BODY APPLICATIONS OF MRI 25

Chapter Three

Mary Perrine, RT (NM) (MRI)

Chief Breast MRI Technologist
Fairfax Radiological Consultants
Fairfax, VA
CHAPTER THREE

Breast MRI
After completing this chapter, the reader will be able to:
I List the indications for breast MRI
I Explain normal vs abnormal findings

I Describe breast anatomy

I Appropriately position patient for breast MRI and MRI-guided biopsy

I Adequately prepare patient and room for biopsy

Improvements in diagnostic imaging have increased the ability for early detection of breast
cancer in recent years. Breast cancer is the most frequently occurring cancer and the second leading
cause of death in U.S. women. With early detection advancements, the five-year survival rate for
breast cancer has risen from 75% in 1975-1977 to 89% in 1996-2004.1

Breast MRI (BMRI) plays a major role in the could lead to the reporting of false negatives,
early diagnosis of breast cancer, as well as such as ductal carcinoma in-situ, invasive
defining the extent of tumor spread. It lobular carcinomas, and rarely some invasive
provides the ability to detect cancers not seen ductal carcinomas.
by mammography or ultrasound. The sensi-
The drawback of this exemplar sensitivity is
tivity for breast MRI in detecting breast cancer
the varying range of specificity. As with any
ranges from 77 to 100%. This high rate of
diagnostic study, there is the potential for false
sensitivity allows us to see everything within
positives, such as fibroadenomas, fibrocystic
the breast, not just cancerous lesions, which

POINTS FOR PRACTICE

1. What is the difference between specificity and sensitivity of breast MRI?
2. What groups should receive high-risk screening with BMRI?
3. Describe the typical breast MR scan protocol.
4. In what plane should BMRI be performed?
5. What is background enhancement? Is it clinically significant?
6. What is fibrocystic change, and why can it be difficult to differentiate between this and
malignancy? When is the preferred time during the menstrual cycle for women to be scanned?
7. What is a kinetic curve, and what can it tell us about lesion enhancement?
8. When is an MRI-guided biopsy indicated, and what type of scan protocol should be used?

©2009, International Center for Postgraduate Medical Education. All rights reserved.
26

changes, hyperplasia, adenosis, inflammatory candidates for breast conservation surgery.

changes, post-surgical changes, high-risk Patients with multicentric tumors (tumors in
lesions, lobular carcinoma in-situ and atypia. multiple quadrants) can sometimes only be
treated with a more extensive surgery. Pre-
operative evaluation is also a useful tool in
MRI vs Mammography
determining the extent of axillary lymph node
It is important to note that while BMRI is involvement (Figure 18).
extremely valuable for the early detection
of breast cancer, it is not a replacement for
Contralateral Breast
mammography. Mammography remains the
imaging of choice due to its ability to detect Breast MRI is a very useful tool in evaluating
architectural changes and calcifications and the contralateral breast. Studies have shown
cost effectiveness. that 3-5% of women with breast cancer will
develop cancer in their contralateral breast in
their lifetime.3 It is, of course, preferable to
INDICATIONS FOR BMRI treat both breasts at the same time if a
contralateral cancer is detected. Under these
circumstances, the patient may become a
High-risk Screening
candidate for BRCA testing. Carriers of one of
One of the earliest indications for MR breast the two BRCA genes (breast cancer genes)
imaging was for evaluation of silicone implant have a higher risk of developing breast and
integrity. However, high-risk screening has also ovarian cancers.
become one of the primary reasons for BMRI.
The American Cancer Society recommends
BMRI for:2
I women who are known to have the
BRCA mutation
I women with a first-degree relative
(mother, sister, daughter) diagnosed with
breast cancer under the age of 40
I a lifetime breast cancer risk of ≥20% Figure 18.
I a history of radiation therapy to the chest Extent
between ages 10-30 of tumor
I other genetic syndromes involvement.

Pre-operative Planning: Extent of Tumor

Pre-operative planning is an essential tool in
the treatment of breast cancer. The extent of
biopsy-proven cancers shown by BMRI greatly
Figure 19.
assists surgeons and oncologists in determining
Post-surgical
a treatment plan for cancer patients. Patients seroma
with multifocal cancers (cancers with multiple with residual
lesions in the same quadrant) can still be cancer.

©2009, International Center for Postgraduate Medical Education. All rights reserved.
 BREAST MRI 27
Chapter Three

a b a b

Figure 20. Neoadjuvant chemotherapy. Figure 21. Neoadjuvant chemotherapy.

(a) Pre-therapy. (b) Post-therapy showing (a) Pre-therapy. (b) Post-therapy showing no
complete response. response.

Post-operative Evaluation
Post-operative evaluation is another indication
for breast MRI. Patients with positive surgical
margins and suspected residual cancer can
greatly benefit from BMRI. Post-operative
evaluation allows visualization of any residual
cancer, the extent of the residual cancer, or
any satellite lesions that may have been
missed during the initial surgery (Figure 19). Figure 22. Axillary lymphadenopathy.

Neoadjuvant Chemotherapy
BMRI can be used to evaluate the effectiveness
of neoadjuvant chemotherapy, therapy given
Biopsy-proven Axillary Carcinoma
prior to surgery, to shrink the size of the tumor.
or Axillary Carcinoma with Unknown
Primary Site
The patient is scanned at intervals after her
BMRI is considered one of the best tools for
initial diagnosis to evaluate the effect of the
evaluating biopsy-proven axillary carcinoma in
chemotherapy on the tumor. Often a complete
patients who have had a negative mammo-
pathologic response is seen. If the tumor is not
gram and sonogram (Figure 22).
responding to the treatment, or if the tumor
has grown, the appropriate treatment can then
be prescribed and the type of chemotherapy Inconclusive Imaging and Asymmetry
changed (Figures 20 and 21).
Patients with inconclusive imaging, distortion
In some cases, a large cancer requiring on one view on mammogram not reproducible
mastectomy can be sufficiently reduced in size by ultrasound, or asymmetry, are good
for the patient to undergo breast conservation candidates for breast MRI. Breast density can
surgery after her neoadjuvant chemotherapy. obscure malignancies on mammography or

