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Technical aspects Patient handling MRI of the breast is a study that requires the administration of a gadolinium-containing contrast agent during the study [ 1 , 2 ].
Early studies have shown that breast MRI without contrast agent is not of diagnostic value [ 3 , 4 ]. The uptake of contrast medium in breast tissue in premenopausal women is also dependent on the phase of the menstrual cycle.
It is essential to perform breast MRI in the correct phase of the cycle as enhancing normal breast tissue may otherwise complicate the interpretation of the study. The optimal time in pre-menopausal women to perform a breast MRI is between the 5th and 12th day after the start of the menstrual cycle [ 5 — 7 ].
Placement of an intravenous cathether should be done before positioning the patient on the MR table. A long IV line avoids table and patient movement before the injection. The contrast agent should preferably be given by a power injector. It is important to position the patient as comfortably as possible in order to avoid motion artifacts.
A dedicated bilateral breast coil is mandatory for this investigation, and the patient should be placed in the prone position with both breasts hanging in the coil loops. The breasts may be supported to further reduce motion artifacts, but should not be compressed. The position of the breast should be checked before the start of the examination, both breasts must be placed as deeply as possible in the coils with the nipples pointing down.
Virtually any MRI scanner can be used to perform contrast-enhanced breast MRI, as long as the system allows image acquisition at a sufficient spatial and temporal resolution see below.
However, scanning protocols need to be adapted to the scanners used, also because the relaxivity of the most commonly used contrast agents decreases at higher field strengths [ 8 , 9 ]. Breast MRI at low and midfield strength 0. As this further decreases the signal-to-noise ratio SNR , this is not optimal. In practice, most studies that employed low or midfield scanners did not obtain a sufficient spatial resolution [ 10 , 11 ]. An increasing field strength 1. A disadvantage is that, at higher field strengths e.
Two-dimensional acquisitions are particularly sensitive to this effect and are therefore discouraged at 3 T [ 13 ]. The signal from the body coil can be used to evaluate the position and anatomy of the breasts. Furthermore, both axillae, the supraclavicular fossae, the chest wall and anterior mediastinum can be checked e. However, this is not the purpose of a breast MRI, and this evaluation may also be omitted as there is no evidence of its diagnostic value.
Afterwards the signal from the dedicated double breast coil should be used. T2-weighted fast spin echo images can be performed as a start. In the T2-weighted images water-containing lesions or edematous lesions have an intense signal, and in this sequence small cysts and myxoid fibroadenomas are very well identified. In most cases cancer does not yield a high signal on T2-weighted images; thus, these sequences can be useful in the differentiation between benign and malignant lesions.
However, as most of these lesions can also be identified on T1-weighted images, there is no evidence as yet of added value of T2-weighted sequences in breast MRI [ 14 , 15 ]. The most commonly used sequence in breast MRI is a T1-weighted, dynamic contrast enhanced acquisition. A T1-weighted 3D or 2D multi-slice spoiled gradient echo pulse sequence is obtained before contrast injection and then repeated as rapidly as possible for 5 to 7 min after a rapid intravenous bolus of a Gd-containing contrast agent.
A 3D pulse sequence offers a stronger T1 contrast and enables thinner slices than 2D; in turn, a 2D sequence suffers less from motion and pulsation artifacts. Both sequences can be performed with and without fat-suppresion [ 16 , 17 ].
The choice of the image orientation is important. For bilateral dynamic breast MRI, axial or coronal orientations are most frequently used. Coronal imaging has advantages in that it can reduce heart pulsation artifacts, but it is more susceptible to respirational motion and also to flow artifacts because vessels tend to travel perpendicular to the slice-encoding direction.
Although bilateral sagittal imaging is possible today, it requires about double the number of slices required for the other orientations. As this hampers the spatio-temporal resolution, such an orientation is currently not feasible. The optimal dose of the contrast medium is unknown and also depends on the contrast agent used. In literature, applied doses range roughly from 0. One study showed some benefit of 0.
However, a more recent evaluation did not find any improvement in diagnostic accuracy using 0.
Consequently, a dose of 0. Peak enhancement in the case of breast cancer occurs within the first 2 min after the injection of contrast medium. Therefore, relatively short data acquisition times, in the order of 60— s per volume acquisition, are necessary.
This allows sampling of the time course of signal enhancement after contrast injection, which is useful because the highly vascularized tumor of the breast shows a faster contrast uptake than the surrounding tissue. More importantly, it enables a detailed analysis of morphologic details, because only in the very early post-contrast phase, the contrast between the cancer and the adjacent fibroglandular tissue is optimal.
