Breast MRI Applications in the Evaluation of Breast Disease
Bernadette A. Redd, MD
X-Ray Associates at Santa Fe
490 A West Zia Road
Santa Fe, New Mexico 87505
Email: bernie.redd@mac.com
Introduction
B
reast MRI is an invaluable tool in the
evaluation of breast disease. It is most im-
portant in the assessment and diagnosis of
breast cancer.
Common indications for breast MRI include:
• Evaluation of high risk patients [6, 12, 14, 20, 21, 28, 30, 31]:
• Breast cancer gene mutation carri-
ers, such as BRCA 1 and BRCA 2
positive patients;
• Personal or family history of breast
cancer;
• Prior biopsy indicating atypia, lobu-
lar carcinoma in situ, or radial scar;
and
• History of radiation to the chest for
Hodgkin’s lymphoma.
• Differentiation of scar from recurrent dis-
ease in patients with a prior history of breast
cancer [4, 8, 11, 23].
• Evaluation of extent of disease in patients
with known breast cancer [1, 2, 3, 5, 7, 16, 18].
Breast MRI Applications in the Evaluation of Breast Disease Bernadette A. Redd, MD
• Assessment of occult breast malignancy in
patients presenting with axillary adenopathy
and unknown primary [22].
• Assessment of response to neoadjuvant
therapy in patients receiving preoperative
chemotherapy prior to breast surgery [25, 26, 33].
• Additional evaluation of selected patients
with inconclusive diagnoses after standard
mammographic and sonographic workup [15].
• Evaluation of breast implant rupture [20].
Breast MRI Interpretation
The principles of breast MRI interpretation are based
on evaluation of tumor kinetic analysis and morpho-
logic analysis. [13, 27, 29, 32].
Tumor kinetic analysis refers to the initial and late
enhancement features of a tumor, after the admin-
istration of contrast. The American College of Ra-
diology BI-RADS lexicon for breast MRI defines
the initial slope of enhancement as the enhancement
pattern within the first two minutes or when the
curve starts to change after contrast administration.
215
The delayed slope is defined as the slope after two
minutes or after the curve starts to change. The ini-
tial slope is described as fast, medium or slow. The
delayed slope is described as persistent, plateau, or
washout. The kinetic curve is a function of temporal
resolution. An ROI cursor, with a minimum of three
pixels, is placed on the most suspicious portion of the
lesion or the fastest enhancing portion of the lesion.
(ACR, BI-RADS BREAST IMAGING LEXICON-
MRI, 2003). Kuhl et al. identified a persistent curve
as predictive of benign disease, a washout curve as
predictive of malignant disease and a plateau curve
as indeterminate [13].
Suspicious lesions are also defined morphologically
as mass or non-mass-like enhancement. Mass-like
enhancement is further characterized by shape, mar-
gin and internal enhancement pattern. Non-mass-
like enhancement is characterized as focal, linear or
ductal. Enhancement distribution for non-mass-like
enhancement is described as segmental, regional,
multiple regions, or diffuse. The internal enhance-
ment pattern for non-mass-like enhancement is also
described. (ACR, BI-RADS BREAST IMAGING
LEXICON-MRI, 2003). Tumor morphologic char-
acteristics are a function of spatial resolution.
Technical Challenges of Breast
MRI Interpretation
• Breast MRI exams frequently have a large
number of images that need to be organized
for efficient interpretation.
• As breast MRI becomes more common, the
need for comparison with prior exams be-
comes more frequent. Prior exams may contain
hundreds of images, sometimes with different
techniques. Side-by-side comparison of images
is necessary for accurate interpretation.
• Accurate assessment of tumor morphology,
location and size often requires the use of
multiplanar reconstruction (MPR) techniques,
maximum intensity projection imaging (MIP),
and subtraction techniques for a complete
description of tumor characteristics.
• Kinetic analysis and measurement tools are
needed to define tumor characteristics.
• Exams contain hundreds of images. It is not
practical to print all images. The breast MRI
workstation needs to be able to print only the
selected pertinent images.
The following are cases illustrating the points dis-
cussed above.