©2009, International Center for Postgraduate Medical Education. All rights reserved.
28

a b c

Figure 23. Inconclusive breast imaging. (a) Distortion one view only on mammography, normal US,
MRI shows invasive lobular carcinoma. (b) Asymmetry on mammography, normal US, MRI shows
invasive ductal carcinoma. (c) Diffuse calcifications on mammography, MRI shows DCIS.

ultrasound but does not affect the ability of An inversion recovery (IR) pulse sequence with
BMRI to visualize suspicious lesions (Figure 23). water suppression is an excellent technique for
determining silicone implant rupture. This
sequence suppresses both fat and water, leav-
Silicone Implant Evaluation
ing only silicone visible on the image (Figure 24).
Breast MRI still plays an important role in the
evaluation of silicone implant integrity. These
images are excellent for visualizing implant BREAST ANATOMY
rupture, as well as differentiating between free
A general knowledge of the anatomical struc-
silicone outside of the capsule and other
tures within the breast and surrounding
anatomical structures.
structures is important for obtaining quality
images (Figure 25).
The breast itself consists of the skin and breast
parenchyma. The skin contains hair follicles
and glands. The breast is supported on the
chest wall by bands of tissue called Cooper’s
ligaments.
In patients with various breast diseases, the
skin can show important changes. Skin thick-
ening can be an indicator of a pathological
Figure 24. finding or can be associated with post-benign
Silicone processes. Skin thickening can also be associ-
implant ated with inflammatory breast cancers,
rupture.
extensive primary invasive breast cancers,

©2009, International Center for Postgraduate Medical Education. All rights reserved.
 BREAST MRI 29
Chapter Three

mammogram a breast with predominate

Pectorallis major muscle parenchymal tissue and little fat is considered
Pectoral extremely dense. One composed mainly of fat
fat pad
is considered to be “fatty replaced.” On MRI,
Suspensory
ligaments the breast can be easily assessed regardless of
Lobes of the the amount of glandular tissue (Figure 27).
mammary
gland
Lactiferous Milk ducts lead to the nipple from the glands.
duct
Areola
The breast has 20-40 lobules that drain into
each duct, and fat surrounds the lobules and
Nipple
ducts.
Lactiferous
sinus At the tip of the breast is the nipple, which is
surrounded by pigmented tissue known as the
areola. Approximately 20 milk ducts empty
into the nipple.
Figure 25. Breast anatomy. Courtesy of
Florida Community College of Jacksonville. Difference in size between each breast is not
uncommon; however, the nipples and areola
are generally symmetric. While breast size and
shape can vary with hormonal changes, the
Paget’s disease of the nipple, and lymphomas. nipples should remain symmetric (Figure 28).
Benign causes of skin thickening can include
mastitis, post-radiation changes, or edema
from heart failure or lymphatic obstruction
(Figure 26).
The breast parenchyma consists of milk-
producing glands called lobules or alveoli.
The parenchyma can be seen extending into
the axillary tail and, in some patients, within
the axilla. The inferior aspect of the breast is
located at the inframammary fold. a b
The amount of breast parenchyma present Figure 27. (a) Dense breast. (b) Fatty breast.
determines the “density” of the breasts. On a

Figure 26. Figure 28.

Skin thick- Normal
ening, post- asymmet-
contrast rical
injection. breast.

©2009, International Center for Postgraduate Medical Education. All rights reserved.
30

Pectoralis
muscle

Figure 30.
Pectoralis Lymph
muscle nodes.

Figure 29.
Invasive ductal
carcinoma
with pectoralis
muscle
involvement.
Figure 31.
Post-
contrast
sternum
with an
“Outside” the breast lie the pectoralis minor, enhancing
the pectoralis major, and sternalis muscles. metastatic
Even though these muscles are not considered lesion.
to be part of the chest wall, a BMRI should
include these muscles, as extensive cancers
can have margins infiltrating into the pectoralis
major muscle.
There are between 15 and 40 axillary nodes
The chest wall includes the intercostal muscle,
that are responsible for most of the lymphatic
serratus anterior, and the ribs. Just like the
drainage within the breast. On sagittal breast
muscles “outside” the breast, the chest wall is
MRI images, lymph nodes located in the axil-
included in a BMRI evaluation (Figure 29).
lary tail give the appearance of grapes hanging
Lymph nodes are commonly seen on breast on a vine. Intramammary lymph nodes are
MRI (Figure 30). They are highly vascular, found within the breast parenchyma. They are
usually present on BMRI with a fatty hilum, most commonly seen in the upper, outer quad-
and are generally associated with a vessel. rant of the breast. Lymph nodes can also be
Lymph nodes should enhance homogeneously seen along the internal mammary chain or
and often show wash-out of contrast. within the supraclavicular location. This is

©2009, International Center for Postgraduate Medical Education. All rights reserved.
 BREAST MRI 31
Chapter Three

