4/15/201

Adiwasono MBS
RS St. Borromeus Bandung

• Clinical or Self Examination

• Ultrasound
• Mammography
• MR breast imaging

• No ionizing radiation
• Highest sensitivity of all imagingmodalities for the
detection of breast cancerGrimm et al
• The high sensitivity of breast MRI is largely because of
improved contrast over mammography, particularly in
women with dense breast tissueGrimm et al
• Highly sensitive in the detectionof invasive malignancies,
with reported rates of 89% to 100% with variable
specificity, reported at 37% to97% Yeh et al
• It can use quantitative methods to improve specificity
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• Less comfortable to patient

• Higher costs
• Longer study time
• Intravenous contrast needed
• Longer interpretation time
• Time consuming to evaluate TIC(time signal intensity
curve)
• Variable specificity, reported at 37% to97% Yeh et al
• The specificity of breast MR has graduallyimproved,
likely because of improved technologyand increased
reader experience

• Inconclusive findings in conventional imaging

• Preoperative staging
• Unknown primary cancer and metastatic
• Evaluation of therapy respon in neoadjuvant
chemotherapy
• Imaging of the breast after conservative therapy and
evalution for recurrence
• Screening of the high risk patient
• Breast implant imaging
• MR guided interventions
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• Phase of menstruation cycle

• Hormone replacement
• Previous breast intervention
– Galactography
– Open biopsy and radiation therapy

Fischer
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Fischer

• Information about the purpose of the examination

• Information about the length of the examination: ~15
minutes
• Reference to the expected background noise
• The need to remain motionless during the
examination to avoid movement artifacts
• Notification of when contrast is administered
(temporary feeling of coolness in the arm)
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• Place venous access (18–20 gauge) intovein

• Connect extension tubes (1.5 m length, 4 mL volume).
• Allow a short rest period (~5 minutes) before positioning
the patient on the MR table
• Place the patient in a comfortable prone position.
• Apply hearing protection (earplugs, MRI-suitable headset
with/without music).
• Give the patient a panic bulb to be used in case of
claustrophobia,nausea, etc.

• Prone patient positioning minimizes the effectsof respiratory

motion on images, and helps tomove the breasts away from
the chest wall and the resulting artifacts from cardiac and
respiratory
• Patient comfort is vital, as the breast MRimaging examination
can last 30 minutes or longer
• Any patient discomfort is likely to manifest asmovement
during or between scans
• Intravenous access for contrast administration should be
placed ahead of time and secured to a powerinjector, so as to
minimize any interaction betweentechnologist and patient
(which may lead to inadvertent patient motion) once the
examination has begun
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• T1 -W non fat sat pre contrast

– To delineate fat versus other breast tissue
– 3 D GRE if possible
• T2- W fat sat pre contrast
– To separate cyst from other solid mass
– STIR as alternative (good fat suppresion)
• Dynamic Contrast Enhanced multiphase
– Back bone of MR breast study

• Sagittal
– most natural way to image the breast (+)
– small FOV->improve spatial resolution->more homogenous for fat
suppresion (+)
– Too many sections to cover both breast (-)
• Coronal
– Cover both breast(+)
– Acquired 50 % rectanguler FOV-> 50 % reduce scan time(+)
– Suffers more motion artifacts(-)
• Axial
– Recommended for cover both breast (+)
– Larger FOV-> less spatial resolution (-)
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• Bilateral
– Important for screening (high risk for breast
cancer)
– Staging for known breast cancer
• Unilateral
– If clinical concern only single breast
–small FOV->improve spatial resolution->more
homogenous for fat suppresion (+)

• Fat suppression is an essential and integral part of a

breast MRI exam
• The fat signal, if not suppressed, could mask the
features of interest and interfere with the evaluation
of benign lesions
• it is very important to suppress fat tissue signal to
improve the detection of enhancing lesions