Nunes et al. noted the association of spiculated and ir-

regular borders and increased peripheral rim enhance-
ment of a focal mass with malignancy. Lobulated and
smooth masses had a high negative predictive value
for malignancy. Focal masses with non-enhancing in-
ternal septations were highly associated with benign
disease, and often represented fibroadenomata [24].
Liberman et al. noted that for non-mass-like lesions,
segmental, clumped, linear and ductal enhancement
features were predictive of malignancy [19].

Accurate interpretation of breast MRI exams com-

bines analyses of both temporal and spatial resolu-
tion features of tumors. While MRI has a high sensi-
tivity for the detection of breast cancer [3, 29], the high-
est sensitivity for the detection of breast cancer is
when all modalities (mammography, ultrasound and
MRI) are combined [29]. Accurate MRI interpretation
is dependent on mammographic and sonographic
comparison imaging.

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CASE 1
HIGH RISK PATIENT: HISTORY OF BREAST
CANCER. DENSE BREAST PARENCHYMA ON
MAMMOGRAPHY. DIAGNOSTIC BILATERAL
MAMMOGRAPHY AND BILATERAL ULTRASOUND
IDENTIFIED BENIGN FINDINGS SIX MONTHS PRIOR
TO MRI EXAM.

Figure 1: Pink arrows indicate two rapidly enhancing masses in the left breast. Orange
arrows demonstrate slowly enhancing foci.

Scanner: GE Twin Speed. Technique: One pre-con-

trast and seven post-contrast sequential series, num-
bered on panels from 1-8, of the left breast in the 2D
mode demonstrated. Images are at the same level in
the left breast, obtained at 90-second intervals be-
fore and after the administration of contrast. The first
post-contrast series and the injection of contrast are
initiated simultaneously.

Breast MRI Applications in the Evaluation of Breast Disease Bernadette A. Redd, MD 217
 Figure 2: Enhancing masses are more conspicuous on subtraction imaging. Subtraction is
performed by selecting the “subtract” icon in the top right corner, indicated with a pink arrow.

Figure 3: Panel A is a subtracted MIP (maximum intensity projection) image of the entire left breast obtained from the
second post-contrast subtracted series. The two rapidly enhancing masses are seen in addition to other slowly enhancing
foci. Panels B and C demonstrate ROI (region of interest) analyses of both masses. Both masses demonstrate fast initial
enhancement and delayed phase washout. ROI cursors within the masses are indicated with yellow arrows. The percent
change in signal intensity after contrast administration is indicated on the horizontal axis at the top of each graph. The
corresponding number of the post-contrast series is indicated on the horizontal axis at the bottom of the graph.

218 SECTION 4 Advanced CT and MR Imaging Throughout the Body

 Figure 4a: A parametric map function has recently been released as part of the
AquariusNET toolbox. This function allows a color code to provide a quick assessment
of kinetic analysis as demonstrated above. The area coded with a red color (blue arrow)
corresponds to a region of fast initial enhancement and delayed phase washout. A similar
kinetic pattern is demonstrated with the ROI cursor (yellow arrow) and graph. The percent
change in signal intensity is seen at the top of the graph (pink arrow) corresponding to the
post-contrast series indicated on the bottom (orange arrow).

Figure 4b Enlarged view of the parametric map

function image from Figure 4a.

Breast MRI Applications in the Evaluation of Breast Disease Bernadette A. Redd, MD 219
 Figure 5: Delayed high resolution sagittal images of the left breast identify an irregular or
slightly spiculated margin of the larger mass (panel A), and a relatively smooth margin of
the smaller mass (panel B) indicated with yellow arrows.

Figure 6: MPR (multiplanar reconstruction) display (panels A, C, and D) of the larger mass obtained from delayed high
resolution sagittal images. Distance from the nipple is indicated on the sagittal component of the MPR (panel D). MPR
is useful in defining the exact 3D location of the mass within the breast for localization on follow-up focused ultrasound.
Many lesions identified on breast MRI can be identified on follow-up focused ultrasound evaluation, allowing ultrasound-
guided biopsy access if necessary. If suspicious MRI lesions are not seen on mammography or ultrasound, MR-guided
biopsy can be performed. Panel B is a volume-rendered reconstruction of the left breast.

