BREAST IMAGING SOCIETY, INDIA

BEST PRACTICE GUIDELINES – MRI BREAST

INTRODUCTION

Magnetic Resonance Imaging (MRI) of the breasts is an established, robust and important
imaging tool in the armamentarium of a trained breast radiologist for the detection and
characterization of breast abnormalities. Its high sensitivity to detect breast cancer has led it
being established as an excellent screening tool in women with strong family history of
breast cancer and with dense breasts & further for pre-therapeutic local staging of newly
diagnosed breast cancers where its role is being increasingly well accepted. It also serves as
a good problem solving tool to clarify findings that are indeterminate on mammography and
breast ultrasound.

Various groups and organisations have established recommendations for appropriate use of
MRI, one such being the American College of Radiology (ACR) which has laid down certain
guidelines to standardise various aspects of conducting and reporting breast MRI studies in
the ACR Breast Imaging - Reporting and Data System ( ACR BI-RADS). At present this is the
most widely used MR Imaging Lexicon in India enabling clinicians across specialities to
communicate well and work towards the common goal of better patient care. With
increasing availability of Breast MRI in facilities across our country it is important to
understand its advantages and limitations so that it can be utilised appropriately and
effectively.

PRE-REQUISITES

 At least a 1.5-T magnet.

 Dedicated bilateral Breast surface Coils capable of simultaneous bilateral imaging.
 Equipment to perform mammographic correlation & directed breast
ultrasonography.
 Ideally MR imaging-guided intervention facility or at least have a referral
arrangement with a cooperating facility that could provide the service.

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TECHNIQUE

Although, there may be minor variations in breast MR imaging acquisition protocols from
centre to centre, there is a general agreement that high-quality imaging should include a
technique that is bilateral, obtained using a dedicated breast coil with complete coverage of
the breasts and axillae, is a dynamic multiphasic contrast enhanced study and has key pulse
sequences with appropriate high spatial and temporal resolution for morphologic and
kinetic assessment of the lesion.(1)

It is always a good idea to talk to the patient prior to the scan to obtain required history,
clinically examine the patient and to prepare her/him by explaining the entire procedure
including the unusual prone position, contrast injection and importance of not moving
during scanning. Proper patient/breast positioning in the coil with application of optimal
lateral compression plates to minimise movement and other inhomogenous fat suppression
artefacts balanced with adequate patient comfort is imperative in obtaining images of
diagnostic quality.

Contrast agent & dose - Gadolinium contrast agent injected intravenously at a dose of 0.1
mmol/kg followed by a 20 ml saline flush at a rate of approximately 2 ml/s, using a power
injector.(1)

Pulse Sequences – For optimal diagnostic usefulness a fluid sensitive sequence with and
without fat suppression – T2 FS/STIR, T1W & T2W 2D or 3D images of at least 3 mm or less
slice thickness with a maximum in-plane pixel dimension of 1 mm or less to achieve good
spatial resolution followed by a multiphase T1-W Dynamic Contrast Enhanced (DCE) series
with pre-contrast, initial post-contrast in a 60 to 120s window for reasonable temporal
resolution & subsequent delayed post-contrast images are required.(1) Silicone selective
sequences may be acquired for implant evaluation. Intravenous contrast administration can
be omitted and a plain study carried out for assessment of implant integrity. Newer
techniques such as Diffusion weighted imaging (DWI) and MR spectroscopy are optional.

Abbreviated (FAST) Breast MRI as a cost effective screening protocol with similar sensitivity
and specificity to a full diagnostic protocol may also be used with fewer sequences (3-4 in
number) in varying combinations as per reader comfort to shorten the scan time. This would
include a fluid sensitive T2 / STIR, pre and a single post-contrast fat suppressed T1W
sequence.

Post processing techniques – Evaluation of images using Subtraction, Maximum intensity

projections (MIP), morphologic and Kinetic analysis on a dedicated workstation.

