This document discusses breast MRI protocols, techniques, and the interpretation of findings. It provides details on coil and patient positioning, recommended MRI field strength, and standard breast MRI protocols. It discusses recognizing normal enhancing structures like vessels, nipples, and lymph nodes. Guidelines are presented for analyzing lesion enhancement and characterizing benign masses based on criteria like smooth margins, shape, homogeneous enhancement, fat content, T2 signal, and rim enhancement. Examples of benign findings like fibroadenomas and fat-containing lesions are also described.

1. PRESENTER
DR. NABA
KUMAR
MODERATOR
DR. ANIL RAWAT
MD, ASSISTANT PROFESSOR
BREAST
IMAGING(MRI)

2. 2
INTRODUCTION
• MRI OF THE BREAST HAS EVOLVED INTO AN IMPORTANT
ADJUNCTIVE TOOL WITH MULTIPLE INDICATIONS IN BREAST
IMAGING, AS RECOMMENDED BY AMERICAN AND
EUROPEAN GUIDELINES.
• BREAST MRI IS CURRENTLY THE MOST SENSITIVE DETECTION
TECHNIQUE FOR BREAST CANCER DIAGNOSIS.

3. 12-01-2020
NEOANGIOGENESIS BY THE MALIGNANT TUMOR SERVES AS
THE BASIS FOR BREAST CANCER DETECTION BY MR IMAGING.
THE NEOVASCULATURE OF CANCERS DOES NOT RESEMBLE
BLOOD VESSELS FOUND IN NORMAL TISSUE OR BENIGN
LESIONS.
THESE NEW BLOOD VESSELS HAVE INCREASED PERMEABILITY
(I.E. “LEAKINESS”) RESULTING IN EARLY TUMOR UPTAKE OF
CONTRAST ON MR IMAGING.
IN MANY, BUT NOT ALL CANCERS, THIS LEAKY VASCULATURE
ALSO RESULTS IN RAPID WASHOUT OF CONTRAST, PRODUCING
A DYNAMIC ENHANCEMENT PATTERN THAT HELPS TO
DIFFERENTIATE MALIGNANT FROM BENIGN ENHANCING
BREAST LESIONS

4. SCREENING:
– WOMEN AT A HIGH-RISK OF BREAST CANCER
- OBSCURED BREAST TISSUE (SILICONE IMPLANT)
DIAGNOSIS:
– SUSPICIOUS LESION ON MAMMOGRAPHY, NEGATIVE
US
– BLOODY NIPPLE DISCHARGE
– INDETERMINATE PALPABLE FINDINGS WITH NEGATIVE
MAMMOGRAM AND US
– OCCULT BREAST PRIMARY IN PATIENTS WITH AXILLARY
METASTASES
INDICATION

5. STAGING:
– CHEST WALL INVASION
– EXTENT OF CANCER IN PATIENTS WITH LIMITED
MAMMOGRAPHIC EVALUATION
– DENSE BREASTS
– IMPLANTS
– INFILTRATING LOBULAR CANCER
– DCIS WITHOUT MICROCALCIFICATIONS
GOALS OF BREAST STAGING WITH MRI:
– PREOPERATIVE MAPPING BEFORE BCT TO
REDUCE THE RATE OF POSITIVE MARGINS
– DETECTION OF MULTIFOCAL OR MULTICENTRIC
CANCER
– DETECTION OF OCCULT CONTRALATERAL
CANCER
– DETECTION OF RESIDUAL DISEASE WHEN INITIAL
LUMPECTOMY IS INCOMPLETE

6. 12-01-2020 6
TREATMENT:
– EARLY ASSESSMENT OF RESPONSE TO
NEOADJUVANT CHEMOTHERAPY
– RESIDUAL DISEASE AFTER COMPLETION OF
NEOADJUVANT CHEMOTHERAPY
– DIFFERENTIATION OF
RECURRENCE/POSTOPERATIVE SCAR

7. COILS AND PATIENT POSITIONING.
FOR BREAST MR IMAGING, THE PATIENT IS PLACED
IN THE PRONE POSITION WITH THE BREASTS IN THE
‘CUPS’ OF THE COIL, WITH JUDICIOUS PADDING TO
MINIMIZE PATIENT MOTION AND TRANSMITTED
VIBRATION. IMMOBILIZATION SHOULD BE ACHIEVED
BY GENTLY FIXATING THE BREAST IN THE SECTION-
ENCODING DIRECTION (CRANIOCAUDAL DIRECTION
FOR TRANSVERSE PROTOCOLS).
PATIENT COMFORT IS VITAL, AS THE BREAST MR
EXAMINATION CAN LAST 30 MINUTES OR LONGER
AND ANY PATIENT DISCOMFORT IS LIKELY TO
MANIFEST AS MOVEMENT DURING OR BETWEEN
SCANS.
BREAST MRI PROTOCOL

