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Breast
Lesion Imaging Characteristics
MR Findings
Kinetic Assessment (MR)
Kinetic Assessment (MR)
Katie M. Davis, DO; Wendie A. Berg, MD, PhD, FACR, FSBI
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KEY FACTS

  • Terminology

    • Top Differential Diagnoses

      • Clinical Issues

        • Diagnostic Checklist

          TERMINOLOGY

          • Definitions

            • Time-intensity curve (TIC): Plot of % increase in signal intensity (SI) (y-axis) as a function of time (x-axis) after contrast injection
              • Most common technique for kinetic assessment
              • Pixel: In-plane resolution of image = field of view (FOV)/matrix size
              • Voxel: Resolution of image in 3 dimensions = pixel size x slice thickness
              • Parametric analysis software calculates kinetic information
                • Each pixel/voxel is color-coded; color maps created based on thresholding and kinetic features
                • Lack of color mapping standard across software platforms; annotations explain color map
                • Signal intensity (pixel basis) plot of lesion enhancement over time
              • Use ≥ 3 pixel-size region of interest (ROI) to manually calculate
            • Initial phase: 1st 120 seconds after contrast injection or when peak enhancement is reached
              • Weight-based, bolus technique, contrast agent administration
              • % SI increase = [(SI post - SI pre)/SI pre] x 100
              • Initial phase slow, medium, or fast
                • Slow: SI increase < 50%
                • Medium: SI increase 50-100%
                • Fast (rapid): SI increase > 100%
              • Enhancement threshold: Designated threshold required to assign color to kinetics on CAD software
                • Can be manually set; usually 50% or 100% ↑ in SI
                • Depends on contrast agent concentration, precontrast tissue T1 signal, flip angle, RF pulse, local vasculature, cardiac output
            • Delayed phase: > 120 seconds after contrast injection, up to 5-10 minutes following contrast injection
              • 3 patterns in delayed phase after exceeding initial enhancement threshold
                • Persistent (type 1 curve): Progressive, continued enhancement with > 10% ↑ over time
                • Plateau (type 2 curve): SI does not change (beyond ± 10%) over time, remains flat
                • Washout (type 3 curve): Subsequent ↓ in SI > 10% from peak over time
              • Signal enhancement ratio (SER): % increase in SI early vs. late [(SI early - SI pre)/(SI late - SI pre)] where "early" is typically 1st postcontrast acquisition (phase) and "late" is typically 2nd postcontrast acquisition (phase)
                • Only calculated on pixels/voxels above enhancement threshold
            • Subtraction images: Precontrast T1 images subtracted from postcontrast T1 images
              • Misregistration artifact: Motion between pre- and postcontrast images causes misregistration, alternating light and dark bands of signal usually best appreciated at edges of breast; can result in misinterpretation if not recognized
              • Most CAD software includes motion correction algorithms
            • Maximum-intensity projection (MIP): Thick-slab 3D reformat of postcontrast subtracted images showing highest pixel values through slab