another route of drainage for the breast. These biopsy, and the breast coil used should be able
lymph nodes should always be assessed in to provide both imaging and biopsy capability.
known malignancy.
It is extremely important to position the
The sternum and ribs are also seen on BMRI. patient properly in the coil. Each breast should
Post-radiation changes in the sternum gener- be centered within the coil and the tissue
ally appear as fatty replacement. Metastatic manually pulled into the coil, ensuring that no
disease can be seen as high signal on T2 and tissue is outside of the coil (Figure 32).
as an increase in signal on the fat-saturated,
post-contrast images (Figure 31).
Routine Breast MR Imaging Protocol
The routine breast imaging protocol should
IMAGING PROTOCOLS include a 3-plane localizer (Table 2, page 47).
This series should be done with relatively thin
Patient comfort is the foremost priority in
slices and is non-fat-suppressed with T2
achieving high-quality imaging. Patients
weighting. This series is required to prescribe
referred for breast MRI are understandably
future series and to check for any incidental
anxious, and a sympathetic approach usually
findings outside of the breast, including liver,
results in a technically better study.
lung and bone lesions, and chest wall abnor-
malities. Appropriate positioning of the patient
Positioning in the Breast Coil in the coil also can be verified on the localizer.
A dedicated breast coil is required to perform
quality imaging as is an injection of contrast. T2-weighted fat suppression
Sites offering BMRI should also have the
Sagittal T2-weighted fat-suppressed or inver-
capacity for performing MR-guided breast
sion recovery imaging is performed separately
on each breast. Fluid and fluid-saturated
tissues have brighter signal on T2-weighted
images. By suppressing fat in this series, even
tiny cysts or areas of edema can be visualized.
These images should be done at no more than
a 4 mm thickness. Care should be taken to
include the axilla and sternum to evaluate
lymph adenopathy and bony structures.
T2 fat-suppressed images can be susceptible
to artifacts caused by the position of the
patient in the coil, metallic foreign bodies such
as biopsy markers and mediports, jewelry, and
clothing. It is recommended that the patient
remove earrings, necklaces, and clothing from
the waist up and any other clothing containing
metal. Care should be taken to screen for
Figure 32. 3-plane localizer shows breast metallic implants and breast tissue expanders
tissue that is not pulled into the coil (arrow). in patients preparing for breast reconstruction.

©2009, International Center for Postgraduate Medical Education. All rights reserved.
32

a b

Figure 33. Phase artifact (a) Phase running right to left shows artifact from cardiac vessel in the
axilla that gives the impression of a large abnormal axillary node. (b) Phase running anterior to
posterior giving unobstructed view of axillary region with no abnormality.

T1-weighted 3D parallel imaging

A T1-weighted 3D parallel imaging sequence
should be done of both breasts simultaneously
to visualize the breast structures in detail.
A corresponding T1 3D with fat suppression is
used pre- and post-contrast. Post-contrast
imaging has specific requirements that include
very thin slices, T1 weighting, fat suppression,
and rapid wash-in/wash-out. This series is
done dynamically with one series pre-contrast
a
and four series post-contrast in less than two
minutes per series. From these data a time
intensity enhancement kinetic curve can be
generated, a valuable tool in determining the
characteristics of a specific lesion.
Figure 34.
Breast MR imaging can be done in the sagittal Silicone
plane to keep the field of view small, from implant.
(a) Inversion
20 - 24 cm, and the resolution at its greatest,
recovery.
although some centers prefer to scan in the (b) Inversion
axial plane. recovery
with water
A T1 3D fat-suppressed series in the axial saturation. b
plane should be done after the dynamic post-

©2009, International Center for Postgraduate Medical Education. All rights reserved.
 BREAST MRI 33
Chapter Three

contrast series. This series is an excellent tool A T1 non-fat-suppressed sagittal sequence

for evaluating the axillary lymph nodes. Be determines the location of the implant, either
aware of the direction of the phase artifact so subpectoral or subglandular. This protocol
that it does not obscure the axilla. Artifact should also be used when evaluating double
thrown across the axilla from cardiac vessels lumen implants.
may give the appearance of abnormal
pathology (Figure 33).
Saline vs Silicone Implant Protocol
Rupture of a saline implant can be evaluated
Silicone Implant MRI Protocol
using the routine breast MR imaging protocol.
BMRI is an excellent tool for the evaluation of A noticeable difference in the ruptured saline
silicone implants (Table 3, page 47). An inver- implant is usually seen on all series. In a 1.5 T
sion recovery pulse sequence is used with a field, the saline implant will be hyperintense
corresponding water-suppressed IR pulse on T2 fat-suppressed images; however, a
sequence to suppress all tissue, leaving only silicone implant will be mostly dark because
the silicone visible. These sequences are done the frequency of fat and silicone are very
in both the sagittal and axial planes, allowing close and when the fat suppresses, the
visualization of any silicone outside of the silicone also suppresses. On an inversion
ruptured capsule, while suppressing any non- recovery the silicone implant is visible, and
silicone fluid that might surround the implant the characteristics within the implant can be
(Figure 34). evaluated (Figure 35).

a b

Figure 35. (a) Silicone implant rupture using inversion recovery. (b) Silicone implant rupture using
water saturation inversion recovery. By doing a water-suppressed inversion recovery, you can
confirm that the area in the superior part of the breast is extracapuslar silicone.

©2009, International Center for Postgraduate Medical Education. All rights reserved.
34

a b c

Figure 36. Background enhancement. (a) Marked. (b) Moderate. (c) Minimal.

In addition, if the patient presents with a mass be difficult to differentiate between fibrocystic
or pain, it is important to do a dynamic change and malignant findings.
contrast series to determine if a pathological
Dramatic changes can be seen when scanning
process is the cause of the patient’s symptoms.
women during different times of the menstrual
cycle. The time in the patient’s cycle should be
noted to assist the radiologist in differentiating
MRI FINDINGS – BENIGN
between normal fibrocystic change and malig-
nancy. Imaging during Day 7-14 of the cycle is
Background Enhancement the preferred time frame in premenopausal
women (Figure 37).
Background enhancement is the normal
enhancement within the breast parenchyma.
It is not directly related to breast density. Cysts
Background enhancement varies by patient
Cysts are commonly seen on BMRI, and one
and is affected by hormonal changes
or several cysts may be present. Simple cysts
(menstrual cycle, hormone replacement
are hyperintense on T2-weighted images. If
therapy, and hormonal chemotherapy) and
fibrocystic changes. Background enhancement
can be classified as minimal, moderate, and
marked (Figure 36).

Fibrocystic Change
Fibrocystic change refers to the change in
cell characteristics of glandular tissue due to
normal hormonal fluctuations during the
menstrual cycle. Breast tenderness, pain, and a b
lumpiness can be associated with fibrocystic Figure 37. (a) Day 10 of the menstrual cycle.
change. Although it is a benign finding, it can (b) Day 28.