220 SECTION 4 Advanced CT and MR Imaging Throughout the Body

 Figure 7: Panel A demonstrates the larger mass on a follow-up focused ultrasound. Panel B
demonstrates the two masses located side by side on follow-up ultrasound. Note that the larger
mass margin is irregular/spiculated, and the smaller mass is well-defined with a smooth margin,
on ultrasound. Panel C is the cranio-caudal (CC) mammographic view of the left breast six
months earlier. Panel D is the new CC mammographic view of the left breast performed after the
MRI and after placement of a skin marker indicating the sonographic location of the mass. The
mass is not conspicuous on the mammogram, despite knowing its exact location. Panels E and F
are, respectively, the mediolateral oblique (MLO) view from six months earlier, and the new MLO
view with a skin marker indicating the sonographic location of the mass.

The TeraRecon workstation receives digitized im-

ages of prior and follow-up mammogram and ultra-
sound studies for comparison. Mammogram images
are received on the workstation for comparison pur-
poses only, not for diagnostic interpretation.

Breast MRI Applications in the Evaluation of Breast Disease Bernadette A. Redd, MD 221
 Figure 8: Panel A is an axial MIP image of the left breast from the subtracted second
post-contrast series. Panel B is the analogous CC mammographic view with the skin
marker indicating the site of sonographic abnormality.

The digitized CC mammographic image can then be

rotated, using tools on the TeraRecon workstation, for
comparison with the analogous axial MIP image.

Discussion: The larger mass is suspicious for ma-

lignancy based on morphology and kinetic analysis.
The smaller mass is suspicious for malignancy based
on kinetic analysis but the morphology favors a be-
nign mass. In the final MRI assessment both masses
are characterized as suspicious for malignancy, BI-
RADS 4. Biopsy of both masses recommended.

Final diagnosis: Larger mass invasive ductal

carcinoma. Smaller mass fibroadenoma.

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CASE 2
HIGH RISK PATIENT: BRCA I POSITIVE. NORMAL
MAMMOGRAM SIX MONTHS PRIOR TO THE
RECENT BREAST MRI EXAM.

Figure 9
Increasing focal clumped enhancement (yellow arrow, panel B) is identified in the medial
aspect of the left breast on an axial MIP image of the left breast. Panel A: Axial MIP image
from one year earlier demonstrates milder focal enhancement at the same site.

Pink arrows indicate stable, but suspicious, linear ductal enhancement.

Panel A: Scanner: GE Twin Speed. Technique: 3D, 3

mm overlapping interpolated images obtained at 80
second intervals, reviewed at 1.5 mm spacing. MIP
of second post-contrast series.

Panel B: Scanner: GE Twin Speed. Technique: 3D, 6

mm overlapping interpolated images obtained at 90
second intervals, reviewed at 3 mm spacing. MIP of
second post-contrast series.

Breast MRI Applications in the Evaluation of Breast Disease Bernadette A. Redd, MD 223
 Figure 10: MPR images of subtracted second post-contrast series obtained using 3D mode,
indicated by yellow arrow. Panel A is the axial MPR image, panel C is the coronal MPR image
and panel D is the sagittal MPR image. Panel B is a MIP of the left breast. MPR allows accurate
localization of the lesion for follow-up directed ultrasound.

Figure 11: Axillary adenopathy indicated by yellow arrows on axial T1 image of panel
A and axial fast spin-echo inversion recovery (FSEIR) image on panel B. T1 and FSEIR
images are obtained using a body coil, not the dedicated breast coil, for larger field of
view (FOV) imaging of the chest.

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 Figure 12
Panel A indicates increasing enhancement (yellow arrow) of lesion on thin
section MIP images one year after panel B MIP image (yellow arrow).

Panel C indicates slow initial enhancement and persistent delayed

enhancement kinetic curve.

Panels D and E show a subtle hypoechoic lesion on follow-up focused

ultrasound (pink arrows), corresponding to the site of abnormality noted on the
MRI exam (yellow arrow, panel A).