8. MR FIELD STRENGTH.
THE CURRENT RECOMMENDATIONS REQUIRE THAT
BREAST MR IMAGING BE PERFORMED AT 1.5 T OR
HIGHER. THE HIGHER FIELD STRENGTH ENABLES
THE ACQUISITION OF HIGH-RESOLUTION IMAGING
WITH ADEQUATE SIGNAL TO NOISE RATIO (SNR) AND
ENABLES THE USE OF FAT SUPPRESSION. IMAGING
AT 3.0 T PROVIDES AN OPPORTUNITY FOR EVEN
GREATER IMPROVEMENT IN SNR, INCREASED
IMAGE RESOLUTION AND FASTER IMAGING.

10. 12-01-2020 10
• BILATERAL MORPHOLOGICAL STUDY USING BILATERAL
UNENHANCED HIGH-SPATIAL RESOLUTION T2
WEIGHTED FAST SPIN-ECHO SEQUENCE WITHOUT FAT
SATURATION IN THE AXIAL PLANE;
• BILATERAL THREE-DIMENSIONAL GRADIENT ECHO T1
WEIGHTED DYNAMIC SEQUENCES IN THE AXIAL PLANE;
WITH OR WITHOUT FAT SATURATION;
• THICKNESS BETWEEN 2 AND 3 MM.
Imaging Protocols

11. 12-01-2020 11
• INTRAVENOUS INJECTION OF GADOLINIUM CHELATES AT
THE STANDARD DOSE OF 0.1 MMOL/KG WITH AN
INJECTION RATE OF 2 ML/S FOLLOWED BY SALINE
FLUSHING USING AN AUTOMATIC INJECTOR.
• FOR DYNAMIC STUDIES PERFORMED BOTH WITH AND
WITHOUT FAT SATURATION, IMAGE POST-PROCESSING
INCLUDING TEMPORAL SUBTRACTION; DYNAMIC ANALYSES
WITH REPRESENTATIVE CURVES ARE PERFORMED.
THE FIRST POSTCONTRAST ACQUISITION IS STARTED AFTER THE
VOLUME OF CONTRAST MATERIAL HAS BEEN INJECTED (I.E. DURING
THE APPLICATION OF THE SALINE FLUSH). HAND INJECTIONS CAN
ALSO BE USED. T1 WEIGHTED SCANS ARE OBTAINED AT EVERY 1
MINUTES FOR AT LEAST 5–7 MINUTES AFTER CONTRAST INJECTION.
IT IS IMPORTANT TO USE THE SAME T1 SEQUENCE AND SCAN
TECHNIQUE WHICH WAS USED FOR PRECONTRAST SCAN.

12. 12-01-2020 12
RECOGNIZING NORMAL
ENHANCING STRUCTURES
• SOME NORMAL BREAST STRUCTURES, SUCH AS
VESSELS, NIPPLES AND INTRA-MAMMARY LYMPH
NODES, MAY NORMALLY ENHANCE AND SHOULD
NOT BE DIAGNOSED AS TUMORS.

13. Sagittal delayed postcontrast image
demonstrating
major anatomic components of the breast

14. 12-01-2020 14
• VESSELS ARE EASILY RECOGNIZED BY THEIR
COURSE, WHICH SHOULD BE ASSESSED IN CINE-
VIEW MODE, BY THEIR TOPOGRAPHY (THEY ARE
OFTEN LOCALIZED AT THE PARENCHYMA AND
FAT JUNCTIONS OR WITHIN FAT LAYERS) AND BY
THEIR HIGH SIGNAL INTENSITY ON T2 WEIGHTED
SEQUENCES, ALTHOUGH THIS MAY BE LOST IN
HIGH-VELOCITY VESSELS

15. 12-01-2020 15
• NIPPLES ENHANCE NORMALLY TO VARYING
INTENSITIES IN BREAST MRI. THIS ENHANCEMENT
IS DUE TO THE RICH BLOOD SUPPLY IN THE
NIPPLE–AREOLAR COMPLEX.
• A NORMAL NIPPLE MAY BE MISINTERPRETED AS A
MASS WHEN IT IS INVERTED OR FLATTENED
AGAINST THE ANTERIOR SURFACE OF THE COIL
DUE TO THE LARGE SIZE OF THE BREAST.
• TO DETERMINE THAT AN ENHANCING LESION IS
ACTUALLY A NIPPLE, VIEWING THE ANATOMIC
IMAGE WITHOUT CONTRAST INJECTION,
COMPARING WITH THE OTHER SIDE AND
PERFORMING THREE-DIMENSIONAL