©2009, International Center for Postgraduate Medical Education. All rights reserved.
 BREAST MRI 35
Chapter Three

a b

Figure 38. Inflamed cyst. (a) Post-contrast. Figure 39. Figure 40. Post-
(b) Post-contrast subtraction. Fibroadenoma. contrast hamartoma.

cysts are complex and filled with proteina- fibroadenoma (Figure 39). Fibroadenomas are
ceous material they will be hyperintense on often proven by biopsy.
T1-weighted images. Inflamed cysts will show
rim enhancement post-contrast. Some larger
Hamartoma
cysts that become painful can be aspirated;
often cysts resolve on their own (Figure 38). Hamartoma are also known as “breast within
a breast.” These rather rare benign lesions
consist of fat, connective tissue, and glandular
Fibroadenomas
tissue. The parenchymal elements in a hamar-
Fibroadenomas are common benign masses toma will enhance more avidly than surround-
often seen on BMRI. They have smooth ing breast parenchyma. No treatment is
margins and are either round or oval in shape. required (Figure 40).
They can vary in size, and a patient may have
one or many. Fibroadenomas have varying
Papillomas
contrast enhancement patterns depending
on the cellularity of the lesion. Dark internal Papillomas are benign tumors that occur
septations on T2-weighted and post-contrast along the milk ducts and can cause benign
images are common characteristics of a nipple discharge. They may be hyperintense

Figure 41. Papillomas.

©2009, International Center for Postgraduate Medical Education. All rights reserved.
36

on T2-weighted images and are often associ-

ated with a dilated duct. Papillomas may show
rapid wash-out of contrast. They are biopsy-
proven and are generally surgically excised
(Figure 41).

Phylloides
Phylloides are generally benign and may look
like a fibroadenoma. However, there are malig-
nant phylloides that tend to demonstrate
malignant features, including irregular shape
and heterogeneous enhancement with contrast
wash-out. Phylloides occur in the connective
tissue of the breast. They are biopsy-proven
and benign lesions require no treatment.

Lactation
Lactating breasts can be difficult to image on
BMRI because of an overall marked increase in
background enhancement and diffuse increase
in T2 signal. It is best not to scan lactating
women unless there is a cause for concern
(Figure 42).

Mastitis Figure 43. Gynecomastia.

Mastitis is a result of a clogged milk duct and
presents on BMRI as an overall increase in

a b

Figure 42. (a) Lactating breast. (b) Post-

contrast image of lactating woman with
MRSA in the right breast. Figure 44. Hematoma.

©2009, International Center for Postgraduate Medical Education. All rights reserved.
 BREAST MRI 37
Chapter Three

enhancement in T2 signal in the affected Post-radiation Changes

breast. The skin may be thickened and lymph
Post-radiation changes may be seen for many
nodes enlarged. When the skin enhances in
years after treatment and consist of breast
mastitis, the enhancement is homogeneous
edema and skin thickening. Typically, overall
and progressive. An abscess appears as a T2
background parenchymal enhancement
hyperintense or heterogeneous mass. Mastitis
decreases after radiation treatment. This
can be difficult to differentiate from inflamma-
decrease is most notable when the patient has
tory carcinoma because the symptoms are
moderate or marked background enhance-
similar: pain, redness and swelling. Mastitis is
ment in the non-treated breast (Figure 47).
usually treated with antibiotics.

Gynecomastia MRI FINDINGS – MALIGNANT

Gynecomastia is tissue enlargement in the
male breast, usually due to increase in Non-mass-like Enhancement
estrogen or decrease in androgen hormones
Malignant tumors tend to have irregular
(Figure 43).
shapes and irregular margins, heterogeneous
enhancement, and wash-out kinetics. When
Post-operative Changes not a discrete mass, the abnormal findings
Post-operative changes seen in MRI include
seroma, hematoma, abscess, scar tissue, and
fat necrosis.
A hematoma is a collection of blood that
usually results from biopsy and resolves on its
own. Hematoma is heterogeneous on all pulse
sequences with peripheral enhancement.
Abscess may be difficult to differentiate from
hematoma due to the similarity in enhance-
ment characteristics (Figure 44).
A seroma is a fluid-filled, surgical cavity. It Figure 45. Seroma.
may present for years after surgery. On post-
contrast images, seromas may demonstrate
rim enhancement (Figure 45).
Scar tissue can show progressive homoge-
neous enhancement. Fat necrosis can be
diagnosed by fat signal intensity on fat-
suppressed and non-fat-suppressed images,
but in the initial stages when fat is not
present, it may appear as a malignancy. Fat
a b
necrosis is often seen at the excisional biopsy
or lumpectomy site (Figure 46). Figure 46. Scar tissue. (a) Non-fat suppres-
sion. (b) Post-contrast.

©2009, International Center for Postgraduate Medical Education. All rights reserved.
38

Foci vs. Mass

The size of the abnormality plays a role in
likelihood of malignancy, as well. A focus or
foci of enhancement is a dot-like area of
enhancement <5 mm in size. A mass is a
space-occupying lesion >5 mm. A mass gener-
ally has a 3D correlate on the pre-contrast or
T2-weighted images.
An abnormality ≤ 5 mm has a likelihood of
disease of approx 3%, whereas a mass ≥10
mm has a 25% to 31% likelihood of malig-
nancy.4

Kinetic Curve
Figure 47. Post-radiation changes seen post-
contrast. Background parenchymal enhance- The wash-in and wash-out contrast enhance-
ment is decreased on the left breast. ment pattern in breast tissues gives us the
ability to create a kinetic curve for the tissue of
interest (Figure 49).
There are three types of contrast enhancement
patterns:5
associated with malignancy are termed non-
mass-like enhancement (NMLE). NMLE in I Type I curve has a rapid initial rise with
malignancy may have a segmental, linear, or the introduction of contrast and then has
ductal distribution. NMLE can have a clumped a rapid wash-out of contrast in the lesion.
or heterogeneous morphology. NMLE can be The likelihood of malignancy with this
regional, multifocal, with more than one type of kinetic curve is approximately
cancer in the same quadrant, or multicentric, 87%.
with lesions seen in more than one quadrant
of the breast (Figure 48).

