2. Technique and Indications Karen Dec M.D. Skagit Radiology, Inc.
Breast MRI:
Technique and Indications
Karen Dec M.D.
Skagit Radiology, Inc.

3. Fundamentals of Contrast Enhanced Breast MRI
Principles of Breast MRI
Technique
Adjunctive Ultrasound
Clinical Indications
Accuracy

4. Principles of Breast MRI
                                                                    
Principles of Breast MRI
Angiogenesis = Abnormal tumor
vessels produce neovascularity
Top left: Implanted cancer cells glow with
green fluorescence protein.
Top right: Three of the original cancer cells have
survived to begin replicating. Signals between the
existing blood vessel and the growing cancer cells
cause the cells to grow toward the vessel.
Bottom left: The cancer cells have reached the
existing blood vessel.
Bottom right: When they number only ,
the cancer cells have created new, fully-functioning
blood vessels.
Graphic illustration by Stanley Coffman, Duke
University Medical Center

5. Principles of Breast MRI
Neovascularity characterized by:
Low resistance, high flow
AV shunting, pooling
Abnormal endothelial permeability
Cancers enhance early and intensely
                 

6. Principles of Breast MRI
                                      
Principles of Breast MRI
Virtual Map of Angiogenesis
Pre-Contrast Post -Contrast

7. Technique Overview Prone positioning
Breast placed in individual holders within coils
Images obtained prior to and following gadolinium administration
6 imaging sequences
- Spatial resolution
- Temporal resolution

8. Technique: MRI Sequences
Coronal Stir Chest
Lymph Nodes
Axillary
Supraclavicular
Internal mammary
Lung Parenchyma
Liver
Bones

9. Technique: MRI Sequences
Axial Stir Breast
Lymph Nodes
Edema
Cysts
STIR axial MR image shows marked asymmetry in appearance of breasts. Left breast has diffusely increased signal within parenchyma and
skin, suggesting diffuse breast edema and skin thickening (arrow).

10. Technique: MRI Sequences
Axial Pre-Contrast and Dynamic Post-Contrast 3D FLASH x 5
Cancers
Other Masses
Draining Veins
Pre-Contrast Minute Post-Contrast Minutes Post-Contrast

11. Technique: MRI Sequences
Axial “VIEWS” MIPS
Volume Interpolated Exam under Water Stimulation
High spatial resolution
Entire case can be displayed for clinicians

12. Technique: MRI Sequences
Diffusion Imaging (DWI)
Measures the mobility of water in tissue
Sensitive to characteristics often disrupted in malignant breast tissues, such as cell organization, density, extracellular space and cell membrane permeability
DWI may be useful for detecting breast cancer in a wide age group of women, including young women with dense mammary glands.*
*Radiation Medicine, 2007, Vol. 25:

13. Assessment Morphologic: Similar to mammography and ultrasound
Dynamic: Blood flow physiology by evaluating dynamic enhancement curves

14. Dynamic Enhancement Patterns
Washout
Plateau (biphasic)
Progressive (monophasic)
Normal

15. Benign Enhancement Pattern
Progressive (monophasic)
Normal

16. Malignant-like Enhancement
Washout
Normal

17. Digital Mammography Primary tool for breast cancer screening
Breast MRI is an adjunct
Mammogram is more sensitive in detection of Ductal Carcinoma in Situ (DCIS)
Can determine if lesion amenable to stereotactic guided biopsy

18. Adjunctive Breast Ultrasound
Accurate, high resolution
breast sonography essential
in localizing lesions for
potential percutaneous
needle tissue sampling

19. Clinical Indications Screening of High-Risk Women
Pre-Operative Staging
Contralateral Breast Cancer in Newly Diagnosed Breast Cancer
Lobular Cancer
Occult Breast Cancer
Close or Positive Surgical Margins
Post-operative Scar vs. Tumor Recurrence
Neo-Adjuvant Chemotherapy
Implants and Known or Suspected Cancer
Problematic Mammogram