16. 12-01-2020 16
• INTRA-MAMMARY LYMPH NODES ARE USUALLY
LOCATED IN THE UPPER OUTER QUADRANT, THEY
MAY APPEAR ANYWHERE IN THE BREAST.
• NORMAL LYMPH NODES HAVE A WELL-DEFINED
MARGIN, CONTAIN A FATTY HILUM, ARE
ADJACENT TO A VESSEL AND HAVE A ROUND,
OVAL OR (MORE TYPICALLY) RENIFORM SHAPE.
• THEY ALSO SHOW HIGH SIGNAL INTENSITY ON T2
WEIGHTED IMAGES. CONVERSELY, ENHANCEMENT
CHARACTERISTICS ARE NOT HELPFUL BECAUSE
NORMAL LYMPH NODES MAY AVIDLY ENHANCE.

17. 12-01-2020 17

18. 12-01-2020 18
• NORMAL FIBRO-GLANDULAR TISSUE, ESPECIALLY IN PRE-
MENOPAUSAL PATIENTS, GENERALLY EXHIBITS A LOW
LEVEL OF ENHANCEMENT SOON AFTER CONTRAST
ADMINISTRATION WITH GRADUAL, PROGRESSIVE AND
FAINT ENHANCEMENT OVER TIME WHICH IS BILATERAL
AND SYMMETRIC.
• SOMETIMES, MULTIPLE BILATERAL FOCI PREDOMINANTLY
LOCATED AT THE OUTER PART OF THE BREAST ARE
ENHANCED. THESE TRANSIENTLY ENHANCING FOCI ARE
USUALLY OBSERVED DURING THE SECOND HALF OF THE
MENSTRUAL CYCLE AND AROUND MENSTRUATION.
• THEREFORE, BREAST IMAGING SHOULD BE PERFORMED
DURING THE SECOND WEEK OF THE MENSTRUAL CYCLE IN
ORDER TO MINIMIZE THE RISK OF FALSE-POSITIVE
DIAGNOSIS

19. 12-01-2020 19
• PROGESTERONE CAN CAUSE ABNORMAL
ENHANCEMENT IN 50% OF CASES.
• WHERE POSSIBLE, HORMONE REPLACEMENT THERAPY
SHOULD BE DISCONTINUED 4–6 WEEKS BEFORE
PERFORMING BREAST MRI.
ANTI-OESTROGEN MEDICATION MAY SUPPRESS THESE
ENHANCEMENTS.
BECAUSE OF THE ADVERSE EFFECTS INVOLVED, DO NOT
RECOMMEND ADMINISTRATION OF ANTI-OESTROGEN
TREATMENT ONLY TO REDUCE PHYSIOLOGICAL BREAST
ENHANCEMENT

20. Axial precontrast T1-weighted images show examples of almost entirely fat (A),
scattered fibroglandular
tissue (B), heterogeneous fibroglandular tissue (C), and extreme fibroglandular

21. ANALYZING ENHANCEMENT
ACCORDING TO THE BI-RADS
CLASSIFICATION IN ORDER TO
CHARACTERIZE BENIGN LESIONS
• WHEN INTERPRETING AN ENHANCEMENT, THE FIRST
STEP IS TO DETERMINE THE TYPE OF ENHANCEMENT
ACCORDING TO THE FOLLOWING CATEGORIES IN THE
BI-RADS LEXICON.
• A LESION IS CLASSIFIED AS A MASS, AN AREA OF
NON-MASS-LIKE ENHANCEMENT OR A FOCUS.
• THE DISTINCTION BETWEEN THESE CATEGORIES IS
CRITICAL BECAUSE IT PAVES THE WAY FOR FURTHER
DIAGNOSTIC PATHWAYS THAT EACH REQUIRES A
DIFFERENT SET OF DIAGNOSTIC CRITERIA FOR
CHARACTERIZING BENIGN LESIONS.
12-01-2020 21

22. MASS
• A MASS IS A THREE-DIMENSIONAL, SPACE-OCCUPYING
LESION MEASURING >5 MM.
• IT IS USUALLY VISIBLE ON PRE-CONTRAST T1 OR T2
WEIGHTED IMAGES.
• IT CONSTITUTES THE MOST COMMON MRI LESION.
• TYPICAL CAUSES OF MASS ARE BREAST CANCERS,
FIBROADENOMAS, PAPILLOMAS, FAT NECROSIS,
ATYPICAL FORMS OF BENIGN PROLIFERATIVE BREAST
DISEASE, SCLEROSING ADENOSIS, INFLAMMATORY
LESIONS AND INTRAMAMMARY LYMPH NODES
12-01-2020 22

24. 12-01-2020 24
BENIGN LESION
CRITERIA ARE AS FOLLOWS:
• SMOOTH MARGINS, CHARACTERISED BY WELL-
DEFINED AND SHARPLY DEMARCATED BORDERS. THIS
IS THE FEATURE WITH THE HIGHEST BENIGN LESION
PREDICTIVE VALUE: 97–100% OF MASSES WITH
SMOOTH MARGINS ARE REPORTED AS BENIGN.
• IT IS IMPORTANT TO NOTE THAT MARGIN ANALYSIS
DEPENDS ON THE SPATIAL RESOLUTION, SO AN
IRREGULAR BORDER MAY APPEAR TO BE RELATIVELY
SMOOTH WHEN INSUFFICIENT RESOLUTION IS USED.