Type 1
Type 2
Type 3
Intensity

0 2 4 6 8
Time in Minutes

Figure 49. Time intensity enhancement

Figure 48. Multicentric breast lesions. curves.

©2009, International Center for Postgraduate Medical Education. All rights reserved.
 BREAST MRI 39
Chapter Three

Invasive Ductal Carcinoma

Invasive ductal carcinoma is the most
frequently encountered cancer seen on breast
MRI. It develops in the ducts and infiltrates
the membranes of the ducts into the surround-
ing tissues. The MR sensitivity is 95-98% for
invasive ductal carcinomas (Figure 51).6

Figure 50. Neoangiogenesis. Medullary & Mucinous Cancers

Medullary and mucinous cancers are rare,
sub-types of ductal carcinoma. They appear
similar to fibroadenomas on breast MRI, with
distinct borders, and require careful patholog-
I Type II curve also shows an initial rise ical determination (Figure 52).
with the introduction of contrast and
then a plateau of contrast enhancement
over time. This lesion has an indetermi-
nate enhancement kinetic pattern. The
likelihood of malignancy with this type
of kinetic curve is approximately 64%.
I Type III curve has an initial rise with the
introduction of contrast and a continuous
enhancement of contrast in the lesion
over time. This is a benign type of
enhancement kinetic curve. The likelihood
of malignancy with this type of kinetic
curve is approximately 6%.
The growth of malignant lesions is dependent
on neoangiogenesis – the formation of a new
blood supply to feed tumor growth (Figure
50). Blood vessels in a malignant lesion are
abnormal and leaky. This leakage causes
contrast to wash out of tumors quickly. This
rapid contrast wash-out is seen in the type III
kinetic curve.

Malignant Tumors
Figure 51.
Fortunately, the mortality rate for breast Invasive ductal
cancer in American woman has decreased in carcinoma
recent years because of earlier detection and with pectoral
advances in treatment and breast imaging. muscle
involvement.

©2009, International Center for Postgraduate Medical Education. All rights reserved.
40

Figure 52. Mucinous carcinoma. Figure 53. DCIS segmental Figure 54. Invasive lobular
clumped enhancement. carcinoma.

Ductal Carcinoma in-situ (DCIS) orange peel (peau d’orange) appearance. On

MRI, the skin is thickened with heterogeneous
Ductal carcinoma in-situ (DCIS) stays within
enhancement, subcutaneous edema, and
the lining of the ducts with no invasion into the
edema through the breast (Figure 55).
breast tissue. DCIS is considered precancerous.
While not all DCIS will develop into cancer, it is
generally treated surgically and with radiation
IMAGING THE AUGMENTED AND
therapy (Figure 53).
RECONSTRUCTED BREAST
The most common types of augmentation
Lobular Cancers
and reconstruction are implants, transrectus
Lobular cancers begin in the cells of the abdominis myocutaneous flap (TRAM), deep
lobular units. Lobular cancer invades nearby inferior epigastric perforator (DIEP), and sili-
tissue, spreading in a weblike pattern and cone injections.
making it difficult to diagnose. It is difficult to
detect with all modalities but best visualized
with breast MRI (Figure 54).

Inflammatory Cancer
Inflammatory cancer is an aggressive breast
cancer that usually presents with redness,
swelling, and pain. It often involves over half
of the breast and commonly infiltrates the skin
and mammary tissues. Inflammation occurs
due to tumor invading the lymphatic system
Figure 55. Inflammatory cancer. Note
and blocking drainage. The skin can have an enhancing skin thickening.

©2009, International Center for Postgraduate Medical Education. All rights reserved.
 BREAST MRI 41
Chapter Three

Pedicle

a b

Figure 56. Implants. Figure 57.

(a) Subpectoral. (b) Subglandular. TRAM flap with implant.

Implants that often shows susceptibility artifacts due to

the surgical procedure. The pedicle is formed
In post-mastectomy patients, silicone or
from part of the rectus muscle that has been
saline implants can be used for reconstruction.
moved from the abdominal wall (Figure 57).
The determination of using silicone or saline
is made by the patient and her surgeon.
Implants can be placed subpectorally or Deep Inferior Epigastric Perforator
subglandularly, most often in the subpectoral (DIEP)
location (Figure 56).
The deep inferior epigastric perforator
Prior to the insertion of the implant, a tissue procedure takes tissue and fat from the lower
expander is sometimes used to “stretch” the abdomen but keeps the muscle intact.
tissue to accommodate the future implant.
Caution should be taken when interviewing
Silicone Injections
patients undergoing reconstruction as there
are several tissue expanders that are not Silicone injections are a type of augmentation
MR compatible. After the tissue is stretched rarely used today. It is important to image with
adequately, the expander is replaced with a water-suppressed inversion recovery to visu-
a permanent implant. alize residual silicone vs granulation tissue.

Transrectus Abdominis Myocutaneous

MRI-GUIDED BREAST BIOPSY (MRBX)
Flap (TRAM)
If an area of abnormality is seen on breast
Transrectus abdominis myocutaneous flap
MRI and cannot be reproduced by either
reconstruction uses the rectus abdominis
mammography or ultrasound, an MRI-guided
muscle to supply blood to the fat and tissue
breast biopsy may be performed. All centers
used to form a new breast. There is also often
providing BMRI should have the capability to
associated fat necrosis. On MRI, there is an
provide MRI-guided breast biopsy.
area of triangular tissue known as the pedicle

©2009, International Center for Postgraduate Medical Education. All rights reserved.
42

a b

Figure 58. (a) Patient positioning, arm up and with the coil pad. (b) Removing the coil pad and
placing the patient’s arm down at her side allows for better posterior access.