Discussion: Lesion in the left breast at 8:00 is highly

suspicious for malignancy because of changes in its
morphology, enhancement intensity, and new asso-
ciated axillary adenopathy, despite the kinetic curve
pattern of enhancement. Final MRI assessment, BI-
RADS 5. Biopsy recommended.

Final diagnosis: Invasive carcinoma with

axillary metastasis.

Breast MRI Applications in the Evaluation of Breast Disease Bernadette A. Redd, MD 225
CASE 3
HISTORY OF BREAST CANCER, FOLLOW-UP
BREAST MRI IN HIGH-RISK PATIENT.

Figure 13: Breast MRI axial inversion recovery (IR) image (panel A) and T1-weighted
image (panel B) obtained using a body coil demonstrate bilateral axillary adenopathy,
larger on the right than the left. A follow-up PET CT fusion scan demonstrates increased
activity in the axillae (panels C and D), corresponding to the prominent nodes seen on
the MR exam (panels A and B). Yellow arrows indicate right axillary adenopathy and pink
arrows indicate left axillary adenopathy.

The TeraRecon workstation processes the PET CT

images for comparison imaging with the MR images
from the breast MRI exam. Images of the breast pa-
renchyma, not included, demonstrated no evidence
of residual or recurrent disease of the parenchyma.

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CASE 4
SCAR VS. TUMOR. PATIENT HAS A HISTORY OF A
RIGHT BREAST SCAR FROM A PRIOR BIOPSY OF
Digitized mammogram images are reviewed on the
THE RIGHT BREAST FOR BENIGN DISEASE. workstation for comparison purposes.
Scanner: Siemens Vision.

Figure 14: Panel A is a CC mammographic view one year prior to panel B.

Biopsy of scar (panel A, yellow arrow) was negative for malignancy.
Panel B CC mammographic view one year after panel A mammogram is still
concerning for increasing density at scar site (yellow arrow).

Figure 15: Panel A: New mammographic CC view suggests increasing density of scar.
Panel B: CC mammographic view from one year prior for comparison. Yellow arrows in
panels A and B indicate scar site on mammogram images.
Panel C: Analogous axial MIP image demonstrates a spiculated enhancing mass
corresponding to the scar identified on mammographic CC images. MIP image is of the
second post-contrast subtraction series.

Breast MRI Applications in the Evaluation of Breast Disease Bernadette A. Redd, MD 227
 Figure 16: Two-dimensional review of one pre-contrast and seven post-contrast series
demonstrates rapidly enhancing lesion with delayed phase plateau to washout kinetic
curve. 2D format indicated with orange arrow in the top left corner. ROI placed on a
portion of the enhancing mass demonstrating early enhancement (blue arrow). ROI icon is
selected from the task bar at the top, indicated with the pink arrow.

Note: Motion is present on the fourth post-contrast
image in the bottom left corner. As a result of mo-
tion, the ROI cursor is moved relative to the site of
enhancement. This is reflected in a focal change in
the slope of the curve. The image corresponding to
the focal change in the delayed phase of enhancement
and the slope are seen together explaining the sudden
change in the slope of the curve (yellow arrows).
Discussion: A spiculated enhancing mass with rapid
initial enhancement and delayed plateau/washout ki-
netics corresponding to the site of mammographic
abnormality is highly suspicious for malignancy. Fi-
nal MRI assessment, BI-RADS 5. Excisional biopsy
recommended, since a core biopsy one year earlier
did not demonstrate malignancy.

Scanner: Siemens Vision. Technique: Pre-contrast Final pathology: Invasive lobular carcinoma.
and seven post-contrast series are of the same level
in the right breast, 3 mm thickness, obtained at 90
second intervals before and after the administration
of contrast.

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CASE 5:
SCAR VS. RECURRENT TUMOR. PATIENT
IS S/P RIGHT MASTECTOMY WITH TRAM
FLAP RECONSTRUCTION. RECONSTRUCTED
RIGHT BREAST CONTAINS A NEW PALPABLE
ABNORMALITY OF THE SUPERIOR MEDIAL ASPECT
OF THE RECONSTRUCTED BREAST.
1.7 X 1 X .7 CM MASS SEEN ON ULTRASOUND,
CORRESPONDING TO THE SITE OF PALPABLE
ABNORMALITY. FINE NEEDLE ASPIRATION
POSITIVE FOR MALIGNANCY. (RECURRENT TUMOR
KNOWN AT THE SITE OF PALPABLE ABNORMALITY
PRIOR TO BREAST MRI EXAM. BREAST MRI TO
EVALUATE FOR RECURRENT TUMOR VS. SCAR AT
OTHER SITES.)