Long acquisition times will be associated with the risk of not resolving fine details of margins and internal architecture; this could have key importance for the differential diagnosis, and may even run the risk of missing cancers altogether because they are masked by adjacent breast tissue.
A dynamic sequence demands at least three time points to be measured, that is, one before the administration of contrast medium, one approximately 2 min later to capture the peak and one in the late phase to evaluate whether a lesion continues to enhance, shows a plateau or shows early wash-out of the contrast agent decrease of signal intensity [ 20 ].
It is thus recommended to perform at least two measurements after the contrast medium has been given, but the optimal number of repetitions is unknown. However, the temporal resolution should not compromise the spatial resolution. It was shown that an increase in spatial resolution results in higher diagnostic confidence even when the temporal resolution is slightly sacrificed. The final spatial resolution of the images depends on different factors, especially the size of the imaging volume, defined by the field of view FOV , the slice thickness and the acquisition matrix.
Therefore, the voxel size should be under 2. Preferably, the in-plane resolution should be substantially higher as morphologic features needed for lesion characterization, such as margin appearance, can only be evaluated when the resolution is sufficiently high. Assessment of lesion morphology can be performed directly on the enhanced fat-suppressed images.
However, as residual fat-signal hyperintense at T1-weighted images may cause difficulties in interpretation, the calculation of subtraction images from the pre- and post-contrast series is recommended [ 22 , 23 ]. Subtraction suppresses the signal from bright fat because fatty tissue hardly enhances.
When subtraction is performed, fat suppression in the acquisition is not needed and is even discouraged, because in the large fields of view that are usually required for axial and coronal imaging, homogenous fat suppression is difficult to obtain. This can be problematic since fat and water resonance frequencies are relatively close at 1. Moreover, fat-suppression increases the noise in the image and usually also compromises spatio-temoral resolution.
Evaluation Use of both detailed morphological information provided by high spatial resolution images and kinetic information curve type provided by at least two repetitions of the high spatial resolution sequence represents the latest trend in acquisition protocols and image interpretation to take into account the increasing importance of detailed morphological information without losing identification of washout enhancement curve types [ 24 ].
It also includes a lexicon that should be used for uniform reporting of the features seen on MRI [ 25 ]. Indications for breast MRI Inconclusive findings in conventional imaging Patients referred by their general practitioner or through a nationwide screening program to secondary care are told that there is a chance that they might have breast cancer.
In this situation imaging, with or without biopsy, should exclude the presence of a malignancy sufficiently. The sensitivity of breast MRI for the detection of cancer is the greatest of all imaging techniques [ 26 — 28 ], and when the findings of conventional imaging are inconclusive i.
In general, a negative breast MRI excludes malignancy. Only in case of mammographic microcalcifications, MRI is unable to exclude cancer sufficiently, and the decision to perform biopsy should be based on mammographic findings in this specific situation [ 29 ]. Tumor size of invasive carcinomas on MRI correspond in general well to pathologic sizes [ 32 , 33 ]. Inadequate size estimation or failure to detect additional foci of disease may thus result in positive resection margins after surgery or early recurrent disease.
On MRI this may be seen as an area of contrast enhancement with a dendritic configuration close to the primary tumor. Consequently, before large adjustments to the surgical management are effectuated, histological analysis of MR-detected additional foci should be performed.
However, it is so far unclear whether breast MRI contributes to better control of the disease or survival of all patients with diagnosed breast cancer. Only one study has evaluated such outcomes, and although MRI appears to reduce the incidence of local recurrence 1. The British COMICE trial is a large multicenter trial that randomizes patients between MRI and no-MRI and evaluates the quality of preoperative staging, the differences in outcome, differences in quality of life and cost-effectiveness [ 52 ]; the first results are expected in This study and similar ongoing studies may provide better evaluation of staging in the near future.
These lesions would probably have presented as metachronous contralateral carcinomas without MRI, as is also clear from the above-mentioned outcome study. Screening of the contralateral breast in patients with proven unilateral breast cancer is thus a valid indication for the performance of preoperative breast MRI. In practice this means that preoperative MRI is recommended in all patients with histologically proven breast cancer, even though the indication for ipsilateral staging of the cancer is still under investigation.
Especially in the case of dense breasts, MRI is recommended preoperatively. Unknown primary In the case of a carcinoma of unknown primary, metastases are diagnosed, but a primary tumor site cannot be identified.