Patient Care and Comfort as comfortable as possible. A head support,

blanket, and the presence of a technologist or
Patients arriving for an MRBX may require
nurse at all times can put the patient at ease.
additional attention. It is important for the
patient to feel as comfortable as possible to
alleviate stress and to help eliminate motion Patient Positioning
during the procedure. A dedicated breast MRI
Patient positioning is critical for an accurate
technologist can make the procedure much
biopsy. Determining the optimal approach
easier for the patient, both physically and
prior to the procedure saves time, and with
emotionally.
proper positioning the procedure will be more
As with any breast biopsy, check to be sure comfortable for the patient. The diagnostic
that the patient has discontinued aspirin, BMRI study, as well as prior mammography
ibuprofen, vitamin E, or any other blood- and sonograms, should be reviewed and an
thinning medications prior to the procedure. appropriate approach determined prior to the
arrival of the patient. Is the lesion on the
It is important to keep this procedure as simple
lateral or medial side of the breast? Is the
as possible. The diagnostic breast MRI should
lesion in the anterior or posterior portion of
be reviewed and the biopsy approach deter-
the breast? Will the patient need to be
mined by the radiologist prior to the procedure
elevated in the coil to access a very anterior or
to minimize the time the patient is in compres-
retro-areolar lesion, or is the lesion so posterior
sion. The team should thoroughly review the
that the patient will need to be lowered down
case, understand what needs to be biopsied,
into the coil? Pulling the breast, using a smaller
and determine the approach and patient posi-
pad on the coil, and placing the patient’s arm
tion before beginning. A set of images showing
down by her side allows for better posterior
the location of the lesion to be targeted should
access (Figure 58). Is there anything to limit
be at the MR console for reference.
access to the lesion – post-surgical seroma or
After the patient arrives and the approach a large blood vessel? It is important to know
determined, it is important to make the patient these answers before you begin.

©2009, International Center for Postgraduate Medical Education. All rights reserved.
 BREAST MRI 43
Chapter Three

a b

Figure 59. Posterior lesion. Figure 60. Medial approach

(a) Poorly positioned breast. (b) Pull the breast for better access. with wedge on lateral side.

Breast Placement the compression grid in this scan. A pre-con-

trast scan is done to ensure the area of interest
It is important to pull the breast into the
is accessible and the fiducial can be seen.
coil to provide both better access and
compression. Care should be taken not to
b
pinch the patient or place the compression Contrast Administration
plate too tightly when immobilizing the
Contrast is administered only after it is
breast (Figure 59).
determined that the area of interest can
If compression is uneven, a wedge can be be visualized and is accessible within the
placed to help provide more uniform compression grid. Contrast is given manually
compression (Figure 60). and post-contrast images are acquired imme-
diately following contrast injection. It is not
Once the patient is comfortable and properly
necessary to use a power injector for this
positioned and the breast is in compression,
procedure; however, it is important to work
a vitamin E capsule or contrast-filled fiducial
quickly and efficiently to reduce lesion wash-
is placed near the expected region of the
out and to minimize background enhancement.
abnormality.
Once the area of interest is identified on post-
contrast images, the coordinates of the lesion
Scan Protocol
are determined within the compression grid
A simple protocol is all that is needed for an and the depth of the lesion is calculated.
MRI-guided biopsy (Table 4, page 48). A
If the area of interest is not visualized post-
three-plane localizer is used to determine that
contrast, perform two to three additional
the patient is adequately positioned and 3D
post-contrast scans and reassess. Was the
sagittal T1- weighted fat-suppressed sequence
contrast adequately administered? Is the
is used to visualize the breast and lesion. Only
compression too tight, not allowing adequate
the area of the questionable abnormality needs
blood flow to the breast? Is the lesion truly a
to be scanned. Be sure to include the face of
suspicious lesion on the diagnostic study or

©2009, International Center for Postgraduate Medical Education. All rights reserved.
44

fibrocystic change that might not be seen at patient to avoid patient movement, ensuring
this point in the patient’s menstrual cycle? the lesion will be in the calculated location.
At this point, the biopsy device can readied.
The patient’s breast is cleaned with a
Biopsy Needle Placement
Chloraprep® or Betadine® and anesthetized
The location of the biopsy needle placement with lidocaine at the surface and to the depth
can be determined once the area of interest is of the lesion.
identified on the post-contrast images.
For mass-like lesions, it is important to choose Introducer Placement
a location that will not “skewer” the lesion,
An introducer guide needle with an introducer
as this is likely to push away or obliterate the
sheath is placed to the appropriate depth
lesion. Instead, the biopsy needle should be
of the area of interest. The guide needle is
placed immediately adjacent to the targeted
removed and replaced with a plastic
lesion.
obturator. The patient is scanned to assess
If the area of interest is linear or is an area of the placement of the introducer. Did the lesion
large clumped enhancement it may be best to move with the insertion of the guide needle?
target the center of the area. Is the introducer properly placed? If yes, then
the biopsy device can be placed and samples
taken. If the lesion has moved with the inser-
Prepping the Skin
tion of the guide needle, recalculate the lesion
While the location of the needle placement depth based on the post-introducer images
is being determined, the patient should be and make the appropriate adjustments.
brought out of the magnet. It is important Replace the obturator and rescan the patient.
that a technologist or nurse be with the

a b c

Figure 61. (a) Post-contrast. (b) Post-obturator. (c) Post-biopsy.