Figure 17
Palpable abnormality is at the anastomotic site of the TRAM flap superiorly and medially.
Axial T1 (panel A) and axial FSEIR (panel B) images obtained using a body coil are
compared to early (panel C) and late (panel D) 3D post-contrast images obtained at the
same level using a dedicated breast coil.

Pink arrows indicate clip artifact from prior surgery in the lateral aspect of the
reconstructed breast. Yellow arrows indicate site of palpable abnormality superiorly and
medially, with a milder degree of artifact.

Panel B IR sequence demonstrates a focal mass- Scanner: GE Twin Speed. Technique: 3D axial imag-
like region of signal alteration, inseparable from the es, 3 mm thickness, interpolated images, reviewed at
muscle, with appearance suspicious for invasion of 1.5 mm spacing. Axial T1 (panel A) and axial FSEIR
the medial aspect of the pectoralis major muscle. The (panel B) images, 5 mm thickness.
post-contrast images demonstrate a corresponding
enhancing mass without conspicuous deep invasion
of the muscle.

Breast MRI Applications in the Evaluation of Breast Disease Bernadette A. Redd, MD 229
 Figure 18
Next level to images seen in figure 17 displayed. T1 (panel A) and IR (panel B) images
demonstrate focal thickening and signal alteration of the medial aspect of the pectoralis
muscle, strongly suspicious for deep muscle invasion. Artifact from surgical clips
obscures the area of the mass on the 3D post-contrast gradient echo sequences (panel
C: early post-contrast, panel D: late post-contrast).

Images from different series using different coils are linked together by selecting the
synchronized mode on the task bar at the top (pink arrow).

Discussion: MRI did not demonstrate other findings

suspicious for recurrent disease. Final MRI assess-
ment BI-RADS 6. Patient undergoing treatment with
chemotherapy.

230 SECTION 4 Advanced CT and MR Imaging Throughout the Body

CASE 6
NEW DIAGNOSIS OF BREAST CANCER, BREAST MRI
TO EVALUATE EXTENT OF DISEASE.

Figure 19
Panel A Mammographic image identifies an area of increased density (yellow arrow);
subsequent biopsy confirmed invasive carcinoma. A second, more subtle nodular focus
(pink arrow) is noted posterior to known site of malignancy, initially thought to be benign on
mammography. Mammogram is a right medio-lateral (ML) view digitized and transmitted to
the TeraRecon workstation for comparison purposes.

Panel B: MIP reconstruction in the sagittal plane, analogous to the ML mammographic

view, demonstrates two enhancing masses. Yellow arrow indicates known site of
malignancy. Pink arrow identifies “new” mass.

Scanner: Siemens Avanto. Technique: 3D contrast

images, 1 mm thickness, obtained at 58 second in-
tervals/series.

Breast MRI Applications in the Evaluation of Breast Disease Bernadette A. Redd, MD 231
 Figure 20
Panel A: Selected axial MRI image demonstrates an enhancement curve with
moderate initial phase enhancement and very delayed washout. ROI in mass
indicated with yellow arrow.

Panel B: High resolution delayed sagittal image of the more posterior smaller
mass seen in the axial plane image on panel A, demonstrates a mildly irregular or
spiculated margin (yellow arrow).

Panel C: Follow-up focused ultrasound directed at the site of the smaller, more
posterior mass seen on MRI and mammography identified a well-defined oval mass
(yellow arrow), thought to have a benign appearance sonographically.

Discussion: Second, smaller mass assessed on MRI

as suspicious for malignancy based on morphology.
Biopsy recommended.

Final diagnosis: Both masses invasive

adenocarcinoma, ductal type, low nuclear grade.

