Breast Mass Protocol
Overview
Currently breast MRI has five
primary purposes; evaluation for breast implant rupture, as diagnostic tool in
the evaluation of known or suspected breast cancer, imaging of the axillary
region in cases of axillary lymphadenopathy with unknown primary, monitoring
response to post-surgical primary chemotherapy, and pre-surgical evaluation of
residual disease following neo-adjuvant chemotherapy.
The following protocol is designed for evaluation of patients with known
or suspected breast cancer and not for breast implant rupture.
Gadolinium (Gd) enhanced imaging is
the mainstay of breast MRI in evaluation of a known or suspected breast tumor,
extent of disease in patients with known breast malignancy, and recurrence of
tumor after treatment. Post-contrast high spatial resolution images are
ideal for evaluating lesion morphology. Post-contrast high temporal
resolution images generally have lower spatial resolution but allow analysis of
enhancement kinetics in any lesion. The sequences described below are
optimized for a spatial resolution sufficient to allow lesion morphology
analysis and for a temporal resolution sufficient to evaluate the enhancement
kinetics. Currently the highest specificity can be attained evaluating
both lesion morphology and the kinetic enhancement pattern of the lesion on
dynamic 3D spoiled gradient echo (SPGR) with fat saturation study.
Scheduling Guidelines
�� Approved Reimbursable
Indications
1. diagnosis is inconclusive, even after standard workup
2. post-op: when scar tissue cannot be differentiated from tumors
3. positive axillary nodes but no known primary
4. rupture of breast implant
5. determination of extent of disease in patients with known malignancy,
prior to treatment (to assure confinement to one segment of the breast)
�� First Ask
1.
Why is the breast MRI being requested? Does the referring physician want
one or both breasts imaged?
2.
Do you have breast implants?
3.
Do you have a breast mass?
4.
Have you had breast cancer?
For
patients with breasts implants, please ask the following:
1.
How long have you had the implants?
2.
What type of implants do you
have? Silicone, saline or both?
3.
Has there been a recent change in
your implants?
4.
Do you or your doctor think there
has been an implant rupture?
The breast MRI for evaluation of
implant rupture alone does not require Gd injection. If the patient has a mass
not related to the implant then she will require an injection of Gd.
For patients with a breast mass, ask
the following questions:
1. Have
you had a recent mammogram?
2. Did
your mammogram have an abnormal finding? Was the abnormal finding in the
area where you feel the mass?
3. Have
you had a breast ultrasound?
4. Have
you had a biopsy of the breast mass? If the answer is ��yes��, what were the results?
5. Do
you have a personal or family history of breast cancer?
6. Is
the breast MRI intended to better characterize the known breast mass, look for
other areas of disease in the same breast, in the contralateral (opposite)
breast or all of the above?
For patients with a history of
breast cancer, ask the following questions:
1- When
did you have breast cancer?
2- Did
you have surgery? When and what type of surgery did you have?
3- Were
your lymph nodes involved with cancer?
4- Have
you had chemotherapy or radiation therapy? If yes, when did you stop your
treatments?
5- Is
your doctor concerned about recurrent cancer or a new breast
cancer? In the same breast or the opposite breast?
6- Have
you had a recent mammogram? Did it show a change?
7- Can
you or your doctor feel a new mass? If yes, is it in the same area as
your previous cancer or in a new area?
8- Do
you know if your breast cancer has spread to other parts of your body?
9- Is
the breast MRI intended to better characterize the new or recurrent finding,
look for other areas of disease in the same breast, in the opposite breast or
all of the above?
�� Ask the patient to bring all available mammograms with her
at the time of the MRI examination. This is extremely important. If mammograms
are not available, notify the radiologist who will be monitoring the
exam. Also have all recent mammogram and ultrasound reports faxed to MRI
unit prior to the date of breast MRI study. All breast masses will be
evaluated with Gd.
�� Whenever possible schedule exam to occur between day five
and day fifteen of the menstrual cycle (day one is the 1st day of
menstruation). Otherwise there may be excessive enhancement of normal breast
glandular tissue requiring a callback exam for reevaluation.
Patient preparation
��
Start intravenous line (20 or 22
gauge IV). If IV caliber is smaller than 22 gauge, then it may be useful warming Gd
contrast up to body temperature to reduce its viscosity.
�� Valium (5-10mg PO) or Xanax (1-2 mg po) if patient is
claustrophobic.
�� Ear plugs
Coil: Dedicated breast coil is optimal for superior signal to
noise.
Patient Positioning: Prone, head first. Patient must have comfortable
pillow for head and arms. Be careful that patient is centered in the coil.
There is a tendency for patient to slide too far superiorly in the coil. To
counteract this tendency, ask the patient to slide 2-3 cm toward feet after she
lies prone on the coil.