©2009, International Center for Postgraduate Medical Education. All rights reserved.
 BREAST MRI 45
Chapter Three

Tissue Sampling contrast images. It is important to adequately

sample the lesion (Figure 61). If a hematoma
It is only necessary to biopsy in the direction
appears, one or two biopsy cores will help
of the lesion. Using a consistent method to
eliminate it so that the biopsy cavity can be
determine the direction of tissue sampling
better seen. If the lesion washes out, use
reduces the chance for error. The direction of
anatomical landmarks to help determine your
tissue sampling is determined in relation to the
position. Once it has been determined that the
guide needle: is the area of interest toward
lesion was adequately sampled, an MR-
the patient’s head, chest, feet, or nipple?
compatible biopsy marker is deployed. It is not
Remember the position of the patient on the
necessary to scan after the marker is deployed.
table will be different from the patient’s posi-
tion on the console monitor. Take great care in Pathological correlation must be done when
determining the correct direction to biopsy. the biopsy results become available. If the
results are discordant with the anticipated
Was the lesion adequately sampled? Care
outcome, the patient may need surgical
should be taken to compare the post-biopsy
excision.
images with the post-introducer images, as the
lesion may have moved after the initial post-

BIOPSY PROCEDURE OVERVIEW

1. Position patient, pull/immobilize breast, place breast in compression, use wedge if needed.
2. Initial scanning – 3 plane localizer and 3D T1 fat-suppressed sagittal of breast.
3. Check location of breast in compression grid using diagnostic MRI and physical landmarks.
4. Inject contrast agent.
5. Scan immediately.
6. When lesion is visualized, the technologist will prepare biopsy device.
7. Determine the physical location of lesion using grid coordinates.
8. Prepare breast with topical cleaning and local numbing agent.
9. Introduce guide needle.
10. Re-scan patient to determine that the needle is correctly placed.
a. If correct, proceed with biopsy.
b. If not correct, reposition guide needle and rescan.
11. Scan to determine if the lesion in question has been adequately biopsied.
a. If yes, always deploy a biopsy marker.
b. If no, take more biopsy cores as needed.
12. Hold manual compression; apply Steri-Strips™, ice pack, and compression.
13. Obtain post-biopsy mammogram.
14. Pathology correlation must be done.

©2009, International Center for Postgraduate Medical Education. All rights reserved.
46

Multiple Biopsies
a b
If more than one biopsy or bilateral biopsy is
needed, more than one area can be targeted
during the biopsy procedure (Figure 62). Care
must be taken to label samples correctly,
remembering to be consistent in the approach
taken to label tissue samples.

Figure 62. Multiple biopsy. (a) Post-contrast.

(b) Post-biopsy.

Patient Care after Biopsy

After completion of the biopsy, the patient can
be removed from compression. Pressure is held
at the biopsy site until bleeding has stopped,
and Steri-Strips™ should be applied, along with
an ice pack and compression binder. A post-
biopsy mammogram is performed to record
placement of the biopsy marker. Post-biopsy
care instructions must be given to the patient
at discharge.

©2009, International Center for Postgraduate Medical Education. All rights reserved.
 BREAST MRI 47
Chapter Three

Table 2.
SAMPLE BREAST MR IMAGING PROTOCOL
Right/Left Sagittal Sagittal Axial
Sagittal Parallel Imaging Parallel Imaging Parallel Imaging
Localizer Calibration T2 F/S Non-F/S Pre/post Post F/S
Plane 3-Plane Axial Sagittal Sagittal Sagittal Axial
FSP SSFSE Fast FSE-XL Parallel Parallel Parallel
GRE imaging imaging imaging
TR MIN ~5000 SET SET SET
TE/TI MIN 85 IN-PHASE IN-PHASE IN-PHASE
ETL/FLIP 14 10 10 10
RBW 83 21 32 42 42
FOV 38 48 ~20 ~20 ~20 ~32
SLICE TK/SKIP 7 8 4/1 3mm 3mm 3mm
MATRIX 256x192 256x192 320x256 384x224 384x350
NEX 1 2 1 1 1
SLICES 15/12/3 46 ~26 100 500 100
OPTIONS FAT/SAT, NPW, ASSET, NPW, ASSET, PURE,
PURE, NPW PURE FAT/SAT FAT/SAT

total – 1 pre/4 post-contrast. Keep scan times on dynamic sagittal parallel imaging pre/post-contrast scans ≤ 2 minutes. To increase scanning
Right and left sagittal T2 FSE are done separately. Sagittal fat/sat parallel imaging pre/post-contrast done with multi-phase imaging. 5 phases

area, increase slice thickness, not number of slices.

Table 3.
SAMPLE SILICONE IMPLANT MRI PROTOCOL
Right/Left Axial Sag. Parallel
Right/Left STIR STIR Axial Imaging
Localizer Calibration STIR Water Sup. Water Sup. STIR Non F/S
Plane 3-plane Axial Sagittal Sagittal Axial Axial Sagittal
PSD SSFSE FAST GRE FSE-IR FSE-IR FSE-IR FSE-IR Parallel
imaging
TR MIN ~8000 ~8000 ~7500 ~7500 SET
TE/TI MIN 50/150 50/150 50/150 50/150 IN-PHASE
ETL/FLIP 12 12 12 12
RBW 83 32 32 32 32 32
FOV 38 48 ~20 ~20 ~32 ~32 ~20
SLICE THK/SKIP 7 8 4/1 4/1 4/1 4/1 3mm
MATRIX 256x192 320x160 256x192 256x192 320x224 320x256
NEX 1 2 1 1 1 1
SLICES 15/12/3 46 ~26 ~26 ~30 ~30 100
OPTIONS NPW, FC, NPW, FC, NPW, FC, NPW, FC, NPW, ASSET,
PURE PURE PURE PURE TURBO+2
WATER-SAT WATER-SAT
This protocol is done only if looking for a silicone implant rupture. If scanning for a breast mass with a questionable implant rupture, add
sagittal parallel imaging fat-sat pre/post-sequence and axial parallel imaging post-contrast sequence to this protocol. Left and right STIR series
should be done separately.