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CASE 7
36-YR FEMALE WITH RIGHT-SIDED BLOODY NIPPLE
DISCHARGE AND ABNORMAL GALACTOGRAM.
PATIENT SCHEDULED FOR DUCT EXCISION.
BREAST MRI TO EVALUATE EXTENT OF DISEASE
PRIOR TO SURGERY. NORMAL MAMMOGRAM
(NOT SHOWN). ULTRASOUND DEMONSTRATED A
DILATED DUCT (NOT SHOWN).

Figure 21
MPR images demonstrate focal, non-mass-like, segmental, confluent, uniform
enhancement in the lower outer quadrant. The multiplanar images are identified in
panels A, C, and D. The MIP slab is indicated with the yellow arrows in panels C
and D, and demonstrated in panel B.

Scanner: Siemens Avanto. Technique: 3D images

acquired at 1 mm thickness. Scan time 58 seconds/
series.

Breast MRI Applications in the Evaluation of Breast Disease Bernadette A. Redd, MD 233
 Figure 22: Panels A and B identify a focal enhancing duct (yellow arrows) extending
into the nipple. Both images are sagittal reconstructions produced from primary axial
plane 3D images.

Figure 23: An angled, thin section slab/MIP reconstruction is created to evaluate segmental
enhancement extending to the nipple.

234 SECTION 4 Advanced CT and MR Imaging Throughout the Body

 Figure 24
ROI is placed on the part of the lesion demonstrating greatest enhancement on the earliest post-
contrast series (yellow arrow).

Peak enhancement is noted during the second post-contrast series (pink arrow). Delayed phase
washout is noted (orange arrow) on the last post-contrast series.

The second through eighth post-contrast series are subtracted images.

Breast MRI Applications in the Evaluation of Breast Disease Bernadette A. Redd, MD 235
 Figure 25: MIP images of the right and left breasts in the axial (panel A), sagittal (panel B)
right breast only, and coronal (panel C) planes are created from the second post-contrast
subtracted series. Asymmetric segmental enhancement of much of the lower outer quadrant
of the right breast (yellow arrows) is identified.

Discussion: Findings involving the right breast are

suspicious for malignancy based on morphology, ki-
netic enhancement pattern, history of bloody nipple
discharge and abnormal galactogram. BI-RADS 4.
Biopsy recommended as planned. (Findings in the
left breast are indeterminate. Patient scheduled for a
call back ultrasound of the left breast).

Final pathology of the right breast: Lower outer

quadrant lumpectomy identified 1 cm invasive ductal
carcinoma and extensive DCIS, all margins positive.
Left breast workup pending.

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CASE 8
ASSESSMENT OF OCCULT BREAST MALIGNANCY
IN PATIENT PRESENTING WITH AXILLARY
ADENOPATHY, UNKNOWN PRIMARY.

Figure 26: Screening mammogram demonstrated

axillary adenopathy (yellow arrow, panel A).
No parenchymal abnormality initially identified
mammographically or sonographically.

Figure 27: Panel A: Mammographic axillary adenopathy indicated with yellow arrow on MLO view.
Panels B and C demonstrate level I axillary adenopathy on axial FSEIR (panel B) and T1 (panel C) images.
Panels D and E demonstrate level II axillary adenopathy on axial FSEIR (panel D) and T1 (panel E) images.

Breast MRI Applications in the Evaluation of Breast Disease Bernadette A. Redd, MD 237
 Figure 28: MIP image (panel C) demonstrates a 2.4 x 4.6 cm irregular mass in the upper outer quadrant of
the left breast. The mass is measured by selecting the ruler icon on the task bar (pink arrow).
MIP slab indicated on panels A and D. Cross-bars in panels A, B, and D localize the mass to the upper outer
quadrant of the left breast.

Figure 29: Kinetic analysis indicates moderate initial enhancement and delayed phase plateau pattern.
Scanner: Siemens Avanto. Technique: 3D images acquired at 1 mm thickness; one pre-contrast and five
post-contrast series obtained.

238 SECTION 4 Advanced CT and MR Imaging Throughout the Body

 Figure 30
Panel A: Sagittal reconstruction of the subtracted second post-contrast series gives
another plane for measuring the mass. Distance from the nipple is determined for
localization. Axillary adenopathy is again seen (yellow arrow).