• To reduce the error in pharmacokinetic modeling in

order to quantify kinetic parameters such as the transfer
constant and the fractional volume ofextravascular
extracellular space.
• Chemical shift can cause a large displacement of fat
signal in the phase-encoding direction of EPI(DWI)
• If a breast MRS voxel contains a large amount of fat, the
sideband of lipid resonance at 1.3ppm could mask the
tCho peak
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• Chemical Selective Fat Saturation

• Inversion Recovery
• SPIR/SPECIAL
• Spectral-selective (water) excitation
• Dixon Technique
• No fat suppresion – use subtraction post processing
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• T2 STIR Silicone
suppresion-fat
suppresion
– Silicone supressed -
water hyperintense
• T2 STIR Silicone
excited-water
suppresion
– Silicone hyperintese
-water supressed
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• At least 1.5 T magnetic field strength or above

• Bilateral Imaging with dedicated coil
• 3D GRE T1-W or derrivate sequence
• Good fat suppresion over both breast
– Use best fat sat technique available
– Manual shimming on both breast
• Thin Image slice  3mm ( 1mm ideally)
• Pixel size less than 1 mm each in-plane direction
• Proper phase encoding direction to minimize artifacts
• Total acquisitions less than 2 minutes
– Peak contrast in malignancy lesions typically occurs between 1-3
minutes post injection
– Meeting temporal resolution and spatial temporal
requirments(isotropic images) and optimal volume coverage
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© 2006 Denis Hoa et al, Campus Medica. www.e-mri.org

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• Sequential acquisition T1-W imagesbefore and after the

injection of a paramagneticcontrast agent
• As the contrast agent perfuses or diffuses into a voxel or
region of interest (ROI)
• It shortens the native magnetic relaxation times of the tissue
as determined by the local concentration of contrast.
• When the contrast agent leavesthe voxel, the relaxation times
increase toward their baselinevalue at a rate determined by
local tissue characteristics
• Each voxel thus yields a signal intensity time course that can
be analyzed to yield estimates of tissuevascularity parameters
including perfusion, permeability, and tissue volume fractions

• MRI pharmacokinetic models allow the quantification of the

exchange of contrast agent between the intravascular andthe
interstitial space
• capturing tumour blood flow,microvasculature, and capillary
permeability
• provides MRI pharmacokinetic parameters ofK-trans, K-ep, and V-e
(%) from post-processed DCE-MRI
• K-trans is related to the rate of contrast agent uptake intotumour
from blood
• K-ep is the rate of contrast agent transportfrom tumour to blood
• V-e(%) is the leakage of fractionalvolume from the extravascular
extracellular space into theplasma compartment
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• Choose a 3D gradient-echo sequence with fat saturation

and the shortest availableTE and TR values. Reducing TE
minimizes T2*-w of the sequence,
• Choose parallel imaging with an acceleration factor of 2 if
it is compatible with obtaining good, artifact-free images
in a scan plane acceptable to theradiologist.
• Choose a field of view that includes all breast tissue.
• Choose a matrix that gives sub-millimeter in-plane pixel
size, with square with square pixels.
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• Choose the right frequency-encoding direction

• Choose the slice thickness and number of slices so that scan
time for a single bilateral acquisition is between 1 and 2
minutes, while making sure that slicethickness does not
exceed 3 mm because some scanners will not beable to meet
these temporal and spatial resolution requirements
• Isotropic or nearly isotropic imaging, with a slice thickness of
0.8 to 1.0 with a slice thickness of 0.8 to 1.0mm,would be
ideal
• Create a multi-series contrast-enhanced protocol with the first
acquisition as the pre-contrast scan. A total of 5 to 7 scans (4
to 6 post-contrast scans)

