Frequently Asked Questions - Breast MRI of Oklahoma - Women's Center at Mercy

What is MRI and how is the procedure done?

Magnetic resonance imaging (MRI) is a method of medical imaging in which the patient’s area of interest is viewed in extremely thin segments from multiple directions, providing computer-generated images. The radiologist can then “page through” the tissue or create a three-dimensional image. No radiation is involved, and there is no flattening or compression of the breast in this 30 to 40 minute procedure. The patient lies face-down on a special table so the breasts can hang through an opening into a special “coil” that transmits and receives the radio frequency signals that are used in MRI. Once positioned, the patient is moved feet first into the magnet so she can still look to the outside. Our breast- dedicated MRI has the largest opening available to alleviate any feelings of claustrophobia. Earplugs are provided to diminish any sound of the MRI. An IV line is established beforehand to allow injection of the gadolinium contrast, which may burn slightly with administration. The most common side effect of gadolinium is headache or nausea. A true allergy is extremely rare (gadolinium is not a typical “dye” as used in so many radiologic procedures, but is actually a metallic element). For patients with moderate or severe renal (kidney) failure, a serious condition called Nephrogenic Systemic Fibrosis can occur in a small percentage after the administration of gadolinium. If you have been diagnosed with kidney failure, you should consider alternatives to MRI. If you are unsure of your status, a screening test for kidney failure will be recommended.

Why is the gadolinium necessary?

Breast cancers have a rich blood supply, so tumors “light up” on MRI, helping to distinguish them from normal breast tissue. These are called areas of “enhancement.” It is the contrast agent (gadolinium) that makes breast MRI so much more sensitive in cancer detection than mammography.

If there is no enhancement, am I cancer free?

The power of breast MRI is indeed its “Negative Predictive Value.” If there is no enhancement, then the chances of breast cancer are extremely low.

What about false positives?

As with mammography and ultrasound, there are false positives with breast MRI. With mammography, even after decades of improvements, only one in five biopsies generated will prove to be cancer, leaving four “false positives.” MRI is slightly better in this regard, but false positives still occur due to benign tumors and other conditions of the breast. The most likely time to experience a false-positive is the baseline exam as there will be no previous study for comparison. Also, false-positives are more common in premenopausal women where we attempt to perform breast MRI during days 6 to 17 of your menstrual cycle to reduce the chance of a false alarm on MRI. For postmenopausal women, there is no special timing, but it might help to stop hormone replacement therapy for several weeks prior to your study.

After having an MRI, if you receive a phone call stating that we have seen an area of “enhancement,” the most likely scenario is a return trip to undergo a double-check ultrasound. If an abnormality is confirmed, a needle biopsy is sometimes recommended. If ultrasound of the area in question is completely negative, then a short-interval MRI might be recommended – or, for more worrisome enhancements, an MRI-guided biopsy is performed. The chance of a call-back for further studies is 1 of 5 on the baseline MRI, but only 1 of 10 on subsequent MRIs.

Are there any other drawbacks to MRI?

COST. MRI is expensive, though most indications are covered by insurance. It helps if you check with your insurer, but here are some guidelines: When using MRI for pre-operative planning in newly diagnosed patients, cancer follow-up, or diagnostic problems not settled by conventional imaging, MRI is almost always a covered expense. When MRI is used to complement mammography as part of an asymptomatic screening program, coverage varies from insurer to insurer (the latest guidelines for screening are covered in a following section). When MRI is used to evaluate breast implants placed for cancer reconstruction, it is a covered expense, but this is not the case for implants placed for cosmetic purposes, even though the FDA has recommended MRI every two years for women with silicone implants.

Could MRI replace mammography?

No. Breast MRI is to be used as an additional tool to improve our present combination of mammography and ultrasound. Also, mammograms are better than MRI at detecting calcifications, which may be one of the early signs of breast cancer.

Who is a candidate for breast MRI?

Newly diagnosed breast cancer patients. MRI will provide more accurate information about tumor size and shape, allowing the surgeon to properly plan treatment. MRI will also help assure that there are no additional areas of cancer in the same breast or on the opposite side. Women contemplating lumpectomy often have anxiety about cancer being present in the remaining breast tissue, and there can be a great deal of reassurance to know through MRI that the problem is limited to one site. Also, in this era of “partial breast radiation” (e.g. Mammosite™), the remaining breast tissue away from the lumpectomy site is not treated, so breast MRI is an excellent tool to help patients select this approach.

Patients with a past history of breast cancer. Women who have undergone lumpectomy and radiation often have scar tissue seen on mammography that can mask a recurrent cancer. Incorporating MRI into the follow-up plan vastly improves the chances of early detection. For women who have undergone mastectomy on one side, there is still a possibility of recurrence of the original tumor, plus the other breast is at increased risk for the development of a new primary breast cancer. Again, MRI is the most sensitive method of detection. Women who have already had bilateral mastectomies may still want to continue with MRI follow-up if they are at risk of local recurrence, especially if they have undergone a reconstruction that can interfere with early detection.

Diagnostic problems not settled by conventional imaging. Usually, breast concerns are completely evaluated through the use of mammography and ultrasound. However, if questions remain, breast MRI can offer great assistance.

Implant status. Breast implants placed as part of cancer reconstruction are studied with MRI as part of routine follow-up, and this is generally covered by insurance. When silicone implants are placed for cosmetic reasons, the FDA under new guidelines recommends breast MRI after 3 years, then every 2 years thereafter, though insurance coverage is less likely here (unless patients qualify for MRI based on other indications).

So what about asymptomatic screening?

Although the American Cancer Society previously suggested breast MRI for high-risk women, detailed guidelines were not introduced until 2007. Yearly breast MRI, in addition to mammography, beginning at age 30 is now recommended by the ACS for women who: 1) test positive for one of the BRCA genes, or a first-degree relative of a known BRCA mutation carrier, 2) have a documented history of any of the rare genetic disorders in which breast cancer is one component, 3) have a past history of being treated with chest irradiation for Hodgkin’s disease between ages 10 and 30, or 4) have been calculated by any of the standard mathematical models to have a 20-25% (or greater) lifetime risk for the development of breast cancer.

The first three indications are straightforward, but relatively rare. However, if you wonder whether or not you meet the “20-25% lifetime risk,” this usually requires a formal risk assessment for mathematical modeling. We also believe it’s important to review your degree of mammographic density in making the decision to use MRI screening. Lastly, we assist you in justifying insurance coverage, and if this is not available, arranging for easier payment strategies. To make an appointment for risk assessment, genetic counseling, and discussion of MRI screening, call Dr. Hollingsworth at 405-936-5455.

What is spiral RODEO™ MRI?

Spiral RODEO™ MRI is a software package that improves the images even beyond what was possible a few years ago. There are many different technologic approaches to breast MRI, but the advantage of our approach is the extremely high spatial resolution and sensitivity for cancer detection. RODEO™ is an acronym for Rotating Delivery of Excitation Off-resonance (physics terminology), and you can see a demonstration of the images at Breast MRI of Oklahoma, LLC. Mercy Women’s Center was selected in 2006 as one of three beta test sites in the world for the implementation of spiral RODEO™ MRI.

How do I schedule a breast MRI?

Unless the radiologist has recommended a breast MRI, you will need a referral from your doctor. You should bring your mammograms and ultrasound with you at the time of the study if these were done at a facility other than Mercy. Any biopsy reports should be faxed to us at 405-749-7078. The more information the radiologist has about your condition, the more meaningful the report to the referring physician will be. For appointments, call 405-749-7077.