MRI BREAST

PROTOCOL
Breast Cancer
• Dedicated breast coil
• STIR and/or T2 (look for cysts, lymph nodes very bright,
mucinous CA)
• T1 no fat sat (look at lymph nodes, fat necrosis, bone
marrow)
• Pre-contrast T1 w/ fat sat (look for intrinsic increased T1
signal, e.g. inspusated secretions or blood in duct)
• Post-contrast T1 w/ fat sat – dynamic acquisition
• Subtraction images
• CAD Stream – to assess enhancement patterns
• Optimal time to image in pre-menopausal patient – day 7-
14 due to hormonal stimulation of glandular tissue
 MR BI-RADS LEXICON
Enhancing Lesions – Lesion Type
• Mass – space occupying lesion (can
appreciate in 3 dimensions).
• Non-masslike enhancement – within
fibroglandular tissue, appears normal on
pre-contrast images.
• Focus – enhancing area less than 5 mm,
difficult to further characterize.
 MASS MORPHOLOGY
• Shape – round, oval, lobular, irregular
• Margins – smooth, irregular, spiculated
• Mass internal enhancement – homogeneous,
heterogeneous, rim, dark internal septations,
enhancing internal septations, central
enhancement
 MASS-IRREGULAR MARGINS,
HETEROGENEOUS ENHANCMENT
 MASS –
HOMOGENEOUS ENHANCMENT
 MASS
• Differential - invasive breast cancer, benign
solid tumor (fibroadenoma, papilloma),
lymph node, fat necrosis
• Enhancement kinetics can help
• Caveat – if enhancing mass morphology
looks like CA, suspicious regardless of
kinetic data
 ENHANCEMENT PATTERNS
(KINETICS)
• Enhancement within cancer often best seen vs.
background tissue in early post-contrast phase (1-
2 minutes)
• “Washout” can be seen with breast CA, evaluate at
3 minutes
• Not all breast CA will wash out
• We evaluate contrast enhancement at 1 min,
• Kinetic data plotted and viewed with CAD Stream
software
 Kinetic Patterns
• Early phase of enhancement (1st part of kinetic
curve)
– 1-2 minutes post contrast administration
– Describe steepness of curve, slow, medium, rapid
• “Delayed” phase of enhancement (not truly
delayed, just evaluation of signal intensity
immediately after the early phase)
– 3 minutes after contrast administration
– Decline (“washout”), plateau, continue to rise
(persistent)
Kinetic Patterns
 MASS
MORPHOLGY

suspicious probably benign Benign

(lymph node)
done
2nd look US kinetics
or biopsy despite
kinetics

suspicious – benign –
2nd look US or biopsy 6 month follow-
up
 Invasive Breast CA
• Morphology often irregular, spiculated
margins (but does not have to be)
• Internal enhancement often heterogeneous
or irregular/thick rim enhancement
• Kinetics often rapid early enhancement
with washout or plateau
Cancer

Irregular, spiculated mass

with heterogeneous rapid
enhancement and washout
 Fibroadenoma
• Focal mass – round or oval with smooth margins
• Can have homogeneous enhancement with dark
septations (dark septations due to internal
lobulated composition)
• Kinetics often rapid early enhancement with
plateau
• Enhancement variable due to degree of
sclerosis/fibrosis (more sclerosis, less
enhancement, sclerosis dark on T2)
Lobular Mass, Smooth Margins =
Fibroadenoma
 Fibroadenoma

Lobular,
smooth mass
with dark
internal
septations

Post-Gd T2
 Lymph Node
• Look for fatty hilum on T1 no fat sat
• Bright on STIR/T2
• Often adjacent vessel
• Enhancement – usually “suspicious”
kinetics
TI FAT/SAT SUBTRACTION STIR

