Breast MRI - High-Risk Screening (Contrast-Enhanced)

Indications

• Women with >=20-25% lifetime risk (BRCA1/2 and untested first-degree relatives, other high-penetrance mutations)
• History of chest radiation between ages 10-30 (e.g., Hodgkin lymphoma)
• Strong family history / risk models indicating high lifetime risk
• Typically annual, often alternating/staggered with mammography

Patient prep

• Schedule premenopausal patients on days 7-14 of menstrual cycle (ideally day 6-16) to minimize background parenchymal enhancement (BPE)
• Screen renal function/eGFR per facility policy for gadolinium; screen for contraindications (non-MRI-safe implants, severe claustrophobia, pregnancy)
• IV access placed; no breast deodorant restriction needed but remove metallic items
• Prone positioning in dedicated breast coil

Contrast

Technique

• 1.5T or 3T scanner with dedicated bilateral breast coil, patient prone
• Localizer, T2-weighted (often fat-suppressed), and pre/post dynamic T1 fat-suppressed 3D gradient-echo (DCE)
• High spatial resolution with adequate temporal resolution; bilateral simultaneous imaging
• Post-processing: subtraction images, MIP, and kinetic curve (early enhancement + delayed washout/plateau/persistent)

Series / Sequences

Key points

• Highest sensitivity modality for invasive cancer; complements rather than replaces mammography
• Report BPE (minimal/mild/moderate/marked) and fibroglandular tissue amount; high BPE lowers specificity (cycle timing mitigates)
• Suspicious washout kinetics + morphology (irregular/rim-enhancing mass, segmental/clumped non-mass enhancement) raise concern
• Use MRI BI-RADS lexicon; MRI-only suspicious lesions require MRI-guided biopsy (or targeted 'second-look' US if a correlate is found)

References