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By: Nour-Eldin A. Nour-Eldin Ref: Werner A. Kaiser, 2008

1. Round shape The round or spherical shape is defined in the first postcontrast image, usually 90 seconds after injection of the contrast agent.

Precontrast Subtraction 1min T2WI STIR image 1min Post contrast2min Post contrast 7min Post contrast Subtraction 2min Subtraction 7min

A round mass lesion is frequently a cyst, myxoid fibroadenoma, or papilloma. Less commonly a myxoid or medullary carcinoma may appear round, although carcinomas will show at least some evidence of peripheral infiltration into surrounding tissues. Interpretition:

2. Oval shape An elliptical or egg shape.

Precontrast Subtraction 1min T2WI STIR image 1min Post contrast2min Post contrast 7min Post contrast Subtraction 2min Subtraction 7min

Elliptical or oval shapes may occur with cysts, myxoid fibroadenomas, and papillomas. Myxoid carcinomas also have relatively well-defined rounded or oval margins. Circumscribed mastitis or a small noninvasive carcinoma (DCIS, approximately 5 mm in size) may have an oval shape with ill-defined margins. Interpretition:

3. Lobulated shape An undulating contour.

Precontrast Subtraction 1min T2WI STIR image 1min Post contrast2min Post contrast 7min Post contrast Subtraction 2min Subtraction 7min

A wavy, lobulated contour is generally the hallmark of a benign lesion, as malignancy generally does not allow for regular, harmonious, undulating contours. Interpretition:

4. Irregular shape An uneven shape; not round, oval, or lobulated.

Precontrast Subtraction 1min T2WI STIR image 1min Post contrast2min Post contrast 7min Post contrast Subtraction 2min Subtraction 7min

Irregular contours of a mass lesion are generally the hallmark of invasive cancers such as invasive ductal carcinoma, lobular carcinoma, and other types. Some noninvasive carcinomas may also have at least partially irregular margins. Interpretition:

5. Well-circumscribed Margin Lesion margins are assessed in the first postcontrast image, usually 90 seconds after the injection of 0.1 mmol/kg body weight gadolinium-DTPA.

Precontrast Subtraction 1min T2WI STIR image 1min Post contrast2min Post contrast 7min Post contrast Subtraction 2min Subtraction 7min

Sharp, well-circumscribed margins are the hallmark of a cyst, fibrous fibroadenoma, myxoid fibroadenoma, or papilloma. Interpretition:

6. Irregular margins Uneven margins, may be round or spiculated; characterized by thin infiltrating lines.

Precontrast Subtraction 1min T2WI STIR image 1min Post contrast2min Post contrast 7min Post contrast Subtraction 2min Subtraction 7min

Irregular margins are typical of invasive carcinomas as well as fibrotic scars with adenosis. Inflammatory masses also tend to have irregular margins (mastitis, abscess), especially after percutaneous biopsy. Interpretition:

7. Blooming sign The lesion margins are sharply defined in the first postcontrast image, then become increasingly unsharp just outside the lesion.

the blooming sign is a typical feature of invasive carcinoma. It may be caused by closely adjacent perifocal inflammation or the activation of tumor angiogenesis. Interpretition:

8. Contrast Sharpness Sign The lesion remains sharply defined throughout the dynamic study. Sharp margins are maintained until the last dynamic postcontrast image (usually 7 minutes after contrast injection).

Precontrast Subtraction 1min T2WI STIR image 1min Post contrast2min Post contrast 7min Post contrast Subtraction 2min Subtraction 7min

Constant sharpness throughout the dynamic study generally signifies a benign lesion, i.e., a fibroadenoma or papilloma. Rarely, medullary carcinomas may also appear sharp throughout the dynamic scans, but in most cases they display subtle infiltrative signs and a blooming sign. Interpretition:

9. Homogeneous Enhancement Complete, uniform enhancement in all portions of the mass.

Precontrast Subtraction 1min T2WI STIR image 1min Post contrast2min Post contrast 7min Post contrast Subtraction 2min Subtraction 7min

Homogeneous enhancement is far more common in benign lesions such as papilloma and myxoid fibroadenoma. Some very small cancers may have this appearance, but most will show centripetal ring enhancement and fine peripheral spiculations. Interpretition:

10. Heterogeneous Enhancement Mixed granular enhancement within the mass; nonspecific enhancement that does not show a ring pattern.

Precontrast Subtraction 1min T2WI STIR image 1min Post contrast2min Post contrast 7min Post contrast Subtraction 2min Subtraction 7min

Heterogeneous enhancement is typical of calcified macrofibroadenoma. Benign or malignant lesions may also display this sign following percutaneous biopsy or hemorrhage. Interpretition:

11. Centrifugal Enhancement The enhancement is initially more pronounced at the center of the mass and then spreads toward the periphery (“filling in from inside to outside”).