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INDICATIONS

Divided into two main categories – Screening and Diagnostic

SCREENING Breast MRI

X-ray Mammography is the investigation of choice for Breast Screening. However,

mammography has its limitations especially in young high risk women with dense breasts.
Among other modalities, contrast enhanced MRI has greater sensitivity compared to X-ray
mammography and sonography for invasive (94-99%) and in-situ cancers (50-80%) in high
risk population. Hence MRI has been widely accepted in its role in the high risk category of
patients as an adjunct screening modality with X-ray mammography and not replacing it. It
may also have a supplemental role in screening of the intermediate (15-20% ) risk category
in the future which is currently under research (2,3,4,5).

Annual screening MRI along with X-ray mammogram should be offered in high risk women
i.e. those with a life time risk of breast cancer of 20% or more (2,4). This subset includes -

 Known BRCA1 or BRCA2 gene mutation

 Untested first-degree relative (mother, father, brother, sister, or child) of BRCA1 or
BRCA2 gene mutation.
 Those with a lifetime risk of breast cancer of 20-25% or greater, according to risk
assessment models.
 Received mantle radiation to the chest for Hodgkin’s disease between the ages of 10
and 30 years.
 Having genetic disease such as Li-Fraumeni syndrome, Cowden syndrome, or
Bannayan-Riley-Ruvalcaba syndrome, or first-degree relatives with it.

Breast MRI may also be considered as a supplement to mammography to screen women at

intermediate risk of breast cancer (15%-20%) such as those with a personal history of breast
cancer and dense tissue or for those diagnosed with breast cancer under the age of 50 (6).

Patients with breast augmentation – Screening breast MRI may also be considered in
patients with silicone or saline implants and/or free injections with silicone, paraffin, or
polyacrylamide gel in whom mammography is difficult and for those who have undergone
implant reconstruction following lumpectomy or mastectomy for breast cancer where
contrast-enhanced breast MRI screening may be beneficial (6).

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DIAGNOSTIC Breast MRI

In its diagnostic role Breast MRI is helpful in the following clinical settings –

Assessment of extent of disease in newly diagnosed breast cancer

Although current literature does not support widespread use of MRI for breast cancer
staging in terms of increasing overall survival and reducing re-excision rates, MRI does have
the superior sensitivity and accuracy for detection of invasive and in situ disease as
compared with Clinical Breast Examination (CBE), mammography & ultrasound with limited
specificity and hence maybe useful in select subpopulations such as
- In dense breasts to assess multifocality /multicentricity & ductal carcinoma in situ
(DCIS) where it influences eligibility for Breast Conservation Surgery (BCS).
- Lobular cancers which are more accurately imaged with MRI by virtue of their
pattern of growth.
- Posterior tumors better imaged with MRI for chest wall invasion
- Patients being planned for partial breast irradiation (PBI) following BCS.

However, in view of its limited specificity It is emphasised that all suspicious MR findings
should be correlated with biopsy prior to definitive therapy to ensure appropriate
treatment. Targeted second-look ultrasound, re-evaluation of mammograms, targeted
mammographic views, or images obtained with digital breast tomosynthesis are useful,
offering possibility of a biopsy under their guidance. Mass lesions identified on MRI are
more likely to have a sonographic correlate than non-mass like lesions (65% vs 12%,
respectively). Hence a second-look US is a useful diagnostic tool for lesions incidentally
detected on breast MRI and also helps in guiding biopsies. In suspicious MR only detected
lesions (BI-RADS 4 or 5) however, an MR-guided biopsy will be required (7).

Assessing Response to Neoadjuvant Chemotherapy in locally advanced breast cancers not

amenable to upfront surgeries, to reduce tumor size to enable BCS and to assess tumor
responsiveness to therapy.

Metastatic axillary adenopathy with occult primary on Clinical Breast Examination (CBE),
Mammography and Ultrasound
MRI accurately detects the occult primary in 62-86 % of cases (8) which is then treated
accordingly or when MRI too is negative, axillary nodal dissection is done along with
mastectomy or Whole Breast Radiation therapy (WBRT).

Scar versus tumor recurrence

For Problem Solving in cases with equivocal or inconclusive findings on mammograms and
ultrasound such as asymmetries with a suspicious appearance, multiple masses,
pathological nipple discharge with no mammographic or sonographic correlate and to
localise lesions for image guided biopsies and wire placements in cases where multiple solid
lesions of similar characteristics are seen [to select the most suspicious (1 or 2) to biopsy
and also where the lesions are difficult to resolve sonographically such as intraductal

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inspissated secretions or intraductal solid lesion where MRI helps in retrospective
identification on re-look ultrasound and localised].