          IMAGING

          • MR Findings

            • Imaging Recommendations

              DIFFERENTIAL DIAGNOSIS

                CLINICAL ISSUES

                • Risk of Malignancy Varies by Kinetics

                  • Associations of Pathologic Findings and Kinetics

                    • Associations of Treatment Response and Kinetics

                      DIAGNOSTIC CHECKLIST

                      • Consider

                        • Image Interpretation Pearls

                          Selected References

                          1. Fujiwara K et al: Grading system to categorize breast MRI in BI-RADS 5th edition: A multivariate study of breast mass descriptors in terms of probability of malignancy. AJR Am J Roentgenol. 210(3):W118-W127, 2018
                          2. Kim KW et al: Diagnostic Usefulness of Combination of Diffusion-weighted Imaging and T2WI, Including Apparent Diffusion Coefficient in Breast Lesions: Assessment of Histologic Grade. Acad Radiol. 25(5):643-652, 2018
                          3. Abe H et al: Kinetic analysis of benign and malignant breast lesions with ultrafast dynamic contrast-enhanced MRI: Comparison with standard kinetic assessment. AJR Am J Roentgenol. 207(5):1159-1166, 2016
                          4. Bae MS et al: Pretreatment MR Imaging Features of Triple-Negative Breast Cancer: Association with Response to Neoadjuvant Chemotherapy and Recurrence-Free Survival. Radiology. 281(2):392-400, 2016
                          5. Ferré R et al: Differentiation of fibroadenomas and pure mucinous carcinomas on dynamic contrast-enhanced MRI of the breast using volume segmentation for kinetic analysis: A Feasibility Study. AJR Am J Roentgenol. 206(2):253-8, 2016
                          6. Lewin AA et al: Assessment of background parenchymal enhancement and lesion kinetics in breast MRI of BRCA 1/2 mutation carriers compared to matched controls using quantitative kinetic analysis. Acad Radiol. 23(3):358-67, 2016
                          7. Blaschke E et al: MRI phenotype of breast cancer: Kinetic assessment for molecular subtypes. J Magn Reson Imaging. 42(4):920-4, 2015
                          8. Yamaguchi K et al: Intratumoral heterogeneity of the distribution of kinetic parameters in breast cancer: comparison based on the molecular subtypes of invasive breast cancer. Breast Cancer. 22(5):496-502, 2015
                          9. Giess CS et al: Background parenchymal enhancement at breast MR imaging: normal patterns, diagnostic challenges, and potential for false-positive and false-negative interpretation. Radiographics. 34(1):234-47, 2014
                          10. Partridge SC et al: Breast DCE-MRI: influence of postcontrast timing on automated lesion kinetics assessments and discrimination of benign and malignant lesions. Acad Radiol. 21(9):1195-203, 2014
                          11. Greenwood HI et al: Ductal carcinoma in situ of the breasts: review of MR imaging features. Radiographics. 33(6):1569-88, 2013
                          12. Hylton NM et al: Locally advanced breast cancer: MR imaging for prediction of response to neoadjuvant chemotherapy--results from ACRIN 6657/I-SPY TRIAL. Radiology. 263(3):663-72, 2012
                          13. Rahbar H et al: In vivo assessment of ductal carcinoma in situ grade: a model incorporating dynamic contrast-enhanced and diffusion-weighted breast MR imaging parameters. Radiology. 263(2):374-82, 2012
                          14. Kim JA et al: MRI findings of pure ductal carcinoma in situ: kinetic characteristics compared according to lesion type and histopathologic factors. AJR Am J Roentgenol. 196(6):1450-6, 2011
                          15. Morris EA, et al: ACR BI-RADS® Magnetic Resonance Imaging. In: ACR BI-RADS® Atlas, Breast Imaging Reporting and Data System. Reston, VA, American College of Radiology; 2013
                          16. Fernández-Guinea O et al: Relationship between morphological features and kinetic patterns of enhancement of the dynamic breast magnetic resonance imaging and clinico-pathological and biological factors in invasive breast cancer. BMC Cancer. 10:8, 2010
                          17. Loiselle CR et al: Dynamic contrast-enhanced MRI kinetics of invasive breast cancer: a potential prognostic marker for radiation therapy. Int J Radiat Oncol Biol Phys. 76(5):1314-9, 2010
                          18. Yamada T et al: Radiologic-pathologic correlation of ductal carcinoma in situ. Radiographics. 30(5):1183-98, 2010
                          19. Jansen SA et al: Kinetic curves of malignant lesions are not consistent across MRI systems: need for improved standardization of breast dynamic contrast-enhanced MRI acquisition. AJR Am J Roentgenol. 193(3):832-9, 2009
                          20. Wang LC et al: MRI-detected suspicious breast lesions: predictive values of kinetic features measured by computer-aided evaluation. AJR Am J Roentgenol. 193(3):826-31, 2009
                          21. Chen JH et al: Magnetic resonance imaging features of fibrocystic change of the breast. Magn Reson Imaging.
                          22. Jansen SA et al: DCEMRI of breast lesions: is kinetic analysis equally effective for both mass and nonmass-like enhancement? Med Phys. 35(7):3102-9, 2008
                          23. Li KL et al: Invasive breast cancer: predicting disease recurrence by using high-spatial-resolution signal enhancement ratio imaging. Radiology. 248(1):79-87, 2008
                          24. Mann RM et al: MRI compared to conventional diagnostic work-up in the detection and evaluation of invasive lobular carcinoma of the breast: a review of existing literature. Breast Cancer Res Treat. 107(1):1-14, 2008
                          25. Jansen SA et al: Pure ductal carcinoma in situ: kinetic and morphologic MR characteristics compared with mammographic appearance and nuclear grade. Radiology. 245(3):684-91, 2007
                          26. Kuhl C: The current status of breast MR imaging. Part I. Choice of technique, image interpretation, diagnostic accuracy, and transfer to clinical practice. Radiology. 244(2):356-78, 2007
                          27. Williams TC et al: Breast MR imaging: computer-aided evaluation program for discriminating benign from malignant lesions. Radiology. 244(1):94-103, 2007
                          28. Macura KJ et al: Patterns of enhancement on breast MR images: interpretation and imaging pitfalls. Radiographics. 26(6):1719-34; quiz 1719, 2006
                          29. Schnall MD et al: Diagnostic architectural and dynamic features at breast MR imaging: multicenter study. Radiology. 238(1):42-53, 2006
                          30. van den Bosch MA et al: Magnetic resonance imaging characteristics of fibrocystic change of the breast. Invest Radiol. 40(7):436-41, 2005
                          31. Liberman L et al: Breast lesions detected on MR imaging: features and positive predictive value. AJR Am J Roentgenol. 179(1):171-8, 2002
                          32. Nunes LW et al: Update of breast MR imaging architectural interpretation model. Radiology. 219(2):484-94, 2001
                          33. Kuhl CK et al: Dynamic breast MR imaging: are signal intensity time course data useful for differential diagnosis of enhancing lesions? Radiology. 211(1):101-10, 1999
                          34. Gallardo X et al: Enhancement of intramammary lymph nodes with lymphoid hyperplasia: a potential pitfall in breast MRI. Eur Radiol. 8(9):1662-5, 1998
                          35. Brinck U et al: The variability of fibroadenoma in contrast-enhanced dynamic MR mammography. AJR Am J Roentgenol. 168(5):1331-4, 1997
                          Related Anatomy
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                          Related Differential Diagnoses
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                          References
                          Tables

