×

Search Radiopaedia.org
Articles
Log In
Cases
Sign Up
Courses
Quiz
Blog
Donate
About
×

Search Radiopaedia.org
Menu

Search
Radiopaedia is free thanks to our Supporters & AdvertisersBecome a Gold Supporter, and see no ads

Articles
Cases
Courses
Log In

• Log in
• Sign up

Sign up

Enter your email and create a password for your account

Email*
Password*
Show password
Must contain:

• at least 8 characters
• 1 uppercase letter, 1 lowercase letter, 1 number

Next Step

Step 1 of 4
ArticlesCasesCoursesQuiz
AboutBlogGo ad-free
Search Radiopaedia.org Search

Breast MRI
Dr Daniel J Bell ◉ and Radswiki et al.

Breast MRI is the most sensitive method for detection of breast cancer. Depending on international health
regulations, it is either applied for screening of women at high risk for developing breast cancer (e.g. BRCA1
and BRCA2 carriers), as an additional diagnostic test in pretherapeutic breast cancer staging, monitoring of
primary systemic therapies and for solving problematic diagnostic situations where direct biopsy is not
possible.

Editorial board note: this article is probably outdated, lacks structure and is in need of a major rewrite. If you
are interested in refining it you are more than welcome.

On this page:
Article:

• Sequences used
• Lexicon
• MRI BI-RADS assessment categories
• Interpretation points
• Indications for breast MRI
• MRI features and PPV
• MRI-detected cancers
• Related articles
• References

Images:

• Cases and figures

Sequences used

• dynamic T1-weighted gradient echo before and after IV gadolinium injection

• T2W-TSE or STIR sequences
• diffusion-weighted imaging (DWI)
• further techniques, e.g. proton MR-spectroscopy, seldom applied outside research settings

Lexicon

General breast composition

• amount of fibroglandular tissue

◦ almost entirely fat: ACR a
◦ scattered fibroglandular tissue: ACR b
◦ heterogeneous fibroglandular tissue: ACR c
◦ extreme amount of fibroglandular tissue: ACR d
• background parenchymal enhancement (BPE)
◦ minimal
◦ mild
◦ moderate
◦ marked
Lesions

Usually, enhancing lesions are meant. Absence of enhancement practically excludes breast cancer with a
negative predictive value (NPV) >99%.

• focus (formerly defined as <5 mm): enhancement too small to be characterised, should be considered as
BPE if symmetric and multiple
• mass enhancement (space occupying lesion, best diagnostic clue: margins can be assessed)
◦ shape: round (non-specific), oval (rather benign), irregular (rather suspicious)
◦ margins: circumscribed (benign), non-circumscribed (rather suspicious), spiculated (highly
suspicious)
◦ internal enhancement pattern: homogenous (rather benign), heterogenous (non-specific), rim (rather
suspicious, in particular, if centripetal, filling up over time), dark internal septations (rather benign),
old BI-RADS included central enhancement (part of the lesion enhances, highly specific for
fibroadenoma)
• non-mass enhancement (best diagnostic clue: margins cannot be assessed due to diffuse enhancement or
grouped multiple spots; non-mass are far more difficult to distinguish and reflect different pathological
entities)
◦ distribution pattern: focal, linear (rather suspicious), regional, multiple regional, segmental (rather
suspicious)
◦ internal enhancement pattern: homogeneous (rather benign), heterogeneous (non-specific), clumped
(rather suspicious), clustered ring (rather suspicious, seldomly seen), old BI-RADS included
stippled, a homogeneous grainy enhancement typically benign
• in all lesions: enhancement kinetics: see breast MRI enhancement curves
◦ washout (rather suspicious), plateau (non-specific), persistent (rather benign) (caveat: lymph nodes
show washout but typical morphology)