Evaluation of Augmented breasts

MR imaging is the most sensitive imaging method to detect breast silicone implant integrity
and does not require injection of intravenous contrast for assessing rupture only. Contrast
may however be indicated in the evaluation of patients with silicone or saline implants
and/or free injections with silicone, autologous fat, paraffin, or polyacrylamide gel as well as
for those who have undergone implant reconstruction following lumpectomy or
mastectomy for breast cancer. The presence of implants does not affect the sensitivity of
MRI for breast cancer detection.

REPORTING BREAST MRI

Report of MRI breasts should clearly mention the clinical indication for which it is being
done along with findings noted on the other conventional imaging modalities, as it should
never be interpreted in isolation. It is also important to remember that mammograms are
obtained in upright position, ultrasound in supine / semi lateral decubitus position and MRI
in prone position, which may lead to mild variation in the lesion location described as the o'
clock position, especially those bordering the quadrants and should be noted as such.
Comparison must be made with any priors available. It is very important to mention the
background breast parenchymal enhancement pattern (BPE) which is inherent to this
modality only along with the breast composition. All findings need to be described as per
standardised descriptors given in international guidelines such as the ACR BIRADS Reporting
System in terms of morphology and kinetic assessment and a final impression should be
mentioned indicating the worst comprehensive BIRADS category with a clear mention of
further investigative advise such as biopsy or a follow up protocol (9).

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DISCLAIMER

The Best Practice Guidelines of Breast Imaging Society, India are the broad guidelines for
investigation, intervention and management of clients opting for breast screening and
patients with breast symptoms in India, and intended for the use of qualified medical
caregivers only. These are based on various national and international guidelines and
personal experiences and opinions of BISI members, as there is no large credible Indian data
to formulate these guidelines. These guidelines are purely recommendatory and general
purpose only in nature. Actual decisions for management of patients should be
individualized according to own judgement of the caregiver and tailored on case-to-case
basis. As scientific knowledge is continuously improving, a regular update of the same by the
caregiver is essential. Failure to do so may result in untoward patient management or
outcome and BISI members or BISI as the organization cannot be held responsible for that in
any manner.

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REFERENCES

1. Wendy B. De Martini, MD, Habib Rahbar, MD; Magn Reson Imaging Clin N Am 21
(2013) 475–482 : Breast Magnetic Resonance Imaging Technique at 1.5 T and 3 T
Requirements for Quality Imaging and American College of Radiology Accreditation

2. American College of Radiology ACR Appropriateness Criteria for Breast Cancer

Screening, 2012, Revised criteria 2017

3. C. Boetes, MD, PhD; Magn Reson Imaging Clin N Am 18 (2010) 241–247 : Update on
Screening Breast MRI in High-Risk Women

4. American Cancer Society Guideline for Breast Screening with MRI as an Adjunct to
Mammography (2007)

5. Mary C. Mahoney, MD, Mary S. Newell, MD ; MagnReson Imaging Clin N Am 21

(2013) 495–508 : Screening MR Imaging Versus Screening Ultrasound Pros and Cons

6. ACR practice parameter for the performance of contrast-enhanced magnetic

resonance imaging (mri) of the breast. Revised 2018 (Resolution 34)
https://www.acr.org/-/media/ACR/Files/Practice-Parameters/mr-contrast-breast.pdf
(accessed on 29th July 2020)

7. Natasha Brasic, MD, Dorota J. Wisner, MD, PhD, Bonnie N. Joe, MD, PhD; Magn
Reson Imaging Clin N Am 21 (2013) 519–532 ; Breast MR Imaging for Extent of
Disease Assessment in Patients with Newly Diagnosed Breast Cancer

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8. Amy Argus and Mary C. Mahoney ; AJR:196, March 2011: Indications for Breast
MRI: Case-Based Review

9. D’Orsi CJ, Mendelson EB, Ikeda DM, et al. Breast imaging reporting and data system:
ACR BIRADS breast imaging atlas. Reston (VA): American College of Radiology; 2003