©2009, International Center for Postgraduate Medical Education. All rights reserved.
48

Table 4.
SAMPLE BREAST MRI-GUIDED BIOPSY PROTOCOL
Sagittal Opt. Axial Opt. Sagittal
Localizer 3D Fat/Sat SPGR Non-Fat/Sat
Plane 3-plane Sagittal Axial Sagittal
PSD SSFSE 3-Plane FSPGR FSPGR FSPGR
TR MIN --- --- ---
TE/TI MIN IN-PHASE IN-PHASE IN-PHASE
ETL/FLIP 30 30 30
RBW 83 32 32 32
FOV 38 20 20 20
SLICE THK/SKIP 5mm 3mm 3mm 3mm
MATRIX 256x192 192x160 192x160 192x160
NEX 1 1 1
OPTIONS NPW, FAT/SAT NPW, FAT/SAT NPW
# SLICE 12/12/3 ~18 ~18 ~18

©2009, International Center for Postgraduate Medical Education. All rights reserved.
 BREAST MRI 49
Chapter Three

POINTS FOR PRACTICE

1. What is the difference between specificity and sensitivity of breast MRI?

Breast MRI has a high sensitivity - it is very good at picking up invasive breast cancers. Because
of the high sensitivity, it also picks up everything else, as well. The specificity is lower because
other enhancing tissues in the breast can give a false positive for breast cancer.

2. What groups should receive high-risk screening with BMRI?

The American Cancer Society Guidelines recommends BMRI for women:
I with the BRCA mutation
I who have a first-degree relative with breast cancer diagnosed under the age of 40
I a lifetime risk of breast CA of ≥ 20%
I a history of chest radiation between ages 10 - 30
I other genetic syndromes

3. Describe the typical breast MRI scan protocol.

The basic breast cancer protocol should include a 3-plane localizer. This series should be done
with relatively thin slices and non-fat-suppressed with T2 weighting. This series is required to
prescribe future series and to check for any incidental findings outside of the breast, including
liver, lung, and bone lesions, and the chest wall. Appropriate positioning of the patient in the coil
also can be verified on the localizer.

4. In what plane should BMRI be performed?

Breast MR imaging can be done in the sagittal plane to keep the field of view small, from 20 -
24 cm, and the resolution at its greatest, although some centers prefer to scan in the axial plane.

5. What is background enhancement? Is it clinically significant?

Background enhancement is the normal enhancement within the breast parenchyma. It varies by
patient and is associated with hormonal changes, including those related to the menstrual cycle,
hormone replacement therapy, and hormonal chemotherapy. Background enhancement is also
affected by fibrocystic changes and individual differences. It is not directly related to breast
density. Background enhancement can be classified as minimal, moderate, and marked and is a
benign finding.

6. What is fibrocystic change, and why can it be difficult to differentiate between this and
malignancy? When is the preferred time during the menstrual cycle for women to be
scanned?
Fibrocystic change refers to the change in cell characteristics of the glandular tissue due to
normal hormonal fluctuations during the menstrual cycle. Breast tenderness, pain, and lumpiness
can be associated with fibrocystic change. Although it is a benign finding, it can be difficult to
differentiate between this change and malignant findings because symptoms can be indicative
of both. Dramatic changes can be seen when scanning women during different times of their
menstrual cycle. The time in the patient’s cycle should be noted to assist the radiologist in
differentiating between normal fibrocystic change and malignancy. Imaging during Day 7-14
of the cycle is the preferred time frame in premenopausal women.

©2009, International Center for Postgraduate Medical Education. All rights reserved.
50

POINTS FOR PRACTICE

7. What is a kinetic curve, and what can it tell us about lesion enhancement?
The wash-in and wash-out contrast enhancement pattern in the breast tissues provides the
ability to create a kinetic curve for the particular tissue of interest. Type I curve has a rapid initial
rise with the introduction of contrast and then has a rapid wash-out of contrast in the lesion.
The likelihood of malignancy with this type of kinetic curve is approximately 87%. Type II curve
also shows an initial rise with the introduction of contrast and then a plateau of contrast
enhancement over time. This lesion has an indeterminate enhancement kinetic pattern. The
likelihood of malignancy with this type of kinetic curve is approximately 64%. Type III curve has
an initial rise with the introduction of contrast and a continuous enhancement of contrast in the
lesion over time. This is a benign type of enhancement kinetic curve. The likelihood of
malignancy with this type of kinetic curve is approximately 6%.

8. When is an MRI-guided biopsy indicated, and what type of scan protocol should be used?
When an area of abnormality is seen on BMRI and cannot be reproduced by either mammog-
raphy or ultrasound, and BMRX may be performed.
A simple protocol is all that is needed for an MRI-guided biopsy. A three-plane localizer is
used to determine that the patient is adequately positioned and 3D sagittal T1-weighted fat
suppressed sequence is used to visualize the breast and lesion. Only the area of the questionable
abnormality needs to be scanned. Be sure to include the face of the compression grid in this
scan. A pre-contrast scan is done to ensure the area of interest is accessible and the fiducial can
be seen.

REFERENCES
1. National Cancer Institute 2008 Surveillance, Epidemiology and End Results. Available at:
[Link] Accessed July 1, 2009.
2. American Cancer Society Guidelines for high-risk screening. Available at:
[Link]
Accessed July 1, 2009.
3. Lehman CD, Gatsonis C, Kuhl CK, et al. MRI evaluation of the contralateral breast in women with recently diagnosed
breast cancer. N Engl J Med. 2007 Mar 29;356(13):1295-1303. Epub 2007 Mar 28.
4. Liberman L, Mason G, Morris EA, Dershaw DD. Does size matter? Positive predictive value of MRI-detected breast
lesions as a function of lesion size. AJR Am J Roentgenol. 2006 Feb;186(2):426-430.
5. Kuhl CK, Mielcareck P, Klaschik S, Leutner C, Wardelmann E, Gieseke J, Schild HH. Dynamic breast MR imaging: are
signal intensity time course data useful for differential diagnosis of enhancing lesions? Radiology. 1999
Apr;211(1):101-110.
6. Berg WA, Gutierrez L, NessAiver MS, Carter WB, Bhargavan M, Lewis RS, Ioffe OB. Diagnostic accuracy of mammog-
raphy, clinical examination, US, and MR imaging in preoperative assessment of breast cancer. Radiology. 2004
Dec;233(3):830-849. Epub 2004 Oct 14.

All images, tables and protocols courtesy of Fairfax Radiological Associates, Fairfax, VA, unless otherwise noted.

©2009, International Center for Postgraduate Medical Education. All rights reserved.