MRI BI-RADS assessment categories

• BIRADS 0: incomplete/non-diagnostic - this category should not be used for marked background
parenchymal enhancement (BPE), motion artifacts etc.
• BIRADS I: negative (no enhancing lesions, no benign changes such as scars, cysts etc.)
• BIRADS II: benign (lymph nodes, inflamed cysts, fibroadenoma, fat necrosis, foci/stippled enhancement,
patchy BPE).
• BIRADS III: probably benign, requiring short term follow-up in 6 months. If the finding is visible on e.g.
US, the most widely available method should be used for follow-up (should be applied only to lesions not
fitting category II and IV, probably benign findings in high-risk screening should rather be biopsied than
followed-up)
• BIRADS IV: suspicious finding requiring biopsy (biopsy should always be tried by US first as the
majority of MRI lesions can be localized by targeted ultrasound)
• BIRADS V: highly suspicious, biopsy mandatory
• BIRADS VI: known, histologically-verified cancer

Diagnosis is established by combining morphological and functional criteria. A circumscribed round lesion with
persistent enhancement is a typical fibroadenoma while the same lesion presenting with washout may be cancer
(typical in high risk population, aggressive cancers).

Interpretation points

Clinical history and correlation with mammography is not only diagnostically useful (e.g. to reduce the number
of BIRADS III category assignments) but should be considered in the report as well in order to demonstrate to
the referring physician that the clinical question has been answered.

Positive predictive value (PPV) of MRI

• in high risk screening population: 3 - 4% prevalence when mammography was negative ( 0.3% when
mammography and ultrasound negative)
• 7% if personal history of cancer
• positive predictive value 24% (½ invasive 4 mm median size / ½ DCIS)
 ◦ biopsy recommended in 17%

Extent of disease

• contralateral breast
◦ 5% prevalence
◦ 20% positive predictive value (biopsy recommended in 1/3) (NEJM 29/3/2007: biopsy
recommended in 12% PPV 25%);
• ipsilateral breast
◦ ~25%

• 50% PPV (biopsy recommended in 50%)

• ipsilateral multifocal ¾ (same quadrant >1cm from index CA or contiguous but extends >4 cm)
multicentric ¼; distribution similar to recurrent disease
• additional sites of ipsilateral cancer more frequent if +FH (42%) & ILC (55%)
• positive predictive value higher the closer the lesion is to the index cancer.
• biopsy to get histological diagnosis no matter how suspicious because result is mastectomy
• younger patients because of 1 - 2% / year recurrence may also benefit from preoperative MRI
• true and false positive rates decrease with each subsequent comparison MRI

MRI sensitivity

• IDC / ILC : >90%

• DCIS : 80 - 90%
• implant rupture : ~94% 9

Indications for breast MRI

ACR guidelines

• high risk screening

◦ personal history
◦ family history
◦ high risk lesions: ADH/ALH/LCIS
◦ BRCA1 / BRCA2 gene positivity
◦ mantle radiotherapy (>4 gray)
◦ Li-Fraumeni syndrome +/- first-degree relatives
◦ Cowden and Bannayan-Riley-Ruvalcaba syndromes and first-degree relatives
• extent of disease (EOD) evaluation in ipsilateral and contralateral breast
• positive margins (better accuracy further from lumpectomy site than near Lx site b/c postop enh/changes)
• neo-adjuvant chemotherapy : to assess residual disease
• metastatic axillary lymphadenopathy of unknown primary (75 - 80% sensitive) - can spare a patient from
having management because may be able to undergo BCT; management path only finds cancer in two-
thirds
• posterior lesion to assess chest wall invasion (pectoralis can be resected so not considered
• chest wall stage IIIB - serratus anterior muscle, rib, intercostal muscles)

ACS recommendations

• BRCA+ : BRCA1 or BRCA2

• 1st degree relative BRCA+ and untested
• those who have had prior radiotherapy to chest wall
• >25% lifetime risk based on genetic models (some of which take breast density into consideration)
• not recommended if lifetime risk <15% because of high false positive rate

Other possible indications

• problem solving (e.g. post operative breasts with distortion)