• 3 plane loc SSFSE

• Calibration Scan
• Ax T2 STIR ASSET
• Ax 3D T1
• Ax VIBRANT Dynamic Contrast ( 6 phase)
• Ax VIBRANT 1 mm Isotropic Post Contrast Delay
• Sagital VIBRANT High Resolution Post Contrast
• Sag T2 FSE Fat sat Right&Left(additional)
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• Routine protocol
• Saline implant
– Sag T2 FSE Fat sat Left&Right
– Sag T2 FSE Water sat Left&Right
• Silicone implant
– Ax T2 STIR Water Suppresion
– Sag T2 STIR Water Suppresion Left&Right
– Ax T2 STIR Silicon Supression ASSET
– Sag T2 FSE Fat Sat Silicon Supression Left&Right
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• Image subtraction, if possible with re-registration of pre- and

post-contrast images
• Maximum intensity projections of subtracted data
• Multiplanar image reconstructions (MPRs)
• Creation of enhancement maps based on multiple time point
acquisitions
• Creation of time-enhancement curves for suspicious
enhancing lesions
• Lesion evaluation for degree of suspicion
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• GÖTTINGEN/FISCHER SCORE
• ACR BI-RADS (Breast Imaging Reporting and Data
System) SCORE
• KAISER SCORE
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ACR BI-RADS
LEXICON

ACR BI-RADS
SCORE

KAISER
IDENTIFICATION
FACTOR
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KAISER
IDENTIFICATION
FACTOR

• Abbreviate MR Breast protocol

– To reduce study time
– To reduce interpretation time
• Quantitative MR methods
– To increase MR breast imaging specitivity

• Lesion size measurement

• Dynamic contrast-enhanced MRI (DCE-MRI)
• Diffusion-weighted MRI (DW-MRI)
• Proton magnetic resonance spectroscopy (MRS)
• Magnetization transfer (MT) MRI
• Chemical exchange saturation transfer (CEST) MRI
• MR elastography
• Hyperpolarized MR
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• MRI is an extremely powerful techniquefor

demonstrating the morphology of breast
lesionsAbramson et al
• Assessing breast cancer response to therapy using
changes in lesion size as the primary measurement
variable
• Can calculate using segmentation algorithm

• ADC values from successivevoxels can then be aggregated to

produce a map of ADC values over the volume of interest
• Cancerous tissues often show significantly reduced ADC values when
compared with healthy tissues, a finding typically attributed to the
increased cell density of many malignancies.
• With treatment, intratumoral ADC values often rise
• Because of decreases in cell density consequent to apoptosis and cell
death, with concomitant disruption of cell membranes allowing
watermolecules to diffuse more freely
• Low tumor ADC values before treatment, followed by rising tumor
ADC values with treatment – provides the basic model forDW-MRI
as a response assessment technique
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• MRS provides information on the concentrations of

different metabolites in tissue
• Many malignancies demonstrate elevated levelsof
choline and lactate, the former due to high rates of
membrane turnover and the latter due to utilization of
anaerobic glycolysis
• Choline is present in less than onemillimolar
concentrations in normal breast tissue but issignificantly
elevated in malignant breast tumorsdue to choline
kinase overexpression driven by HIF-1
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• MT is a method for detecting and quantifying the protons

associated with tissue macromolecules
• MT takes advantage of the communication between
macromolecular protons and water to elicit an indirect
measurement of their properties
• To measure extracelluler matrix (ECM) of breast
• The expression of the ECM macromoleculesfibronectin,
collagen type IV, and laminin is altered in breast
cancerIoachim et al
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• CEST is similar to MT, but rather than focusing on macromolecules,

CEST seeks to specifically irradiate tissue metabolites such as amides,
amines, and hydroxyl groups that are also in exchange with free
water
• CEST focused at the amide proton resonance (3.5ppm) provides
information on the amide protons of protein/peptide backbones and
has been used to study tissues where either the protein/peptide
concentration or the pH may be alteredit also call as Amide Proton
Transfer(APT) imaging
• Because tumor cells may accumulate defective proteins at a higher
rate than normal and/orexperience alterations in pH due to hypoxia
• To differentiate cellular protein contentbetween tumor and healthy
cells