Panel B: ROI placement for kinetic analysis (yellow arrow). Slow initial enhancement and
delayed phase plateau pattern noted. Kinetic pattern will vary depending on the site of the
ROI within the lesion.

Panel C: Follow-up focused ultrasound of the upper outer quadrant of the left breast
identifies a 7 mm mass, considerably smaller than the mass seen on MRI.

Discussion: Mass is assessed on MRI as highly

suspicious for malignancy. (BI-RADS 5). Biopsy
recommended.

Final pathology: Ultrasound-guided biopsy identified

poorly differentiated adenocarcinoma in the upper
outer quadrant of the left breast at the site of MRI
and sonographic abnormality.

Breast MRI Applications in the Evaluation of Breast Disease Bernadette A. Redd, MD 239
 Figure 31
Panels A and C demonstrate MIP images of the left breast showing the
mammographically occult mass (yellow arrows). Axillary adenopathy is indicated with a
pink arrow in panel C.

Panels B, D, and E identify a subtle area of increased parenchymal density on CC (panel

B), ML (panel D), and MLO (panel E) mammographic views (yellow arrows) in the upper
outer quadrant of the left breast corresponding to the mass identified on axial and sagittal
MIP images (panels A and C, respectively). Axillary adenopathy on the sagittal MIP image
(panel C) and on the MLO mammographic view (panel E) is indicated with a pink arrow.

The digitized mammographic images are transmitted

to the TeraRecon workstation for comparison pur-
poses. Mammogram images are rotated at the work-
station for analogous viewing with MIP images.

240 SECTION 4 Advanced CT and MR Imaging Throughout the Body

 Figure 32
Side-by-side comparison of subtracted axial images from pre- (panel A) and post- (panel B)
neoadjuvant chemotherapy breast MRI exams provide the most accurate assessment of response
to neoadjuvant therapy. Subtraction processing is rapidly performed at the workstation by
selecting the “subtract” icon (see Figure 2). Processed DICOM subtracted images are saved for
direct comparison with prior exam.

New bone marrow enhancement of the sternum in panel B (yellow arrow) indicates reactive bone
marrow change due to neoadjuvant therapy.

Breast MRI Applications in the Evaluation of Breast Disease Bernadette A. Redd, MD 241
 Figure 33
Panel A: Axial MIP image of post-contrast subtracted series, demonstrating mass (yellow arrow)
prior to neoadjuvant chemotherapy.

Panel B: Axial MIP image of last post-contrast subtracted series after neoadjuvant chemotherapy
demonstrates site of previously noted mass (yellow arrow). Minimal residual enhancement (yellow
arrow) is suggestive of fibrosis and/or minimal residual disease.

It is important to review the last post-contrast series

closely for evidence of residual disease in post-neo-
adjuvant therapy patients. Tumor kinetics frequent-
ly change after the administration of neoadjuvant
therapy. Residual disease can demonstrate subtle
enhancement.

Final pathology (after neoadjuvant chemotherapy):

5 mm focus of DCIS with findings suspicious for
invasion. Nodes negative.

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CASE 9:
ASSESSMENT OF RESPONSE TO
NEOADJUVANT THERAPY

Figure 34
Panels A and B: Single slice images from early and late post-contrast 3D gradient echo
subtracted images indicate large tumor burden with prominent enhancement and washout
on visual inspection.

Panels C and D: Follow-up exam subtracted images at comparable levels linked to the prior
exam, for direct assessment of change in tumor burden during the course of neoadjuvant
chemotherapy. At this point in treatment, MRI findings indicate a partial response to
neoadjuvant chemotherapy.

Hard-copy prints of selected images can be obtained

by selecting the “output” folder icon at the top of
the page (pink arrow). Images can be captured in the
folder and then printed (lower pink arrow) for distri-
bution with the written report. Images in the output
folder can be viewed in the folder to the right of the
active images.