These metastases may either present in the axillary lymph nodes, the supraclavicular lymph nodes, the bones, the liver, the brain or the lungs. MRI thus can subsequently be used to plan the most appropriate treatment as the size of these lesions on MRI is usually concordant with the size at pathology, thus MRI may prevent unnecessary mastectomies or assign patients with large tumors to neoadjuvant protocols.
The evaluation of therapy response in the neoadjuvant chemotherapy setting Neoadjuvant chemotherapy is the administration of chemotherapy prior to surgical treatment of cancer. Its principal indication is the treatment of unresectable breast cancers, and its goal in this setting is to reduce the tumor to a size that allows resection.
However, many studies have shown that the prognosis of breast cancer is equal when chemotherapy precedes or follows after surgery. Because there are some theoretical benefits in the neoadjuvant setting, and tumor response can be closely evaluated with the tumor in situ, neoadjuvant chemotherapy is also the standard of care in large T2 and T3 tumors.
MRI has been shown to be superior to evaluate tumor response to neoadjuvant chemotherapy compared to clinical examination, mammography or ultrasound and is thus the imaging investigation of choice. If neoadjuvant chemotherapy is given to a patient, the first breast MRI should be performed before the start of chemotherapy.
A second MRI, for the evaluation of the effect of chemotherapy on the tumor, should be performed when approximately half of the course of chemotherapy has been administered.
A third MRI investigation should be performed after the final course of chemotherapy to evaluate the residual disease. In most hospitals four to six cycles of chemotherapy are given in the neoadjuvant setting. The effect of the chemotherapy in partial responders is less well established. Several studies compared the ability of clinical examination, mammography, ultrasound and MRI in the assessment of final response [ 70 — 80 ]. They showed that MRI measurement after therapy correlated best with the pathological findings and was the best technique for assessing response.
Nevertheless, MRI is unable to detect small residual tumor foci that may persist after neoadjuvant chemotherapy.
Radiological complete response is thus no proof for pathological complete response pCR ; therefore, resection of the initial tumor bed is still essential in the treatment of these patients [ 77 , 79 ].
Observation of response during treatment is important as this is the only measure that justifies the applied chemotherapeutic regimen and is the only response evaluation that allows a change in this regime before its completion.
Currently, the performance of MRI halfway during treatment may only change the treatment in clear non-responders and those with progressive disease as there are no other criteria for early response evaluation. This is due to the fact that size of the tumor often does not immediately decrease.
Therefore, the performance of MRI earlier in the treatment e. In another study early change in volume was the most predictive of final response [ 75 ].
The value of these MRI investigations first should be established, and criteria for early response need to be defined. Several other techniques, such as MR spectroscopy [ 81 ], diffusion imaging [ 82 ] and FDG-PET [ 83 — 85 ] show promise in the early evaluation of tumor response to therapy.
However, none of these techniques have been tested in large-scale prospective studies and can thus not yet be recommended for clinical practice. For a more detailed description of the studies so far performed in the evaluation of response to neoadjuvant chemotherapy, we refer to the review by Tardivon et al.
Imaging of the breast after conservative therapy MRI may be considered after breast-conserving therapy BCT in three instances: first as an evaluation tool for residual disease after positive tumor margins, second as a method of evaluating suspected recurrence by either clinical examination, mammography or ultrasound and third as a screening tool in all patients who undergo BCT. Unfortunately, early postoperative MRI is hampered by strongly enhancing resection margins in response to the surgical intervention.
Jessie Aw. Stuart Currie. Edward Lin. Laird Birmingham. Paul E. Richard Hopkins. Peter R. Jos W. Nassir Ghaemi.
Tammy Y. Vish Bhattacharya. Dan Stein. William D. Donna Dickenson. Henry J. Stephen Gillam. Serge Gauthier. Sailesh Kumar.
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Harry Potter. Popular Features. New Releases. Description Breast MRI is no longer the domain of specialised centres; it is now a mainstream diagnostic technique, and an understanding of its applications is essential for any clinician involved with breast imaging. Introductory chapters on breast MRI basics, anatomy and pathology are followed by detailed chapters on the use of MRI in screening, staging, problem-solving and MRI-guided interventions, each containing diagnostic algorithms, tables and lists for quick access to key diagnostic information.
Each chapter also contains a selection of self testing questions, and numerous Appendices concisely summarise tumour classification and current breast cancer treatment options.
The Handbook of Breast MRI is an invaluable practical diagnostic resource for radiologists, surgeons, oncologists and all clinicians involved in breast cancer management.
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