                          Tables

                          KEY FACTS

                          • Terminology

                            • Top Differential Diagnoses

                              • Clinical Issues

                                • Diagnostic Checklist

                                  TERMINOLOGY

                                  • Definitions

                                    • Time-intensity curve (TIC): Plot of % increase in signal intensity (SI) (y-axis) as a function of time (x-axis) after contrast injection
                                      • Most common technique for kinetic assessment
                                      • Pixel: In-plane resolution of image = field of view (FOV)/matrix size
                                      • Voxel: Resolution of image in 3 dimensions = pixel size x slice thickness
                                      • Parametric analysis software calculates kinetic information
                                        • Each pixel/voxel is color-coded; color maps created based on thresholding and kinetic features
                                        • Lack of color mapping standard across software platforms; annotations explain color map
                                        • Signal intensity (pixel basis) plot of lesion enhancement over time
                                      • Use ≥ 3 pixel-size region of interest (ROI) to manually calculate
                                    • Initial phase: 1st 120 seconds after contrast injection or when peak enhancement is reached
                                      • Weight-based, bolus technique, contrast agent administration
                                      • % SI increase = [(SI post - SI pre)/SI pre] x 100
                                      • Initial phase slow, medium, or fast
                                        • Slow: SI increase < 50%
                                        • Medium: SI increase 50-100%
                                        • Fast (rapid): SI increase > 100%
                                      • Enhancement threshold: Designated threshold required to assign color to kinetics on CAD software
                                        • Can be manually set; usually 50% or 100% ↑ in SI
                                        • Depends on contrast agent concentration, precontrast tissue T1 signal, flip angle, RF pulse, local vasculature, cardiac output
                                    • Delayed phase: > 120 seconds after contrast injection, up to 5-10 minutes following contrast injection
                                      • 3 patterns in delayed phase after exceeding initial enhancement threshold
                                        • Persistent (type 1 curve): Progressive, continued enhancement with > 10% ↑ over time
                                        • Plateau (type 2 curve): SI does not change (beyond ± 10%) over time, remains flat
                                        • Washout (type 3 curve): Subsequent ↓ in SI > 10% from peak over time
                                      • Signal enhancement ratio (SER): % increase in SI early vs. late [(SI early - SI pre)/(SI late - SI pre)] where "early" is typically 1st postcontrast acquisition (phase) and "late" is typically 2nd postcontrast acquisition (phase)
                                        • Only calculated on pixels/voxels above enhancement threshold
                                    • Subtraction images: Precontrast T1 images subtracted from postcontrast T1 images
                                      • Misregistration artifact: Motion between pre- and postcontrast images causes misregistration, alternating light and dark bands of signal usually best appreciated at edges of breast; can result in misinterpretation if not recognized
                                      • Most CAD software includes motion correction algorithms
                                    • Maximum-intensity projection (MIP): Thick-slab 3D reformat of postcontrast subtracted images showing highest pixel values through slab