 • recurrent breast cancer / scar changes (not usual before 2 - 3 years; peak 5 - 7 years; increased risk if EIC,
younger age, positive margins (wait at least 1 month postop to scan), no radiotherapy)
• to assess for synchronous, multifocal or multicentric disease

MRI features and PPV

Mass

• spiculated mass: 80%

• irregular shape: 32%
• <5 mm mass: 3%

Non-mass

• calcifications
◦ segmental: 67%
◦ clumped ductal: 31%

Ductal enhancement

• malignant causes: DCIS, invasive cancer

• benign high risk causes: ADH, LCIS
• benign: fibrosis, ductal hyperplasia, fibrocystic change

MRI-detected cancers

• 40-50% cancers should be <1 cm

• at least 20-30% should be DCIS
• positive nodes <20%

False negatives

• technical causes : breast tissue not included in the coil, motion, bad contrast injection, too much
compression
• marked background enhancement

caveat: if mammography or ultrasound is positive or palpable finding need to treat / biopsy / excise despite
negative MRI

Ultrasound correlation

• MSKCC: only 23% probably low but if lesion is less than 1 cm or deep within lots of background
parenchyma in a large breast may want to go directly to MR guided biopsy

References
Related Radiopaedia articles

Breast imaging and pathology

• breast screening
◦ breast screening programmes
• mammography
◦ breast imaging and the technologist
◦ forbidden (check) areas in mammography
◦ mammography views
◾ craniocaudal view
 ◾ mediolateral oblique view
◾ additional (supplementary) views
◾ true lateral view
◾ mediolateral view
◾ lateromedial view
◾ lateromedial oblique view
◾ late mediolateral view
◾ step oblique views
◾ spot view
◾ double spot compression view
◾ magnification view
◾ exaggerated craniocaudal (axillary) view
◾ XCCL view
◾ XCCM view
◾ cleavage view
◾ tangential views
◾ caudocranial view
◾ bullseye CC view
◾ rolled CC view
◾ elevated craniocaudal projection
◾ caudal cranial projection
◾ 20° oblique projection
◾ inferomedial superolateral oblique projection
◾ Eklund technique
◦ normal breast imaging examples
• digital breast tomosynthesis
• breast ultrasound
◦ breast echotexture (BI-RADS categories)
◦ breast ultrasound features: benign vs malignant
◦ ultrasound evaluation of breast cysts
◦ volumetric breast ultrasound
• breast ductography
• breast MRI
◦ breast MRI classification flowchart
◦ breast MRI enhancement curves
• breast morphology
◦ architectural distortion
◦ asymmetry in breast size
◦ breast density
◾ asymmetrical breast density
◦ breast implants
◾ capsular contracture
◾ gel bleed in breast implants
◾ rupture of breast implants
◾ keyhole sign
◾ linguine sign
◾ salad oil sign
◾ snowstorm sign
◾ stepladder sign
◾ subcapsular line sign
◾ teardrop sign
◦ fibrocystic change
◦ free silicone breast injections
◦ parenchymal patterns in breast imaging
 ◦ tubular breasts
• breast pathology
◦ malignant lesions
◾ breast cancer
◾ breast adenocacrinoma
◾ ductal breast carcinoma
◾ ductal carcinoma in situ (DCIS)
◾ comedo-type ductal carcinoma in situ
◾ non-comedo type ductal carcinoma in situ
◾ invasive ductal carcinoma
◾ extensive intraductal component
◾ invasive ductal carcinoma not otherwise specified
◾ scirrhous carcinoma of the breast
◾ medullary carcinoma of the breast
◾ mucinous carcinoma of the breast
◾ Paget disease of the breast
◾ tubular carcinoma of the breast
◾ tubulolobular carcinoma of the breast
◾ malignant papillary lesions of the breast
◾ papillary carcinoma of the breast
◾ intracystic papillary carcinoma of the breast
◾ lobular breast carcinoma
◾ lobular carcinoma in situ (LCIS)
◾ invasive lobular carcinoma of the breast
◾ adenoid cystic carcinoma of the breast
◾ apocrine carcinoma of the breast
◾ breast cancer metastases
◾ metastatic intramammary lymph node
◾ breast lymphoma
◾ breast sarcoma
◾ angiosarcoma of the breast
◾ pleomorphic sarcoma of the breast