25. 12-01-2020 25
• FURTHERMORE, A MASS WITH SMOOTH MARGINS
MAY APPEAR TO BE POORLY DELINEATED ON
SUBTRACTED IMAGES OWING TO MIS-
REGISTRATION AS A RESULT OF SLIGHT MOTION
BETWEEN PRE- AND POST-CONTRAST
SEQUENCES (RADIOGRAPHIC ARTIFACT).
• MARGIN ANALYSIS SHOULD THEREFORE BE
PERFORMED ON ANATOMICAL SEQUENCES ON
THE FIRST POST-CONTRAST NATIVE IMAGE IN
ORDER TO AVOID MIS-REGISTRATION

26. 12-01-2020 26
SHAPE OF THE MASS
• ROUND OR OVAL MASS SHAPE. THIS HAS ALSO
BEEN FOUND TO BE PREDICTIVE OF BENIGNITY,.
ACR BI-RADS descriptors for mass shape on MRI: (A) Round;
(B) Oval; (C) Irregular; (D) Spiculated.

27. 12-01-2020 27
ENHANCEMENT
• HOMOGENEOUS ENHANCEMENT WITHIN THE MASS IS
HIGHLY SUGGESTIVE OF BENIGNITY IN TUMORS >1 CM.
• HOWEVER, IN THE SMALLEST TUMORS, THE RELIABILITY
OF THIS FINDING IS LOWER BECAUSE THE SPATIAL
RESOLUTION MAY LIMIT EVALUATION AND BECAUSE
SMALL BREAST CANCERS USUALLY HAVE A
HOMOGENEOUS CONTENT

28. 12-01-2020 28
FAT CONTENT WITHIN THE
MASS
• INVESTIGATED IN UNENHANCED T1 OR T2
WEIGHTED SEQUENCES WITHOUT FAT
SUPPRESSION, WHICH GIVES A HYPER-INTENSE
FAT SIGNAL.
• FAT CONTENT OCCUPYING A PART OF A MASS IS
SPECIFIC TO BENIGN LESIONS, NAMELY
HAMARTOMA, FIBROADENOMA, INTRAMAMMARY
LYMPH NODES OR FAT NECROSIS.
• IN THE CASE OF FAT NECROSIS, EVEN IF THE
LESION APPEARS IRREGULAR IN BOTH SHAPE AND
MARGIN, WITH A RIM ENHANCEMENT, THE KEY
TO DIAGNOSIS IS A FAT-SPECIFIC INTERNAL

29. FAT IN THE LESION = BENIGN
–INFLAMMATORY L.N.
–FAT NECROSIS
–HAMARTOMA
EXCEPT IF RAPIDLY ENLARGED
BIOPSY IS A MUST
IN T2 FAT-SUPPRESSION WATER IS BRIGHT.
•BRIGHT LESIONS = BENIGN
–CYST
–L.N.
–FAT NECROSIS
•EXCEPT “COLLOID CARCINOMA”
THE ONLY MALIGNANT LESION BRIGHT IN
T2FAT SAT
T1 HIGH SIGNAL =FAT
HIGH SIGNAL ON T2 FAT
SAT

31. 12-01-2020 31
• STRONG HYPER-SIGNAL ON NON-FAT-
SUPPRESSED T2 WEIGHTED SEQUENCES.
A CLEAR SIGN OF FIBRO-ADENOMA
• THIS FINDING HAS RECENTLY BEEN QUESTIONED, WITH
T2 HYPERINTENSE SIGNALS DESCRIBED IN SEVERAL
BREAST CANCERS INCLUDING (PREDOMINANTLY)
MUCINOUS CARCINOMAS, INVASIVE DUCTAL
CARCINOMAS, METAPLASTIC CARCINOMAS AND
INTRACYSTIC PAPILLARY CARCINOMAS.

