between different imaging tools results in our study that in need for follow up imaging after a specific time or even biopsy assessment.
Summary & conclusion
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Conclusion This combination of DCE- MR with 1H- MRS and DW- MRI & ADC data (value and signal ) had the higher accuracy (99.5%) sensitivity (99.5%) and specificity(98.65%) in evaluating suspicious breast lesions rather than DCE- MRI, with good efficient discrimination in between benign and malignant breast lesions . These functional modalities can efficiently be used in the absence of DCE- MRI, especially in patients with contraindications for contrast administration such as patients with renal failure, with subsequent reduction in the needs for unnecessary interventions as reducing unnecessary tissue biopsies , good planning for effective treatment with staging and early treatment of different breast lesions.