Centrifugal enhancement does not support a diagnosis of carcinoma and is much more consistent with a benign lesion. Interpretition:

12. Centripetal Enhancement Peripheral ring enhancement occurs initially and then spreads toward the center of the mass (“filling in from outside to inside”).

Precontrast Subtraction 1min T2WI STIR image 1min Post contrast2min Post contrast 7min Post contrast Subtraction 2min Subtraction 7min

Centripetal enhancement is the classic enhancement pattern of carcinoma. The portions of the tumor that are most viable and have the best blood supply are located at the periphery of the mass and show the greatest contrast uptake. The center of the tumor, meanwhile, is an area of necrosis, fibrosis, or hemorrhage, causing a delay in contrast uptake. Interpretition:

13. Dark internal septations Sharp, low-intensity, nonenhancing lines visible within the mass throughout the dynamic study.

Precontrast Subtraction 1min T2WI STIR image 1min Post contrast2min Post contrast 7min Post contrast Subtraction 2min Subtraction 7min

Hypointense, nonenhancing septations within a lesion are generally a benign sign, because a carcinoma wound tend to erode, infiltrate, or break down internal septa. Interpretition:

14. Enhancing Internal Septations Lines within a mass that enhance after contrast administration.

Precontrast Subtraction 1min T2WI STIR image 1min Post contrast2min Post contrast 7min Post contrast Subtraction 2min Subtraction 7min

Enhancing septations within a mass lesion are very suspicious for an inflammatory process (abscess) or a malignant tumor. Generally they do not indicate invasive ductal carcinoma, however. They are more characteristic of a metastasis, lymphoma, medullary carcinoma, lobular carcinoma, or an illdefined linear necrotic area within a carcinoma. Interpretition:

15. Segmental Enhancement Granular, triangular area of enhancement pointing toward the nipple. This sign may be present in one or more ducts. All types of enhancement curve may be seen. Usually limited to one breast.

Precontrast Subtraction 1min T2WI STIR image 1min Post contrast2min Post contrast 7min Post contrast Subtraction 2min Subtraction 7min

A segmental, usually triangular area of enhancement pointing toward the nipple is a typical sign of noninvasive carcinoma (DCIS), particularly when it is unilateral and is relatively well demarcated from other, unaffected areas of the breast parenchyma. The segmental pattern refers to the overall collection of small foci and/or infiltrative changes, which have a granular or reticular appearance. Mastitis may appear as a triangular enhancing area, but this is uncommon. Interpretition:

16. Hypointensity on T2- weighted TSE images The signal intensity of the viable portions of the lesion on T2-weighted turbo spin-echo images is lower than the signal intensity of normal surrounding breast parenchyma.

Precontrast Subtraction 1min T2WI STIR image 1min Post contrast2min Post contrast 7min Post contrastSubtraction 2min Subtraction 7min

A mass lesion whose T2-weighted signal intensity is less than or at most equal to that of the normal glandular tissue may be a carcinoma or fibrous fibroadenoma. Interpretition:

17. Isointensity on T2- weighted TSE images The signal intensity of the viable parts of the lesion on T2- weighted turbo spin-echo images is in the same range as that of normal surrounding breast parenchyma.

Precontrast Subtraction 1min T2WI STIR image 1min Post contrast2min Post contrast 7min Post contrast Subtraction 2min Subtraction 7min

Isointensity is typically seen in fibrous fibroadenomas and myxoid fibroadenomas that have slight intralesional hemorrhage after biopsy. Carcinomas may have the same signal intensity as the surrounding glandular tissue on the T2-weighted TSE image, but they are usually hypointense to breast parenchyma Interpretition:

The signal intensity of the viable parts of the lesion on T2- weighted turbo spin-echo images is higher than that of normal surrounding breast parenchyma. Areas of intratumoral necrosis, if present, are disregarded. 18. Hyperintensity on T2- weighted TSE images

Precontrast Subtraction 1min T2WI STIR image 1min Post contrast2min Post contrast 7min Post contrast Subtraction 2min Subtraction 7min

Hyperintensity is an important differentiating criterion between myxoid fibroadenomas and carcinomas. Carcinomas are dark on the T2-weighted TSE image, while myxoid fibroadenomas are generally brighter than the glandular tissue. Interpretition:

19. Hook sign The hook sign is a fine, thread-like connection passing from the lesion to the pectoralis muscle. Usually this line shows little or no enhancement after contrast administration.