T1 NON-CONTRAST/NO FAT SAT

 NON-MASSLIKE
ENHANCEMENT
• Distribution – focal, linear, ductal,
segmental, regional, multiple regions,
diffuse (emphasis on whether oriented
along ductal distribution or not)
• Additional descriptors – homogeneous,
heterogeneous, stippled/punctate, clumped,
reticular/dendritic
• Symmetric vs. asymmetric
 T1 FAT SAT POST CONTRAST
NO SUBTRACTION WITH SUBTRACTION
 NON-MASSLIKE
ENHANCEMENT
• Differential – intraductual CA (DCIS),
lobular CA, mastopathic changes (focal
adenosis), hormonal stimulation
• Use kinetics with caution (only helpful
when suspicious)
 DCIS
• Non-masslike enhancment that follows
ductal system (segmental or linear
distribution)
• Enhancement often clumped or stippled
• Kinetics unreliable
 DCIS
• Linear, beaded pattern
of enhancement
DCIS
 Lobular CA
• Due to diffuse growth pattern, invasive
lobular CA will often not appear as focal
mass but as non-masslike enhancement
• Kinetics unreliable
Hormonal Stimulation
 Hormonal Stimulation
• If screening MRI, try to image at best time
(week 2 of menstrual cycle – we aim for
day 7-10 but day 7-14 acceptable, most
stimulation/background enhancement week
1 and 4)
Fibrocystic Change

Diffuse, stippled
enhancement usually with
associated T2
hyperintensities
 FOCUS OF ENHANCEMENT
• Enhancing area less than 5 mm
• Too small to further characterize
• Recommendations depend on other findings
(single, multiple, symmetry, risk status of
patient)
 OTHER FINDINGS
• Nipple retraction
• Nipple invasion
• Pre-contrast high duct signal
• Focal skin thickening
• Diffuse skin thickening
• Skin invasion
• Edema
• Lyphadenopathy
• Pectoralis muscle invasion
• Chest wall invasion
• Hematoma/blood
• Abnormal signal void (clip)
• Cysts
 BACKGROUND
ENHANCMENT
• Sensitivity of breast MRI for CA dependent on
degree of background enhancement of
fibroglandular tissue (background enhancement
may mask enhancing breast CA)
• Report degree of background enhancement
– Severe background enhancement – strong,
multifocal/diffuse fibroglandular enhancement
– Mild to moderate background enhancement
– Absence of background enhancement
 LYMPH NODES
• Evaluate axillary regions, internal
mammary region, mediastinum,
supraclavicular region for lymphadenopathy
• Look for normal fatty hilum on T1 no fat
sat
• Bright on STIR/T2
• Often adjacent vessel
• Enhancment – usually “suspicious” kinetics
NORMAL LYMPH NODES - STIR
Suspicious mass with axillary
LAD
Abnormal internal mammary
lymph node
 CYSTS
• Very bright on STIR/T2
• Can be multiple and can change in size
• On pre-contrast T1
– if simple iso to darker than surrounding tissue
– if contain protein from blood products can be
intermediate-to-high signal
• On post-contrast T1
– if simple no enhancement
– if inflammation may have thin peripheral enhancement
STIR - CYST
CASES
DCIS
INVASIVE DUCTAL, ABNORMAL
AXILLARY LYMPH NODE WITH
NODAL EXTENSION
DCIS WITH FOCUS OF
INVASION
 T1 FAT SAT POST CONTRAST
NO SUBTRACTION WITH SUBTRACTION
INFLAMMATORY
BREAST CANCER
T1 FAT SAT POST W/
SUBTRACTION
LARGE AREA DCIS
STIR POST SUBTRACTION
MULTIPLE SIMPLE CYST WITH
SINGLE INFLAMMATORY CYST
T1 FAT SAT SUBTRACTION
AXIAL STIR
INVASIVE DUCTAL CA LEFT,
RIGHT LUNG MASS
 Clinical history:
47 year old female with remote left
mastectomy for malignancy. New
right axillary LAD, which was
biopsied and found to be breast
cancer. Right mammo stable with
dense breasts.