20. High Risk Screening
Annual Breast MRI and Mammography Screening is Recommended
for Women Who Have:
BRCA1 or BRCA2 gene mutation
First degree relative with BRCA1 or BRCA2 gene mutation and have not been tested themselves
Lifetime risk of breast cancer has been scored at 20-25% or greater, based on one of several accepted risk assessment tools that look at family history and other factors
Chest wall radiation between the ages of 10 and 30 at dosages above 4 Gy
Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or may have one of these syndromes based on a history in a first-degree relative

21. High Risk Screening Decisions should be made on a case by case basis.
Currently there is insufficient evidence to recommend for or against annual
breast MRI screening in women who:
have a lifetime risk of 15-24% as defined by several accepted risk assessment tools, such as BRACAPRO,
that look at family history and other factors
have lobular carcinoma in situ (LCIS)
have atypical ductal hyperplasia (ADH)
have heterogeneously or extremely dense breasts on mammography (refer to first line of report)
Have a personal history of breast cancer including ductal carcinoma in situ (DCIS)
Decisions should be made on a case by case basis.

22. Clinical Indications Pre-Operative Staging Index tumor Size
Multi-focality or multi-centricity
Involvement of skin, pectoral muscle, chest wall
Contralateral breast
Lymph node status
Hematogenous metastases

23. Clinical Indications Detection of Contralateral Breast Cancer in Newly
Diagnosed Breast Cancer
As many as 10% of women with breast cancer will develop a new tumor in the opposite breast with a negative mammogram and physical exam at the initial time of diagnosis.
Finding cancers earlier may help women make treatment decision, potentially sparing additional surgery, radiation therapy and chemotherapy later.
UW Researchers performed breast MRI on 969 patients with newly diagnosed breast cancer and detected 30 early stage tumors not detected on mammogram or physical exam *
Memorial Sloan Kettering found contralateral breast cancer more often identified when index cancer was infiltrating lobular carcinoma **\
* NEJM 2007 vol. 356,No. 13:
** AJR 2003, vol. 180:

24. Clinical Indications Lobular Infiltrating Carcinoma
Insidious cancer- Difficult to detect on
mammography and physical exam
Multifocal / multi-centric in up to 35% of cases and bilateral in 10%
Frequent cause of positive lumpectomy margins

25. Clinical Indications Occult Breast Cancer
About 0.3% of breast cancers present with malignant axillary lymph nodes, but normal breast exams and mammograms
Mastectomy standard treatment for occult malignancy
Up to 2/3 can be localized with MRI allowing breast conservation surgery

26. Clinical Indications Close or Positive Surgical Margins
Up to 50% of lumpectomies have inadequate margins, requiring additional resection
MRI can locate residual or additional tumor foci
Applied pre-operatively, MR significantly decreases re-operations

27. Clinical Indications Post-operative Scar vs. Tumor Recurrence
At 6 months or more after surgery
“Mature scar”, which may simulate cancer morphologically, does not enhance
Recurrent tumor shows malignant-like enhancement curve

28. Clinical Indications Neo-adjuvant Chemotherapy
MRI improves the “T” classification as well as staging
Can document tumor response to chemotherapy

29. Clinical Indications Implants and Known or Suspected Cancer
MRI is not affected by implants or silicone
Improves diagnostic confidence
Allows U/S guided needle biopsy prn
Women with history of silicone injections can benefit from MRI screening

30. Clinical Indications Inappropriate Indications:
Screening for Average Risk Women
Screening for Women with Less than 15% Lifetime Risk
As a Replacement for Mammography or Sonography
To Biopsy or Determine the Need for Biopsy of a Suspicious Lesion Detected by Other Methods: Mammography, Ultrasound, and Physical Exam

31. Accuracy Varies Considerably with Different Techniques
Sensitivity: > 95-98% *
Specificity: %
Negative Predictive Value: > 95%
Positive Predictive Value: ~ 65-75%
* For DCIS sensitivity is lower, especially for low or intermediate grade lesions

32. Conclusions
Bilateral, dynamic and high-spatial resolution breast MRI is widely accepted
In the past, primarily employed as a problem-solving tool
Now, central role in the diagnosis and staging of breast cancer
Increasing use in the treatment of breast cancer
Multi-modality approach makes it work