Precontrast Subtraction 1min T2WI STIR image 1min Post contrast2min Post contrast 7min Post contrast Subtraction 2min Subtraction 7min

The hook sign in a lesion with a malignant-type enhancement curve strongly supports a diagnosis of carcinoma. Found in many carcinomas, the hook sign may be quite small and may even extend a considerable distance from the pectoralis muscle Interpretition:

20. Root sign The root sign refers to a localized irregularity, usually enhancing, in the margins of a lesion.

Precontrast Subtraction 1min T2WI STIR image 1min Post contrast2min Post contrast 7min Post contrast Subtraction 2min Subtraction 7min

The root sign is a small irregularity in the margins of a lesion that is otherwise sharply circumscribed. This feature may represent a fibroadenoma with localized peripheral fibrosis or a well-circumscribed carcinoma, usually of the medullary type, with an associated DCIS border. Interpretition:

21. No Enhancement MRI signal intensity increases by less than 2% after the injection of 0.1 mmol/kg body weight gadolinium- DTPA during the first 90 seconds after contrast injection and also within the first 7 minutes.

Precontrast Subtraction 1min T2WI STIR image 1min Post contrast2min Post contrast 7min Post contrast Subtraction 2min Subtraction 7min

1.Basically this sign is a very strong indicator of a benign condition (adenosis, fibrous fibroadenoma, scar, fat necrosis, etc.). 2.It can also be seen in scar tissue that is more than 6 months old. Interpretition:

22. Slow wash-in (“Wash-in” describes the maximum rise of signal intensity that occurs during the first 90 seconds after the injection of 0.1 mmol/kg body weight gadolinium-DTPA or a similar contrast agent.) In cases with slow wash- in, the MRI signal intensity increases by less than 50% over the precontrast signal intensity within 90 seconds after injection of the contrast agent.

Precontrast Subtraction 1min T2WI STIR image 1min Post contrast2min Post contrast 7min Post contrast Subtraction 2min Subtraction 7min

basically describes a slow rate of initial contrast enhancement. This pattern is typically seen in fibrous fibroadenomas, scars, and foci of adenosis. Interpretition:

23. Medium wash-in Wash-in” describes the maximum rise of signal intensity that occurs during the first 90 seconds after the injection of 0.1 mmol/kg body weight gadolinium-DTPA or a similar contrast agent.)

Precontrast Subtraction 1min T2WI STIR image 1min Post contrast2min Post contrast 7min Post contrast Subtraction 2min Subtraction 7min

The moderately intense initial enhancement of a mass lesion is most commonly seen in a fibroadenoma or papilloma. Less frequently it occurs in carcinomas after chemotherapy. Medium wash-in occurring in a non-mass lesion may indicate mastitis, a fresh scar, or a hormonal effect Interpretition:

24. Fast wash-in A maximum signal increase of more than 90% occurs within 90 seconds after injection of the contrast agent (0.1 mmol/kg body weight gadolinium-DTPA). This sign is also known as the “90/90 rule.”

Precontrast Subtraction 1min T2WI STIR image 1min Post contrast2min Post contrast 7min Post contrast Subtraction 2min Subtraction 7min

Rapid initial enhancement immediately after contrast administration is typical of invasive carcinoma but may also been seen in focal components of noninvasive carcinoma (DCIS). Approximately 20% of papillomas and myxoid fibroadenomas exhibit a fast wash-in curve. Interpretition:

25. Plateau curve No further rise of signal intensity occurs in the enhancement curve after 90 seconds or after the curve has started to change.

Precontrast Subtraction 1min T2WI STIR image 1min Post contrast2min Post contrast 7min Post contrast Subtraction 2min Subtraction 7min

When the enhancement curve of a mass lesion plateaus after the initial upslope, a carcinoma or papilloma should be considered. This pattern is less commonly seen in myxoid fibroadenoma. Interpretition:

26. Rising curve Progressive rise in the enhancement curve occurs after 90 seconds or after the curve has started to change.

Precontrast Subtraction 1min T2WI STIR image 1min Post contrast2min Post contrast 7min Post contrast Subtraction 2min Subtraction 7min

Signal intensity that continues to increase after the initial wash-in most likely indicates a benign mass lesion such as myxoid fibroadenoma or papilloma. Interpretition:

27. Washout curve A decline in signal intensity occurs after the initial upslope during the first 90 seconds or when the curve has started to change.

Precontrast Subtraction 1min T2WI STIR image 1min Post contrast2min Post contrast 7min Post contrast Subtraction 2min Subtraction 7min

Washout, defined as a decline of signal intensity occurring after an initial rise, is the main kinetic criterion for breast cancer. The rapid washout of Gd-DTPA from these lesions is most likely caused by the arteriovenous shunts that exist within the network of tumor vessels. Interpretition:

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