32. 12-01-2020 32
• RAPID AND STRONG FIBRO-ADENOMA ENHANCEMENT
IS A COMMON FINDING IN PRE-MENOPAUSAL
PATIENTS AND MUST NOT LEAD TO A FALSE POSITIVE
CANCER DIAGNOSIS.
• CONVERSELY, SMOOTH MARGINS AND BENIGN
MORPHOLOGY OF A MASS SHOULD BE CONSIDERED
WITH CAUTION IN PATIENTS WITH BREAST CANCER 1
(BRCA1) MUTATIONS, GIVEN THE HIGH FREQUENCY
OF BREAST CANCER WITH BENIGN APPEARANCE IN
BRCA1-MUTATED PATIENTS.

33. Fat containing hamartoma with
central high signal on T1WI (arrow)
Fibroadenoma (left) and a colloid
carcinoma (right). Both are bright on
T2WI.

34. 12-01-2020 34
RIM ENHANCEMENT
• REGARDED AS SUGGESTIVE OF MALIGNANCY.
• A REGULAR ENHANCED RIM WHICH MAY BE THICK,
MAY BE SEEN AROUND CYSTS, SEROMAS AND
CIRCUMSCRIBED FAT NECROSIS.
• DIFFERENTIATING THESE ENTITIES FROM A
MALIGNANCY IS BASED ON MASS CONTENT
ASSESSMENT, WITH A STRONG AND HYPER-INTENSE
FLUID-SPECIFIC SIGNAL SHOWN IN CYSTS AND
SEROMAS AND A FAT-SPECIFIC SIGNAL SHOWN IN
CIRCUMSCRIBED FAT NECROSIS.

35. ACR BI-RADS descriptors for internal enhancement characteristics
of a mass on MRI: (A) Homogeneous; (B) Heterogeneous; (C) Rim
enhancement.

36. ONCE THE BREAST LESIONS OF INTEREST HAVE
BEEN IDENTIFIED, ENHANCEMENT KINETICS
CHARACTERISTICS SHOULD BE EVALUATED AND
REPORTED FOR EACH FINDING
ENHANCEMENT KINETICS
ENHANCEMENT KINETICS ARE EVALUATED IN 2
PHASES,THE INITIAL PHASE AND THE DELAYED
PHASE .
THE INITIAL PHASE IS WITHIN THE FIRST 2 MINUTES
AND
IS DESCRIBED AS SLOW, MEDIUM, OR FAST.
SLOW INITIAL PHASE ENHANCEMENT IS A LESS THAN
50% INCREASE IN SIGNAL INTENSITY.
MEDIUM INITIAL PHASE ENHANCEMENT IS A 50% TO
100% INCREASE
FAST INITIAL PHASE ENHANCEMENT IS A GREATER
THAN 100% INCREASE IN SIGNAL INTENSITY.

37. THE DELAYED PHASE IS DESCRIBED AS
PERSISTENT, PLATEAU, OR WASHOUT.PERSISTENT
ENHANCEMENT IS CONTINUOUSLY INCREASING.
PLATEAU ENHANCEMENT DEMONSTRATES NO
CHANGE AFTER THE INITIAL PHASE, AND WASHOUT
SHOWS DECREASING SIGNAL INTENSITY.
THE MOST SUSPICIOUS KINETIC FEATURE SHOULD
BE REPORTED, BECAUSE ANY ONE LESION MAY
DISPLAY MANY DIFFERENT TYPES OF KINETIC
ENHANCEMENT. ALTHOUGH SOME STUDIES HAVE
SHOWN MALIGNANT LESIONS ARE MORE LIKELY TO
DEMONSTRATE WASHOUT KINETICS, OTHERS HAVE
NOT FOUND KINETICS TO BE SIGNIFICANT
PREDICTORS OF MALIGNANCY.
IT IS FOR THIS REASON THAT THE MORPHOLOGY OF
THE LESION SHOULD BE THE MOST IMPORTANT

39. COMPUTER AIDED DETECTION
–IS A PURELY KINETIC EVALUATION.
–NOT EVALUATE THE ANATOMY OR PATHOLOGY OF THE
IMAGES.
–CAD LOOKS AT THE CURVES AND PEAK
ENHANCEMENTS FOR THE CONTRAST (AUTOMATED
KINETICS).
–NOT ALL MRI SCANNERS CAN DO.
–IT CAN DO MULTIPLANAR RECONSTRUCTION AND
SUBTRACTION VERY WELL AND VERY QUICKLY
•IN CAD, RED IS BAD: IT MEANS TYPE 3 WASHOUT,
AND PROBABLY CANCER.
WHEN YOU LOOK AT CAD IMAGES, TAKE NOTE OF THE
WORST (RED) AREAS.

40. CAD with a large area of type 3 enhancement

41. Abnormally enhancing area in the left breast.
•The CAD has detected some very small areas with
type 3 washout (in red).
•This is a large invasive ductal carcinoma.