                                  IMAGING

                                  • MR Findings

                                    • Imaging Recommendations

                                      DIFFERENTIAL DIAGNOSIS

                                        CLINICAL ISSUES

                                        • Risk of Malignancy Varies by Kinetics

                                          • Associations of Pathologic Findings and Kinetics

                                            • Associations of Treatment Response and Kinetics

                                              DIAGNOSTIC CHECKLIST

                                              • Consider

                                                • Image Interpretation Pearls

                                                  Selected References

                                                  1. Fujiwara K et al: Grading system to categorize breast MRI in BI-RADS 5th edition: A multivariate study of breast mass descriptors in terms of probability of malignancy. AJR Am J Roentgenol. 210(3):W118-W127, 2018
                                                  2. Kim KW et al: Diagnostic Usefulness of Combination of Diffusion-weighted Imaging and T2WI, Including Apparent Diffusion Coefficient in Breast Lesions: Assessment of Histologic Grade. Acad Radiol. 25(5):643-652, 2018
                                                  3. Abe H et al: Kinetic analysis of benign and malignant breast lesions with ultrafast dynamic contrast-enhanced MRI: Comparison with standard kinetic assessment. AJR Am J Roentgenol. 207(5):1159-1166, 2016
                                                  4. Bae MS et al: Pretreatment MR Imaging Features of Triple-Negative Breast Cancer: Association with Response to Neoadjuvant Chemotherapy and Recurrence-Free Survival. Radiology. 281(2):392-400, 2016
                                                  5. Ferré R et al: Differentiation of fibroadenomas and pure mucinous carcinomas on dynamic contrast-enhanced MRI of the breast using volume segmentation for kinetic analysis: A Feasibility Study. AJR Am J Roentgenol. 206(2):253-8, 2016
                                                  6. Lewin AA et al: Assessment of background parenchymal enhancement and lesion kinetics in breast MRI of BRCA 1/2 mutation carriers compared to matched controls using quantitative kinetic analysis. Acad Radiol. 23(3):358-67, 2016
                                                  7. Blaschke E et al: MRI phenotype of breast cancer: Kinetic assessment for molecular subtypes. J Magn Reson Imaging. 42(4):920-4, 2015
                                                  8. Yamaguchi K et al: Intratumoral heterogeneity of the distribution of kinetic parameters in breast cancer: comparison based on the molecular subtypes of invasive breast cancer. Breast Cancer. 22(5):496-502, 2015
                                                  9. Giess CS et al: Background parenchymal enhancement at breast MR imaging: normal patterns, diagnostic challenges, and potential for false-positive and false-negative interpretation. Radiographics. 34(1):234-47, 2014
                                                  10. Partridge SC et al: Breast DCE-MRI: influence of postcontrast timing on automated lesion kinetics assessments and discrimination of benign and malignant lesions. Acad Radiol. 21(9):1195-203, 2014
                                                  11. Greenwood HI et al: Ductal carcinoma in situ of the breasts: review of MR imaging features. Radiographics. 33(6):1569-88, 2013
                                                  12. Hylton NM et al: Locally advanced breast cancer: MR imaging for prediction of response to neoadjuvant chemotherapy--results from ACRIN 6657/I-SPY TRIAL. Radiology. 263(3):663-72, 2012
                                                  13. Rahbar H et al: In vivo assessment of ductal carcinoma in situ grade: a model incorporating dynamic contrast-enhanced and diffusion-weighted breast MR imaging parameters. Radiology. 263(2):374-82, 2012
                                                  14. Kim JA et al: MRI findings of pure ductal carcinoma in situ: kinetic characteristics compared according to lesion type and histopathologic factors. AJR Am J Roentgenol. 196(6):1450-6, 2011
