Breast MR/procedures

Question 1

Indications for breast MRI (6)

Answer 1

Implant evaluation

axillary mets w/ unknown primary

extent of disease

assessing response to therapy

diagnostic delemma

high risk screening

Question 2

1. Who gets a screening MR?
2. Which risk model do you use?

Answer 2

1. People w/ lifetime risk >15-25%

People who got 20Gy of radiation to chest

2. Use Tyrer Cuzickrisk model because it includes family history. The “Gail” risk model does not.

Question 3

6 sequences that you use for breast MR

Answer 3

T2 w/ FS

T1 Pre w/ FS

T1 Post

Saggital

Subtracted

MIP

Question 4

1. Flaring artifact
2. How to fix it

Answer 4

Non-uniform fat suppression when breast tissue is very close to coil elements.

This artifact is not related to fat suppression.

You have to put padding b/w the breast tissue and coil elements.

Question 5

Background parenchymal enhancement

1. When in cycle should you scan in order to minimize BPE
2. what other factors effect it?

Answer 5

1. Days 7-14
2. Hormone therapy (should be stopped)

Serms decrease BPE

Tamoxifen rebound results in increased BPE

-lumpectomy and radiation

Question 6

Does nipple enhance on Breast MR?

Answer 6

Yes. Enhancement is normal

Question 7

Defninitition of “foci” in MR

Answer 7

Dot of enhancement (<5mm). Too small to characterize.

If there are many foci, then it is probably BPE

Question 8

1. What does it mean if mass/foci in MR is T2 bright?
2. What is the one exception?
3. Benign things that enhance (name 3)

Answer 8

1. T2 bright = BR2
2. Mucinous (colloid) cancer
3. fibroadenoma, Papilloma, Lymph nodes

Question 9

Appearance of firoadenoma on MR

Answer 9

Circumscribed round/oval mass

Variable on T2

On post-contrast, it can enhance, and have non-enhancing septations

Question 10

If a lesion is not T2 bright, then what do you look at?

2. Mass margin should be evaluated on the first post-contrast series. What border feature is most predictive of malignancy?

Answer 10

1. Look at morphology, then kinetics
2. Spiculated

Question 11

1. Non-mass like enhancement is classic imaging for what?
2. It is described by distribution. The distribution is its most predictive feature. Which distributions are bad?

Answer 11

1. DCIS is Classic, but it can also represent IDC
2. Segmental is worst distribution. Linear, and focal distribution is bad.

Question 12

BiRADS - MR lexicon

1. Shape - 3
2. Margins - 3
3. Enchancement - 4

Answer 12

1. Round, oval, irregular
2. Circumscribed, spiculated, irregular
3. Homogenous, heterogenous, rim, Dark internal septations.

Question 13

BIrads - MR lexicon for NME

1. Disribution - 6
2. Internal enhancement - 4 - (which is the wort kind)

Answer 13

1. Focal, segmental, linear, regional, multiple regions, diffuse
2. Homogenous, heterogenous, clumped, clustered ring

Clustered ring is the worst kind.

Question 14

2 types of breast implants. 2 locations.

Answer 14

1. Saline and silicone (can’t see through silicone on Mammo)
   - For Silicone, you body will form a fibrous capsule around implant.
2. subglandular/retromammary, subpectoral/retropectoral

Question 15

1. Saline -types of ruptures
2. Types of silicone ruptures

appearance on Mammo, u/s and MRI

*if you see silicone in a lymph node, you need to recommend MRI to evaluate for extracapsular rupture.

Answer 15

1. Saline - no capsule (no such thing as ‘intracapsular rupture”)
2. Silicone: both intra and extra capsular rupture.
   mammo: You can’t see intra on mammogram.

u/s: extracapsular creates snowstorm appearance

intracapsular creates ‘step ladder’ appearance.

MRI: intracapsular has linguine sign

Question 16

What type of mammo views do you need to get with implants

Answer 16

4 views of each breast. CC, MLO, and implant displaced CC and MLO.

Question 17

When can you BR-0 an MR study?

Answer 17

Never.

Unless the study was technically limited.

Question 18

Can you BR3 a solitary focus on MRI

Answer 18

If it is solitary focus with persistent kinetics on baseline exam, you can give it a BR3

Question 19

Describe Cowden Syndrome (4 things)

Answer 19

Bowel hamartoma, follicular thyroid cancer, Lhermitte Duclos, breast cancer

Question 20

1. u/s biopsy - how to position
2. What should be needle projectory?

Answer 20

1. roll breast away from lesion (thin the tissue)

Raise ipsilateral arm.

2. parallel to chest wall

Question 21

1. For ultrasound biopsy of a ‘disapearing lesion,’ which part of the lesion swould you biopsy?
2. If there are 2 lesions and 1 of them is obvious/large and the other is less obvious, which do you biopsy first?

Answer 21

1. biopsy the posterior part first, becase then you can still see the anterior part.
2. Biopsy the one you see worse first. This is because then if things get distorted, you can probably still see the big one.

Question 22

Situations when a stereo biopsy is difficult

Answer 22

Thin breast (<2-3cm compressed thickness)

Lesions too close to skin

subareolar lesions

posterior lesions

Question 23

How do you calculate depth when doing a stereo biopsy?

Answer 23

Get a +15 degree and -15 degree images. Then the computer will calculate depth (z axis)

Question 24

What is stroke margin?

What do you want, a positive or negative stroke margin?

Answer 24

Distance between when where the needle is supposed to end after the throw, and the skin on the opposite side

Positive stroke margin: You still have space between needle throw and skin

Negative stroke margin (bad): your needle through will puncture skin

Question 25

Stereo targeting error: how can you tell X vs. Y vs. Z axis error?

Answer 25

on X axis, images will project with different relationship to the lesion (ex. one projects over the lesions, when the other is off the lesion) On Y axis, both images will be either superior or inferior to the lesion On Z axis, both images will either be not deep enough, or too deep

Question 26

What is management of high risk lesions?

Answer 26

Surgical excision

Question 27

A 39-year-old female is scheduled for a contrast-enhanced breast MRI for high-risk screening evaluation. She undergoes laboratory testing for renal function due to her history of diabetes mellitus. Her laboratory results are creatinine of 1.8 mg/dL and a calculated GFR of 28 mL/min/1.73 m 2. No prior laboratory data are available to review. Which of the following is the most appropriate next step in the evaluation of this patient?

Answer 27

a discussion of the patient’s risk-benefit ratio with the referring physicians is necessary to determine if the examination is essential. If intravenous gadolinium-based contrast administration is needed, it is recommended that one use the lowest possible dose to obtain a diagnostic study. The Food and Drug Administration (FDA) has determined that the risk for patients with chronic insufficiency is greatest when the estimated glomerular filtration rate (eGFR) is \<30 mL/min/1.73 m 2. Nephrogenic systemic fibrosis (NSF) is a rare but serious systemic disease characterized by fibrosis of the skin and other tissues throughout the body. The first report on NSF was published in 1997, and there is increasing evidence that this condition is associated with renal failure and the administration of large amounts of gadolinium.

Question 28

Answer 28

motion artifact

Question 29

when should you bracket cancer when using wire localization

Answer 29

when cancer is \>2.5 cm