0:00

So this was really a good example to show you of

0:04

what poor positioning can do to fat suppression.

0:09

When you're looking here, let's just

0:11

look first of all at the axial T1.

0:14

Let me just rotate it.

0:16

So you can see here that this lady has very

0:18

large breasts, very dependent, and they're

0:22

pooling down in the bottom of the table.

0:27

So you can sort of see that they're

0:29

not hanging completely dependently.

0:31

And this can be.

0:32

A significant problem.

0:33

So when we look at the non-fat suppressed

0:36

ones, everything looks okay when we

0:39

start to look at fat-suppressed ones.

0:44

You can see here that we have a lot

0:45

of lack of fat suppression on these

0:48

areas of the breast, effectively, you

0:50

know, touching the bottom of the table.

0:55

Breast positioning, as you'll see with the

0:58

next one, is very important and I would really

1:01

recommend that you spend some time training

1:04

your technologists, if they've not already been

1:06

trained, how to position the breast correctly.

1:09

Um, if you, um, have MR dedicated

1:14

techs, getting the mammo techs to

1:18

train the MR techs can be very helpful.

1:22

Um, you know, making sure that the nipple

1:25

is, um, lying straightforward.

1:29

So it's there's not a lot of deviation,

1:30

the breast that they get the coils placed

1:33

symmetrically, um, that they include enough

1:37

breast tissue and axillary tissue within,

1:40

um, the area that's going to be imaged

1:43

and to try and avoid artifacts like this.

1:45

Now, sometimes it's just You know, impossible

1:48

with ladies who have really big breasts.

1:50

You can put a little, um, cushion, um, under

1:55

their sternum to kind of bring their breasts

1:57

up a bit if you're still able to get adequate

1:59

coverage, but sometimes this is a problem.

2:01

So, you know, how good are we at

2:03

looking at this part of the breast?

2:05

Probably not great.

2:06

In this case, we don't see

2:08

anything in her, uh, MIP.

2:10

We don't see anything obvious there, but because

2:13

of that lack of fat suppression, you're going

2:14

to have to look at that area really carefully.

Wk 4, Case 2 - Review

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Pro Tip: Click on a word in the transcript to jump to that point in the video

0:00

So this was really a good example to show you of

0:04

what poor positioning can do to fat suppression.

0:09

When you're looking here, let's just

0:11

look first of all at the axial T1.

0:14

Let me just rotate it.

0:16

So you can see here that this lady has very

0:18

large breasts, very dependent, and they're

0:22

pooling down in the bottom of the table.

0:27

So you can sort of see that they're

0:29

not hanging completely dependently.

0:31

And this can be.

0:32

A significant problem.

0:33

So when we look at the non-fat suppressed

0:36

ones, everything looks okay when we

0:39

start to look at fat-suppressed ones.

0:44

You can see here that we have a lot

0:45

of lack of fat suppression on these

0:48

areas of the breast, effectively, you

0:50

know, touching the bottom of the table.

0:55

Breast positioning, as you'll see with the

0:58

next one, is very important and I would really

1:01

recommend that you spend some time training

1:04

your technologists, if they've not already been

1:06

trained, how to position the breast correctly.

1:09

Um, if you, um, have MR dedicated

1:14

techs, getting the mammo techs to

1:18

train the MR techs can be very helpful.

1:22

Um, you know, making sure that the nipple

1:25

is, um, lying straightforward.

1:29

So it's there's not a lot of deviation,

1:30

the breast that they get the coils placed

1:33

symmetrically, um, that they include enough

1:37

breast tissue and axillary tissue within,

1:40

um, the area that's going to be imaged

1:43

and to try and avoid artifacts like this.

1:45

Now, sometimes it's just You know, impossible

1:48

with ladies who have really big breasts.

1:50

You can put a little, um, cushion, um, under

1:55

their sternum to kind of bring their breasts

1:57

up a bit if you're still able to get adequate

1:59

coverage, but sometimes this is a problem.