◾ fibrosarcoma of the breast
◾ myxofibrosarcoma of the breast
◾ leiomyosarcoma of the breast
◾ primary osteosarcoma of the breast
◾ inflammatory carcinoma of breast
◾ intracystic breast cancer
◾ male breast cancer
◾ malignant phyllodes tumour
◾ metastases to the breast
◾ metaplastic carcinoma the breast
◾ gamuts
◾ multifocal breast cancer
◾ pregnancy-associated breast cancer
◾ recurrent breast cancer
◾ residual breast cancer
◾ metachronous breast cancer
◾ multicentric breast cancer
◾ synchronous breast cancer
◾ triple receptor negative breast cancer
◾ well-defined breast cancer
◦ borderline breast disease / high risk breast lesion
◾ atypical ductal hyperplasia
◾ atypical lobular hyperplasia
◾ columnar alteration with prominent apical snouts and secretions (CAPSS)
◾ flat epithelial atypia
◾ lobular intraepithelial neoplasia (LIN III)
◾ papillary lesions of the breast
◾ radial scar / complex sclerosing lesion
◾ sclerosing adenosis
◦ benign lesions
◾ adenosis of the breast
◾ blunt duct adenosis of the breast
◾ microglandular adenosis of the breast
◾ benign papillary lesions of the breast
◾ papilloma
◾ solitary papilloma of breast
◾ central solitary papilloma of breast
◾ peripheral solitary papilloma of breast
◾ intraductal papilloma
◾ sclerosing papilloma
◾ multiple papillomata of breast
◾ juvenile papillomatosis of breast
◾ breast cyst
◾ breast sebaceous cyst
◾ complex breast cyst
◾ breast haematoma
◾ breast hamartoma
◾ breast within a breast
◾ breast lipoma
◾ ductal adenoma of the breast
◾ epidermal inclusion cysts of the breast
◾ fat necrosis of the breast
◾ fibroadenoma
◾ complex fibroadenoma
◾ giant fibroadenoma
◾ juvenile fibroadenoma
◾ granular cell tumour of the breast
◾ gynaecomastia
◾ lymphocytic mastitis
◾ diabetic mastopathy
◾ mammary fibromatosis
◾ oil cyst
◾ phyllodes tumour
◾ post-surgical breast scar
◾ post-traumatic fibrosis
◾ pseudoangiomatous stromal hyperplasia (PASH)
◾ pseudogynaecomastia
◾ tubular adenoma
◦ breast calcifications (approach)
◾ morphology
◾ microcalcifications within breast
◾ pleomorphic microcalcifications within breast
 ◾ rounded microcalcification within breast
◾ punctate microcalcification within breast
◾ amorphous calcification within breast
◾ macrocalcifications within breast
◾ coarse macrocalcifications within breast
◾ popcorn calcification within breast
◾ egg shell/rim calcification within breast
◾ distribution
◾ cutaneous calcification
◾ diffuse/scattered calcification
◾ regional calcification
◾ clustered calcification / grouped calcification
◾ linear calcification
◾ segmental calcification
◾ location
◾ lobular calcification within breast tissue
◾ intraductal calcification within breast tissue
◾ milk of calcium within a breast cyst
◾ vascular calcification in breast tissue
◾ skin (dermal) calcification in / around breast tissue
◾ suture calcification within breast tissue
◾ stromal calcification within breast tissue
◾ artifactual calcification from outside the breast
◾ suspicious breast calcifications
◦ infection/inflammation
◾ breast abscess
◾ subareolar abscess
◾ breast cellulitis
◾ mammary duct ectasia
◾ mastitis
◾ puerperal mastitis
◾ plasma cell mastitis
◾ granulomatous mastitis
◦ vascular lesions
◾ breast aneurysm
◾ breast varix
◦ systemic disease
◾ breast amyloidosis
◾ granulomatosis with polyangiitis: breast manifestations
◦ gamuts
◾ breast lumps
◾ stellate breast lesions: causes (mnemonic)
◾ giant breast masses
◾ differential diagnosis of dilated ducts on breast imaging
◾ fat-containing breast lesions
◾ hereditary breast and ovarian cancer syndrome
◾ non-palpable breast lesions
◾ male breast disease
◦ classification systems
◾ ACR 5-tier system
◾ BI-RADS
◾ BI-RADS 0
 ◾ BI-RADS I
◾ BI-RADS II
◾ BI-RADS III
◾ BI-RADS IV
◾ BI-RADS V
◾ BI-RADS VI
◾ Nottingham classification
◾ Tabar 5-tier grading system
• breast cancer staging