                                                  15. Morris EA, et al: ACR BI-RADS® Magnetic Resonance Imaging. In: ACR BI-RADS® Atlas, Breast Imaging Reporting and Data System. Reston, VA, American College of Radiology; 2013
                                                  16. Fernández-Guinea O et al: Relationship between morphological features and kinetic patterns of enhancement of the dynamic breast magnetic resonance imaging and clinico-pathological and biological factors in invasive breast cancer. BMC Cancer. 10:8, 2010
                                                  17. Loiselle CR et al: Dynamic contrast-enhanced MRI kinetics of invasive breast cancer: a potential prognostic marker for radiation therapy. Int J Radiat Oncol Biol Phys. 76(5):1314-9, 2010
                                                  18. Yamada T et al: Radiologic-pathologic correlation of ductal carcinoma in situ. Radiographics. 30(5):1183-98, 2010
                                                  19. Jansen SA et al: Kinetic curves of malignant lesions are not consistent across MRI systems: need for improved standardization of breast dynamic contrast-enhanced MRI acquisition. AJR Am J Roentgenol. 193(3):832-9, 2009
                                                  20. Wang LC et al: MRI-detected suspicious breast lesions: predictive values of kinetic features measured by computer-aided evaluation. AJR Am J Roentgenol. 193(3):826-31, 2009
                                                  21. Chen JH et al: Magnetic resonance imaging features of fibrocystic change of the breast. Magn Reson Imaging.
                                                  22. Jansen SA et al: DCEMRI of breast lesions: is kinetic analysis equally effective for both mass and nonmass-like enhancement? Med Phys. 35(7):3102-9, 2008
                                                  23. Li KL et al: Invasive breast cancer: predicting disease recurrence by using high-spatial-resolution signal enhancement ratio imaging. Radiology. 248(1):79-87, 2008
                                                  24. Mann RM et al: MRI compared to conventional diagnostic work-up in the detection and evaluation of invasive lobular carcinoma of the breast: a review of existing literature. Breast Cancer Res Treat. 107(1):1-14, 2008
                                                  25. Jansen SA et al: Pure ductal carcinoma in situ: kinetic and morphologic MR characteristics compared with mammographic appearance and nuclear grade. Radiology. 245(3):684-91, 2007
                                                  26. Kuhl C: The current status of breast MR imaging. Part I. Choice of technique, image interpretation, diagnostic accuracy, and transfer to clinical practice. Radiology. 244(2):356-78, 2007
                                                  27. Williams TC et al: Breast MR imaging: computer-aided evaluation program for discriminating benign from malignant lesions. Radiology. 244(1):94-103, 2007
                                                  28. Macura KJ et al: Patterns of enhancement on breast MR images: interpretation and imaging pitfalls. Radiographics. 26(6):1719-34; quiz 1719, 2006
                                                  29. Schnall MD et al: Diagnostic architectural and dynamic features at breast MR imaging: multicenter study. Radiology. 238(1):42-53, 2006
                                                  30. van den Bosch MA et al: Magnetic resonance imaging characteristics of fibrocystic change of the breast. Invest Radiol. 40(7):436-41, 2005
                                                  31. Liberman L et al: Breast lesions detected on MR imaging: features and positive predictive value. AJR Am J Roentgenol. 179(1):171-8, 2002
                                                  32. Nunes LW et al: Update of breast MR imaging architectural interpretation model. Radiology. 219(2):484-94, 2001
                                                  33. Kuhl CK et al: Dynamic breast MR imaging: are signal intensity time course data useful for differential diagnosis of enhancing lesions? Radiology. 211(1):101-10, 1999
                                                  34. Gallardo X et al: Enhancement of intramammary lymph nodes with lymphoid hyperplasia: a potential pitfall in breast MRI. Eur Radiol. 8(9):1662-5, 1998
                                                  35. Brinck U et al: The variability of fibroadenoma in contrast-enhanced dynamic MR mammography. AJR Am J Roentgenol. 168(5):1331-4, 1997