Breast MRI

Question 1

breast MRI protocol

Answer 1

prone with dedicated breast coil; bilaterally

T1, T2 w/ and w/o FS
pre and post contrast sequences
GRE
MIPs

Question 2

BIRADS lexicon: breast tumor kinetics

Answer 2

slow, medium, rapid early enhancement

delayed phase (2 min): persistent (type 1), plateau (type 2), washout (type 3)

Question 3

delayed kinetics

Answer 3

Type 1: continued increasing enhancement (benign 83% of the time; 9% malignant)

Type 2: early rise in enhancement, but levels off in delayed phase (PPV of 64-77% cancer)

Type 3: decreased signal intensity, suspicious for malignancy (PPV 87-92%); include LN, adenosis, papillomas

Question 4

more important on MRI: morphology or pattern of enhancement?

Answer 4

morphology; spiculated lesion is still suspicious despite enhancement

Question 5

BIRADS MRI mass lexicon

Answer 5

round, oval, lobular, irregular

Question 6

IBRADS mass margin lexicon

Answer 6

smooth, irregular, spiculated

best evaluated precontrast

Question 7

BIRADS lexicon internal enhancement

Answer 7

homogenous, heterogenous, rim enhancement, enhancing internal septations and central enhancement, dark internal septations (fibroadenoma)

Question 8

MRI focus

Answer 8

dot of enhancement <5mm without mass or abnormality

may depend on menstrual status/multiplicity for cancer concern

Question 9

non masslike enhnacmenet

Answer 9

enhancing region not a focus or mass

Question 10

BIRADS NMLE distribution lexicon

Answer 10

linear/ductal: points toward nipple
segmental: trianglar shaped; most common with DCIS
focal area: <25% of quadrnat
regional: geographic distribution >25% quadrant
multiple regions: 2 regions of NMLE
diffuse: throughout breast

Question 11

BIRADS NMLE internal enhancement lexicon

Answer 11

heterogenous
homogenous
clumped (bunch of grapes/cobblestone)
stippled/punctate
reticular/dendritic

Question 12

T2 signal of a benign lesion

Answer 12

T2 hyperintensity within the enhancing portion of mass suggestive of benign lesion; myxoid fibroadenoma

Question 13

T1 findings to look for on breast MRI

Answer 13

susceptibility artifact from biopsy clips/calcifications

hyperintense hemorrhagic cysts/proteinaceous ductal fluid

Question 14

Mass or NMLE with a type I kinetic curve and benign morphology

Answer 14

BI-RADS 2: Bilateral stippled foci of enhancement, without a dominant mass or suspicious focal NMLE.
BI-RADS 3: Mass or NMLE with benign morphology and enhancement kinetics, and negative targeted ultrasound. In order for follow-up to be appropriate (rather than biopsy), the lesion must demonstrate only benign features on MRI. It is specifically these benign features, rather than the negative targeted ultrasound, that allow a lesion to be classified as BI-RADS 3.
BI-RADS 4: Solitary, dominant, or asymmetric NMLE in a high risk patient.

Question 15

Mass or NMLE with type II or III kinetic curve and benign morphology:

Answer 15

BI-RADS 4: A notable exception is a benign intramammary lymph node, which is typically located in the lateral breast adjacent to a vessel, and is reniform in shape.

Question 16

•Mass or NMLE with type I kinetic and malignant morphology classification

Answer 16

i BI-RADS 4.

Question 17

A mass or NMLE with a type II–III kinetic curve and malignant morphology

Answer 17

BI-RADS 4 or 5.

Question 18

Indications for screening breast MRI

Answer 18

high risk patients: family history, gene mutations, exposure to thoracic radiation (lymphoma)

BRCA1/2

Question 19

other indications for breast MRI

Answer 19

• evaluate extent of disease/impact management
• multifocal breast cancer
• muticentric disease (more than one quadrant) requiring mastectomy
• measure tumor size; evaluate LN, pectoralis invasion
• assess residual disease
• evaluate for local recurrence or metachronous primary
• follow response to neoadjuvent chemotherapy
• diagnostic problem solving
• evaluate silicone implants