Breast MRI Applications in the Evaluation of Breast Disease Bernadette A. Redd, MD 243
CASE 10
ASSESSMENT OF RESPONSE TO NEOADJUVANT
THERAPY IN A 27-YR.-OLD WITH A LARGE TUMOR
AT PRESENTATION.

Figure 35
Sequential 2D (orange arrow) fat suppressed T1-weighted gradient echo
images before (panel A) and after the administration of contrast (panels B-H)
demonstrate an enhancing mass with necrotic and solid components. Visual
inspection of the mass over time demonstrates rapid initial enhancement and
delayed phase washout (yellow and pink arrows, respectively).

Panel H: Post-contrast images indicate tumor is close to the pectoralis major

muscle (pink arrow).

244 SECTION 4 Advanced CT and MR Imaging Throughout the Body

Figure 36: Panel A: High resolution delayed sagittal image indicates superficial
contact of the tumor with the pectoralis major muscle.

Panel C: Axial MIP image indicates two enhancing masses (yellow arrows) and
smaller, less specific focus of enhancement (pink arrow).

Panels B and D are post-neoadjuvant therapy images, suggesting a complete

response to therapy (yellow arrows). Persistent, small, non-specific focus of
enhancement seen (pink arrow).

Final MRI assessment: Complete response to neo-

adjuvant therapy. BI-RADS 6. Pathologic correla-
tion recommended.

Final pathology: No residual malignant disease.

Breast MRI Applications in the Evaluation of Breast Disease Bernadette A. Redd, MD 245
CASE 11
ADDITIONAL EVALUATION IN PATIENT WITH
INCONCLUSIVE DIAGNOSIS AFTER STANDARD
MAMMOGRAPHIC AND SONOGRAPHIC WORKUP.
DIAGNOSTIC MAMMOGRAPHIC WORKUP
IDENTIFIED A SPICULATED 2 CM MASS DEEP IN
THE SUPERIOR MID-REGION OF THE LEFT BREAST.
ULTRASOUND IDENTIFIED A 2 CM INCREASED
ECHOGENICITY MASS. BIOPSY OF THE MASS
IDENTIFIED FIBROSIS WITH NO EVIDENCE OF
MALIGNANCY. ARE MAMMOGRAPHY FINDINGS
DISCORDANT WITH THE PATHOLOGY?

Figure 37
Panels A, B, and C demonstrate a persistent mass-like density (yellow arrows). A spiculated
margin is seen on the CC compression view (panel B).

246 SECTION 4 Advanced CT and MR Imaging Throughout the Body

 Figure 38
Non-fatty parenchymal tissue (yellow arrows) is seen on delayed post-contrast MRI sagittal image
(panel A) and on non-contrast T1-weighted images (panels B and D) corresponding to the area of
mammographic abnormality (panels C and E, yellow arrows).

Sagittal MRI images (panels A and B) are compared with an MLO cone compression view (panel
C). An axial T1-weighted image (panel D) is rotated for comparison with a compression CC
mammographic view (panel E).

Breast MRI Applications in the Evaluation of Breast Disease Bernadette A. Redd, MD 247
 Figure 39
T1-weighted axial (panel A) and FSEIR axial (panel B) images are linked (pink arrow) to early and late post-
contrast images (panels C and D, respectively). MR images are compared at a level corresponding to the
mammographic abnormality (panel A, yellow arrow). No enhancement of breast parenchyma is seen on the
post-contrast images (panels C and D).

Discussion: Mammographic abnormality is consistent

with an area of parenchymal fibrosis.

Final assessment: Benign findings, BI-RADS 2.

248 SECTION 4 Advanced CT and MR Imaging Throughout the Body

CASE 12
EVALUATION OF BREAST IMPLANT RUPTURE

Figure 40
Panel A: Sagittal FSEIR image with water suppression identifies a retropectoral silicone implant. The
orange arrow indicates the pectoralis major muscle. Yellow arrows indicate the implant shell pulling
away from the fibrous capsule, indicative of intracapsular rupture with mild collapse.

Panel B: Coronal plane FSEIR of the same breast demonstrates a focal area of implant herniation
through the fibrous capsule (pink arrow).

Breast MRI Applications in the Evaluation of Breast Disease Bernadette A. Redd, MD 249
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