2:01

So, you know, how good are we at

2:03

looking at this part of the breast?

2:05

Probably not great.

2:06

In this case, we don't see

2:08

anything in her, uh, MIP.

2:10

We don't see anything obvious there, but because

2:13

of that lack of fat suppression, you're going

2:14

to have to look at that area really carefully.

Report

HISTORY: 32 year old female presents for high risk screening MRI

Summary of prior imaging

Mammography: Scattered fibroglandular densities. Normal mammogram.
Ultrasound: NA
Breast MRI: NA

FINDINGS

Quality control issues: ☐None ☐Poor/lack contrast bolus ☒Poor fat suppression
☐Susceptibility ☐Movement ☒Other: Positioning of the anterior breast is poor

There is indenting and flattening of the anterior most portion of both breasts. There is poor fat suppression in these regions.

Background Parenchymal Enhancement: Minimal
Amount of Fibroglandular Tissue: Scattered fibroglandular tissue

LEFT BREAST
Narrative: No suspicious enhancement or lymphadenopathy.

Associated findings LEFT: ☒NONE, ☐Nipple retraction, ☐Nipple involvement, ☐Skin retraction, ☐Skin thickening, ☐Skin invasion-direct, ☐Skin invasion-inflammatory, ☐Pectoral muscle invasion, ☐Chest wall invasion, ☐ Architectural distortion

Non-enhancing findings LEFT: ☒NONE, ☐High ductal signal pre contrast T1, ☐Cyst(s), ☐Hematoma/seroma, ☐Post therapy skin/trabecular thickening, ☐Non-enhancing mass, ☐Architectural distortion, ☐Signal void from clips

Fat containing lesions LEFT: ☒NONE, ☐Fat necrosis, ☐Hamartoma, ☐Post-operative seroma/hematoma with fat

Lymph nodes LEFT: ☒Normal axillary, ☐Abnormal axillary, ☐ Abnormal internal mammary

RIGHT BREAST
Narrative: No suspicious enhancement or lymphadenopathy.

Associated findings RIGHT breast: ☒NONE, ☐Nipple retraction, ☐Nipple involvement, ☐Skin retraction, ☐Skin thickening, ☐Skin invasion-direct, ☐Skin invasion-inflammatory, ☐Pectoral muscle invasion, ☐Chest wall invasion, ☐ Architectural distortion

Non-enhancing findings RIGHT breast: ☒NONE, ☐High ductal signal pre contrast T1, ☐Cyst(s), ☐Hematoma/seroma, ☐Post therapy skin/trabecular thickening,
☐Non-enhancing mass, ☐Architectural distortion, ☐Signal void from clips

Fat containing lesions RIGHT: ☒NONE, ☐Fat necrosis, ☐Hamartoma, ☐Post-operative seroma/hematoma with fat

Lymph nodes RIGHT: ☒Normal axillary, ☐Abnormal axillary: description, ☐ Abnormal internal mammary: description

Extramammary findings: None

SUMMARY: Suboptimal positioning for MRI, limiting evaluation of the anterior portion of both breasts. No suspicious enhancement or lymphadenopathy.

LEFT BI-RADS: 1: Negative: Routine breast MRI screening if cumulative lifetime risk =>20%
RIGHT BI-RADS: 1: Negative: Routine breast MRI screening if cumulative lifetime risk =>20%

RECOMMENDATIONS: Continue high risk screening MRI and annual screening mammogram.

Case Discussion

Faculty

Petra J Lewis, MBBS

Professor of Radiology and OBGYN

Dartmouth-Hitchcock Medical Center & Geisel School of Medicine at Dartmouth

Sheryl G. Jordan, MD

Professor, Department of Radiology

University of North Carolina School of Medicine

Ryan W. Woods, MD, MPH

Assistant Professor of Radiology

University of Wisconsin School of Medicine and Public Health

Practice Cases

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Wk 4, Case 2 - Review