42. 12-01-2020 42
NON-MASS-LIKE
ENHANCEMENT
• NON-MASS-LIKE ENHANCEMENT REFERS TO ENHANCEMENT
OF AN AREA THAT IS NEITHER A MASS NOR A FOCUS.
• THERE IS NO SPACE-OCCUPYING EFFECT AND THE LESION IS NOT
SEEN ON UNENHANCED SEQUENCES.
• TYPICAL CAUSES OF NON-MASS-LIKE ENHANCEMENT INCLUDE
MASTOPATHIC CHANGES, FIBROCYSTIC CHANGES DUE TO
HORMONAL STIMULATION, INFLAMMATORY CHANGES FOR BENIGN
LESIONS OR DUCTAL CARCINOMA IN SITU (DCIS), INVASIVE
LOBULAR CARCINOMA AND SOME CASES OF OESTROGEN
RECEPTOR-NEGATIVE INVASIVE DUCTAL CARCINOMA.
• NON-MASS-LIKE ENHANCEMENT IS THE MAJOR CAUSE OF FALSE-
POSITIVE BREAST FINDING

43. NON MASS LIKE ENHANCEMENT

45. Nonmass-like enhancement: Enhancement occurs in an
area of the fibroglandular tissue that otherwise appears
normal on precontrast images and there is no space-
occupying effect

46. 12-01-2020 46
BENIGN LESION CRITERIA IN
PATIENTS WITH A NON-MASS-
LIKE ENHANCEMENT
• BILATERAL SYMMETRIC NON-MASS-LIKE
ENHANCEMENT, WHICH IS HIGHLY SUGGESTIVE
OF BENIGN CHANGES.
• PRESENCE OF SEVERAL CYSTS (MICROCYSTS OR
MACROCYSTS) VISIBLE ON T2 WEIGHTED IMAGES
AND DISTRIBUTED OVER THE ENHANCED AREA.
THIS FEATURE IS HIGHLY INDICATIVE OF
FIBROCYSTIC MASTOPATHY.

47. 12-01-2020 47
THERE IS LOCALIZED ENHANCEMENT THAT IS BOTH
REGIONAL IN TERMS OF DISTRIBUTION (RATHER THAN
DUCTAL OR SEGMENTAL)
STIPPLED (COMPOSED OF MULTIPLE ENHANCING
DOTTED FOCI) IN TERMS OF INTERNAL PATTERN
WHEN IT OCCURS IN A NON-MENOPAUSAL PATIENT
WITHOUT STRONG RISK FACTORS AND ANY
SUPPORTING ABNORMALITY NOTED ON
MAMMOGRAPHY OR ULTRASOUND IMAGES.

48. 12-01-2020 48
FOCUS
• A FOCUS IS A TINY ENHANCEMENT DOT MEASURING <5
MM IN SIZE. IT IS NOT A SPACE-OCCUPYING LESION.
(A FOCUS IS PUNCTATE ENHANCEMENT THAT IS TOO SMALL
TO CHARACTERIZE AND HAS NO PRE-CONTRAST CORRELATE)
• A FOCUS IS USUALLY DUE TO BENIGN LESIONS SUCH AS
PAPILLOMAS, FIBRO-ADENOMAS, INTRA-MAMMARY
LYMPH NODES OR FOCAL FIBROCYSTIC CHANGES.
• IT SELDOM REPRESENTS A FOCAL SMALL INVASIVE CANCER
OR DCIS.

49. 12-01-2020 49
• A FOCUS IS USUALLY TOO SMALL TO BE WELL
CHARACTERIZED MORPHOLOGICALLY, AND A
SMOOTH OUTLINE MUST NOT BE CONSIDERED AS AN
ADDITIONAL ARGUMENT FOR BENIGNITY.
• ENHANCEMENT QUANTITATIVE ANALYSIS WITH
CURVES IS NOT POSSIBLE FOR FOCI, AND THE
ENHANCEMENT INTENSITY AND THE PRESENCE OF
WASHOUT MUST BE VISUALLY ANALYZED.
• CORRELATIONS WITH ULTRASOUND OR
MAMMOGRAPHY FINDINGS GENERALLY DO NOT

50. 12-01-2020 50
• CONSIDER FOCI AS BI-RADS 2 WHEN THEY ARE
NUMEROUS AND/OR BILATERAL AND AN
ISOLATED FOCUS AS BI-RADS 3 WHEN THERE IS
NEITHER WASHOUT NOR BRCA MUTATION.
• CONSIDER ISOLATED FOCI WITH EITHER
WASHOUT OR BRCA MUTATION AS BI-RADS 4,
FOR WHICH BIOPSY IS RECOMMENDED.