• MRE is based on use of the elastic properties of tissue asan

imaging contrast mechanism.
• The general concept of elastography, realized first in
ultrasound and later developed in MRI
• To measure tissue response to applied physical deformation
• Elastography allows for generation of tissue elasticity maps
providing spatial visualization and quantification of the
distribution of elastic properties within an object
• Cancer progression is accompanied by extracellular matrix
remodeling and increasing mechanical stiffness
• Quantifying in vivo stiffness of breast tumors (as well as
differentiation of fibroglandular and adipose tissue) have
demonstrated the ability to improve diagnostic sensitivity and
specificity over more traditional breast MRI
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• Hyperpolarized MR seeks to overcome the limitations of

conventional MRS by exploiting exogenous contrast agents
that have been “hyperpolarized,”ie, a large proportion of their
nuclear spins have been aligned with the magneticfield or
polarized.
• Increase in signal intensity translates into increased sensitivity
for detecting metabolic markers of cancer such as lactate and
bicarbonate that may be present atmillimolar and potentially
submillimolar concentrations that may not be amenable to
conventional MRS.
• The technique may also beexploited to provide better spatial
resolution and significantly faster examination times
compared with conventional protonMRS

• Hyperpolarized contrast agents that are suitable for injection

into living organisms. Carbon-13(13C) sites without directly-
attached protons are most commonly used
• Clinical translation of hyperpolarized MR technology is limited
by demanding instrumentation and softwarerequirements,
including multinuclear MRI scannercapability,highly
specialized RF pulse sequences (tailored to the RF
coil ,magnetic field strength, and metabolic contrast agent),
and multinuclear RF coils.
• It can analyses of choline, pyruvate, fumarate, and
bicarbonate as potential biomarkers
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• Liethner et al, Clinical role of breast MRI now and goingforward, Clinical
Radiology, Elseiver, New York,2017
• Wang C. Lilian, MR Imaging Future Imaging Techniques, Radiology Clinic
North America, Elseiver, Chicago, 2017
• Moschetta et al, Abbreviated Combined MR Protocol: A NewFaster Strategy
for Characterizing Breast Lesions, Clinical Breast Cancer, Elseiver, 2016
• Rao et al, A Pictorial Review of Changes in the BI-RADS Fifth Edition1 ,
Radiographics:36, RSNA,2016
• Lin et al, Fat suppression techniques in breastmagnetic resonance imaging: a
critical comparison and state of the art, Reports in Medical Imaging:8,
Dovepress, Indiana, 2015
• Fischer,Uwe, High-Resolution MRI of Breast,Thieme, 2nd edition, Germany,
2012
• Tabar et al, Imaging of The Breast: Technical Aspects and Clinical Implication,
Intech, Croatia,2012

• Abramson et al, Current and emerging quantitative magnetic resonance imaging

methods for assessing and predicting the response of breast cancer to
neoadjuvant therapy, Breast Cancer: Targets and Therapy, Dovepress, Tennessee,
2012
• Juanpere et al, Imaging of breast implants—a pictorial review, Insights Imaging,
Springer,2011
• Yeh D. Eren, Breast Magnetic Resonance Imaging: Current Clinical Indications,
Magnetic Resonance Imaging Clinic North America: 18, Elseiver, Boston,2010
• Weinstein et al, Breast MR Imaging: Current Indications and Advanced Imaging
Techniques, Radiology Clinic North America: 48, Elseiver,Philadelphia, 2010
• Moon et al, Dynamic Contrast-Enhanced Breast MR Imaging, Magnetic Resonance
Imaging Clinic North America: 17, Elseiver,2009
• Kaiser A. Werner, Signs in MR-Mammography, Springer, Berlin, 2008
• Hendrick R. Edward,Breast MRI: Fundamental and Technical Aspects, Springer,
Chicago, 2008
• Morris A. Elizabeth, Breast MRI: Diagnosis and Intervention, Springer, New York,
2005