Promoted articles (advertising)

Edit article Share article

• View revision history

URL of Article https://radiopaedia.org/articles/breast-mri?lang=gb

Article information
rID: 12182
Systems: Breast, Oncology
Section: Approach
Tags: oncology, rewrite
Synonyms or Alternate Spellings:

• MRI breast
• MRI of the breast
• Magnetic resonance imaging of the breast
• MR mammography

Support Radiopaedia and see fewer ads

Cases and figures

Case 1 : showing breast cancer + lipomaCase 1 : showing breast cancer + lipoma
Drag here to reorder.

Case 2 : showing invasive ductal carcinomaCase 2 : showing invasive ductal carcinoma

Drag here to reorder.

Case 3 : showing invasive lobular carcinomaCase 3 : showing invasive lobular carcinoma

Drag here to reorder.
Case 4 : showing extra-capsular implant ruptureCase 4 : showing extra-capsular implant rupture
Drag here to reorder.

Case 5 : showing multicentric lobular cancerCase 5 : showing multicentric lobular cancer

Drag here to reorder.

Case 5 : colour coded image shows large breast cancerCase 5 : colour coded image shows large breast cancer
Drag here to reorder.

Case 6: pseudoangiomatous stromal hyperplasiaCase 6: pseudoangiomatous stromal hyperplasia

Drag here to reorder.
Case 7: enhancement curve Case 7: enhancement curve
Drag here to reorder.

Case 8: high grade ductal carcinoma in situCase 8: high grade ductal carcinoma in situ
Drag here to reorder.
:

Encyclopaedia
By Section:

• Anatomy
• Approach
• Classifications
• Gamuts
• Interventional radiology
• Mnemonics
• Pathology
• Physics
• Radiography
• Signs
• Staging
• Syndromes

By System:

• Breast
• Cardiac
• Central Nervous System
 • Chest
• Forensic
• Gastrointestinal
• Gynaecology
• Haematology
• Head & Neck
• Hepatobiliary

• Interventional
• Musculoskeletal
• Obstetrics
• Oncology
• Paediatrics
• Spine
• Trauma
• Urogenital
• Vascular

Patient Cases
• Breast
• Cardiac
• Central Nervous System
• Chest
• Forensic
• Gastrointestinal
• Gynaecology
• Haematology
• Head & Neck
• Hepatobiliary

• Interventional
• Musculoskeletal
• Obstetrics
• Oncology
• Paediatrics
• Spine
• Trauma
• Urogenital
• Vascular

Radiopaedia.org
• About
• Blog
• Donate
•
• Editors
• Expert advisers
• Help
•

• Facebook
 • Twitter

• Newsletter

Contact Us
Terms of Use
Privacy Policy
Licensing
Sponsorship
Developers

Updating… Please wait.

Unable to process the form. Check for errors and try again.

Thank you for updating your details.

© 2005–2019 Radiopaedia.org
Accept
This site is for use by medical professionals. To continue you must accept our use of cookies and the site's
Terms of Use.

Privacy - Terms