Landmark:
Mark at center of the breast coil
This is a quick localizer sequence
obtained in three planes. It is used to confirm optimal patient positioning
within the breast coil. The sagittal views are most helpful. Bright signal from
the inferior aspect of the coil should end at the inframamary fold. This will allow maximum coil signal superiorly.
��
Prescribe graphically on an axial
slice that is centered between the axilla and inframammary fold, not the center of the breast. This will allow better
visualization of the axillary nodes.
�� Scan direction should be from left edge to right edge of the
breast.
�� One or both breasts may be scanned depending on the clinical
circumstances.
�� Make field of view large enough to include axilla
to assess lymph nodes.
This
sequence is helpful for differentiating the cysts from tumor or fibrosis.
�� This is the main sequence to identify
and characterize malignant lesions.
�� The scan plane may be sagittal for a
single breast or axial for both breasts. With ��Vibrant�� it is possible to prescribe 2 separate volumes, one for
each breast. Coronal can also cover both breasts but does not correspond to a
standard mammographic view.
�� Keep FOV as small as possible but include
both breasts. This helps to ensure homogeneous fat saturation and optimal
spatial resolution.
�� If the # of scan locations or the
phase encoding steps are increased, scan time will increase and the temporal
resolution will be decreased. Longer scan
time generally gives higher spatial resolution as a trade off to high temporal
resolution. In the Scanning Range area the following options are available:
FOV, slice thickness and number of scan locations. An optimal FOV is generally
around 28-32 cm depending on patient size. If a larger volume is necessary, it
is preferable to increase the slice thickness over the number of scan
locations. This will allow one to cover a larger volume in the same amount of
time, obviously at the expense of temporal resolution. However the ��ZIP2�� option allows obtaining relatively thin reconstructed
images. These parameters are designed for imaging the breast tissue pre and
post contrast. If one is interested in including the axillary region, a larger
volume maybe necessary. This can be done by increasing the number of scan
locations at the expense of temporal resolution. If the scan time is increased,
check the multiphase screen as you may need to decrease the number of phases
from nine to eight.
��
All pre, during and post-Gd
acquisitions should be done in the same series to facilitate optimal
subtraction technique. It is important to turn on the multiphase option to
ensure that the scanner memory can accommodate the number of post contrast
sequence planned.
�� It is very important that the patient
does not move between the pre, during and post-Gd scans.
�� To minimize the chance of motion, be
sure to start the IV line before performing the pre-contrast acquisition.
In general, the IV should be placed before the patient enters the magnet
because the prone position can make starting the IV extremely difficult.
�� This sequence is obtained with the ��ZIP2�� option turned on. This allows you to obtain the images with
a 5-6 mm slice thickness but to reconstruct the images at 2.5-3 mm for
interpretative review.
�� Emphasize with the patient the importance
of avoiding coughing, wiggling or other large motions during or in between
these scans.
�� Manually prescan to ensure the best possible fat saturation (use cstun).
If homogeneous fat suppression is a problem with the larger FOV used for axial
imaging, the scan can be performed without fat suppression and supplemented
with a post processing subtraction technique for optimal visualization of areas
of contrast enhancement. With ��Vibrant�� it is possible to optimize field homogeneity for two regions,
one for each breast.
�� As the machine readily defaults to
frequency R/L direction, make sure that the frequency direction is A/P. If the
primary area of interest is in the axillary tail region, you may consider A/P
phase encoding direction with R/L frequency encoding direction. This is the one
exception to frequency A/P because if phase is A/P then cardiac and respiratory
motion creates phase artifact that superimposes on the breasts.
Dictation Template
Patient History:
1. Clinical abnormalities: palpable lesion? (size,
location, duration) nipple discharge?
2. Previous biopsies: date, location, results
3. Hormonal status: Last menstruation date (menstrual
cycle phase), post-menopausal, peripartum, exogenous hormones, tamoxifen
Comparison with Previous Studies:
�� Most recent
mammogram (date)
�� Previous breast MRI (date)
�� Ultrasound or nuclear medicine study
Technique:
The patient was imaged in a 1.5
Tesla magnet using a dedicated breast coil. Sagittal T1 weighted (6 mm),
pre, during, and post-Gd 3D-FSPGR (2.5-3 mm) with fat saturation images were
obtained. An initial set of dynamic FSPGR gadolinium enhanced images were
obtained in the axial plane to include both breasts with eight 3D data-sets
acquired at 92 second intervals. IV ��.. mL of gadolinium bolus was administered in 20-30 seconds
beginning simultaneously with the second dynamic acquisition.
Post
processing techniques: MPR/MIP, time-intensity curves,
subtraction
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