51. FEATURES OF A FOCUS
MALIGNANT FEATURES BENIGN
FEATURES
NOT BRIGHT ON T2
NO FATTY HILUM
WASHOUT KINETICS
LARGER OR NEW SINCE
PRIOR EXAMINATION
BRIGHT ON
T2-WEIGHTED IMAGING
FATTY HILUM
PERSISTENT KINETICS
STABLE SINCE PRIOR
EXAMINATION

52. Example of a focus denoted by a red arrow on axial
subtraction image (A) with no correlate on axial
precontrast

53. 12-01-2020 53
Benign patterns enhancement

54. ASSOCIATED FINDINGS
•SKIN OR NIPPLE INVOLVEMENT
•CHEST WALL INVASION
•ADENOPATHY
relatively small carcinoma in
the right breast, with
extensive thickening of the
skin
relatively small carcinoma in the
right breast, with extensive
thickening of the skin

55. 12-01-2020 55
THE TWO MAIN REASONS FOR
FAILING TO DETECT LESIONAL ENHANCEMENT
SMALL TUMOR SIZE
AND
BACKGROUND ENHANCEMENT IN THE
SURROUNDING NORMAL FIBRO-GLANDULAR
TISSUE.

56. 12-01-2020 56
• 83% OF FALSE-NEGATIVE STUDIES BECAUSE OF STRONG
BACKGROUND ENHANCEMENT IN THE FIBROGLANDULAR TISSUE
AROUND THE CANCER.
• THEREFORE THE BACKGROUND ENHANCEMENT MUST BE
GRADED INTO FOUR CATEGORIES (AS IS THE CASE FOR THE
BREAST DENSITY ON MAMMOGRAMS) AND COMMUNICATED IN
THE MR REPORT, IN ORDER TO OBTAIN INFORMATION ABOUT
THE EXPECTED MR SENSITIVITY.
• FURTHERMORE, IN CASES OF STRONG BACKGROUND
ENHANCEMENT, IT IS CRUCIAL TO PAY SPECIAL
ATTENTION TO THE FIRST POST-CONTRAST
ACQUISITION IN ORDER TO BETTER DETECT A TUMOR
ENHANCING EARLIER THAN THE SURROUNDING
PARENCHYMA.

57. 12-01-2020 57
• MIS-REGISTRATION DUE TO MOTION BETWEEN
PULSE SEQUENCE IMAGES LEADS TO
SUBTRACTION ARTEFACTS AND PSEUDO-
ENHANCEMENT, SO TRUE ENHANCEMENT MAY BE
OVERLOOKED ON THE SUBTRACTED IMAGES.
• INTERPRET MR EXAMINATIONS ON POST-
CONTRAST NATIVE IMAGES AND COMPARE PRE-
& POST-CONTRAST NATIVE IMAGES.

58. FALSE-POSITIVE:
• FIBROCYSTIC CHANGE
• HORMONE-RELATED ENHANCEMENT
• FOCAL FIBROSIS, SCAR, FAT NECROSIS
• INTRADUCTAL PAPILLOMA
• FIBROADENOMAS
• INTRAMAMMARY LYMPH NODE
FALSE-NEGATIVE:
• STRONG BACKGROUND ENHANCEMENT
• NONENHANCING DCIS
• NONENHANCING INVASIVE LOBULAR
CARCINOMA
• RECENT RADIOTHERAPY
CHALLENGES IN MR INTERPRETATION.

59. FINAL ASSESSMENT
JUST AS WITH MAMMOGRAPHY AND ULTRASOUND
EXAMINATIONS,
A FINAL BI-RADS ASSESSMENT CATEGORY SHOULD BE
ASSIGNED FOR EACH STUDY. THE FINAL ASSESSMENT
CATEGORIES ARE THE SAME FOR MR IMAGING AS FOR
MAMOGRAPHY AND ULTRASOUND
CATEGORY 0: INCOMPLETE, NEED ADDITIONAL
IMAGING
EVALUATION
CATEGORY 1: NEGATIVE
CATEGORY 2: BENIGN
CATEGORY 3: PROBABLY BENIGN
CATEGORY 4: SUSPICIOUS
CATEGORY 5: HIGHLY SUSPICIOUS OF
MALIGNANCY
CATEGORY 6: KNOWN BIOPSY-PROVEN
MALIGNANCY

60. MCQ

61. 12-01-2020
• BREAST MR IMAGING SHOULD BE
PERFORMED ON WHICH PHASE OF CYCLE:
a) FIRST WEEK OF THE MENSTRUAL CYCLE
b) SECOND WEEK OF THE MENSTRUAL CYCLE
c) THIRD WEEK OF THE MENSTRUAL CYCLE
d) END OF THE MENSTRUAL CYCLE
Aiims-Mamc-Pgi's Comprehensive Textbook Of Diagnostic
Radiology,2nd edition – A systemic approach to breast imaging
,volume 3-Chapter 206
Reference:

62. 12-01-2020 62
• IF A MASS IS HAVING SMOOTH BORDER +
HOMOGENEOUS ENHANCEMENT WITH/WITHOUT
NON-ENHANCING SEPTA) + T2 HYPER-INTENSE
SIGNAL AND/OR KINETIC PROGRESSIVE
ENHANCEMENT + NON-BRCA1 PATIENT, WHICH OF
THE FOLLOWING BIRADS SHOULD BE GIVEN:
a) BIRADS 2
b) BIRADS3
c) BIRADS 4
d) BIRADS1
Ans: b
Aiims-Mamc-Pgi's Comprehensive Textbook Of Diagnostic
Radiology,2nd edition – A systemic approach to breast imaging
,volume 3-Chapter 206

63. ANS: b
• PATTERN OF NON MASS ENHANCEMENT MOST
CHARACTERISTIC OF MALIGNANCY IS :
1. FOCAL
2. LINEAR
3. DUCTAL
4. SEGMENTAL
Aiims-Mamc-Pgi's Comprehensive Textbook Of Diagnostic
Radiology,2nd edition – A systemic approach to breast imaging
,volume 3-Chapter 206

64. Ans:4
•"LINGUINE SIGN“ Is Seen In Intracapsular Implant Rupture
,Extracapsular Implant Rupture Represents Which Image
A
B C
a-A
b-B
c-C

65. Known case of rt breast
lumpectomy showing Post
operative seroma in rt breast
retromammary region ,showing
adjacent oval shape irregular
margin mass 3x4.2 cm with
mild skin thickening upper
outer quadrents without e/o
muscle infiltration with
diffusion restriction within
A-BIRADS 5 B-BIRADS 4 C-BIRADS 3
ANS A

66. 12-01-2020 66
• IF THE FOCI ARE MULTIPLE AND/OR BILATERAL
OR SINGLE + NO WASHOUT + NO BRCA PATIENT,
THE LESION FALLS INTO WHICH OF THE
FOLLOWING BIRADS MRI GRADING:
a) BIRADS 2
b) BIRADS3
c) BIRADS 4
d) BIRADS1
ANS B
Aiims-Mamc-Pgi's Comprehensive Textbook Of Diagnostic
Radiology,2nd edition – A systemic approach to breast imaging

67. 12-01-2020 67
• WHICH OF THE STATEMENT IS FALSE REGARDING NON MASS
ENHANCEMENT:
a) NON-MASS-LIKE ENHANCEMENT REFERS TO ENHANCEMENT
OF AN AREA THAT IS NEITHER A MASS NOR A FOCUS.
b) THE ENHANCEMENT PATTERN IS DISTINCT FROM THAT OF
NORMAL SURROUNDING TISSUE WITH NO SPACE-OCCUPYING
EFFECT.
c) THE LESION IS SEEN ON UNENHANCED SEQUENCES.
d) CAUSES INCLUDE MASTO-PATHIC CHANGES, FIBROCYSTIC
CHANGES DUE TO HORMONAL STIMULATION,
INFLAMMATORY CHANGES FOR BENIGN LESIONS OR DUCTAL
CARCINOMA IN SITU (DCIS).
ANS -A
Aiims-Mamc-Pgi's Comprehensive Textbook Of Diagnostic
Radiology,2nd edition – A systemic approach to breast
imaging ,volume 3-Chapter 206

68. A B C
IMAGE A,B,C SHOWS FOLLOWING CURVES
A-TYPE 2,TYPE3,TYPE1
B-TYPE 3,TYPE-2,TYPE-1
C-TYPE 1,TYPE 3,TYPE 2
ANS -C

69. Ref -Radiology Assistant by Marieke
Hazewinkel ,pub date 2009,may.
ANS -C
MR spectroscopy in a malignant breast lesion. Single voxel
MR spectroscopy showing markedly elevated which peak?
A-MYOINOSITOL
B-NAA
C-TOTAL CHOLINE
D-LACTATE

70. This peak is primarily derived from free choline,
phosphocholine, and glycerophosphocholine and is
commonly referred to as total choline (tCho). Several
other compounds including taurine, glucose,
phophoethanolamine, and myoinositol also make
minor contributions to this resonance.
Normal MRS peak
My: Myoinositol 3.5ppm
Cho: Choline 3.2ppm
Cr: Creatine 3.0ppm
Naa: Naa 2.0ppm
ANS -C
References
Baltzer PAT, Dietzel M. Breast lesions: diagnosis by using
proton MR spectroscopy at 1.5 and 3.0 T — Systematic
review and meta-analysis. Radiology 2013; 267:735-746.

71. THANK YOU